Neurochemistry and Neuroanatomy of APD

1. Neurochemistry and Neuroanatomy of APD

2. Background • Most research focused on behavioral disturbances • APD • Impulsive Aggression • Criminality • CD and ODD • Externalizing disorders • Novelty Seeking • Sensation Seeking • Little empirical attention to affective-interpersonal factor of psychopathy

3. Neurochemical Disturbances • Monoamine neurotransmitters • Serotonin • Dopamine • Epinephrine and Norepinephrine • Hormones • Testosterone • Cortisol • Thyroid

4. Serotonin • Lower levels of serotonin consistently associated with • Aggression • Criminal behavior • Suicidal behavior • Disturbances in serotonergic functioning early in life closely related to behaviors that progress to APD • Disruptive behavior disorders • Aggression • Family history of APD

5. Serotonin deficits more fundamentally linked to Factor 2 features of psychopathy (impulsive-antisocial) • Serotonin levels • Low in spinal fluid • High in blood platelet cells • Specificity of site unclear but evidence points towards deficient serotonin precursor uptake or synthesis

7. d-fenfluramine • Releases synaptic serotonin to activate postsynaptic serotonin receptors. The functional status of the serotonin is measured by levels of peripheral prolactin • Blunted prolactin response to fenfluramine • Convicted murderers w/APD • APD heroin users • Increased impulsive aggression • Children with aggressive and antisocial relatives

8. Genetic polymorphisms • Variations in the DNA sequence coding • Dopamine • THP • Serotonin Transporter • MAO-A • Norepinephrine

9. Hormones • Testosterone levels higher in violent people engaging in violent and aggressive behavior. Also related to hostility. • After age 25 • androgen levels decrease • violent crime rates decrease

10. Dabbs & Morris (1990) • Studied 1,496 Vietnam Vets • Vets with high testosterone levels and low social integration (e.g., low SES, unmarried) most likely to be delinquent

11. HPA Axis functioning • Low cortisol response related to violent offending, physically abusive behavior, aggressiveness, externalizing symptoms in childhood • Unclear whether this is a blunted basal output or a blunted cortisol response to stress

12. Physiological Arousal • Antisocial personalities have lower resting heart rates (Raine, 1993) • Ortiz and Raine (2003) Meta-analysis • Anti-social behavior in children • 40 studies, n = 5,868, d = -.44 • Theories • reduced fear • autonomic underarousal

13. Complications During Birth • Violent offenders more likely than nonviolent or non-criminals to have had a complicated birth • Likelihood of violence increases with complicated birth and • parental psychiatric illness or • minor physical anomalies

14. Head Injuries • Study of death-row inmates (Lewis, 1986) • All 15 claimed a history of head injury • 12 of 15 showed neurological impairment • Study of 14 death-row juvenile offenders (Lewis et al., 1988) • All 14 had history of head injury • 8 of 14 severe enough to be hospitalized • Study of 16 death row inmates (Freedman & Hemenway, 2000) • 88% (14) had history of head injury • 88% had been physically or sexually abused • 88% had parents who abused drugs and alcohol

15. Arthur ShawcrossGenesee River Killer • Killed 2 children, 11 prostitutes • Head injuries • 09 Hit in head with stone • 10 Hit head jumping into lake • 16 Hit in head with discuss • 17 Hit in head with sledge hammer • 23 Fell 40’ from ladder and hit his head, was unconscious

16. David Berkowitz“Son of Sam” • Killed 6, started over a thousand fires • Head injuries • 7 Hit by a car, suffered head injuries • 7 Ran into a wall and suffered head injuries • 8 Hit in the head with a pipe, 4-inch gash in forehead

17. Richard Ramirez“The Night Stalker” • Killed 14 • Head injuries • 02 Dresser fell on his head, received 30 stitches, almost died • 06 Hit by a swing, knocked unconscious, caused a deep gash • 11 Diagnosed with epilepsy

18. Robert Garrow • Killed 7 people • Head Injuries • 2 years old: Mother splits his head open with a crowbar during a beating • 5 years old: Knocked unconscious when mother hits him in the head with a piece of wood • 6 Years old: Beaten unconscious by his father • 36: Receives head injury in auto accident

19. Raymond Fernandez • Killed 17 people in the late 1940s • History • Normal, friendly personality prior to injury • Hit on head with a steel hatch cover • In coma for a week • Complete personality change • Killed 17 women over next few years • Executed in Sing Sing in 1951

20. Brain Abnormalities

21. Brain Damage • 57% of violent criminals • 94% for homicide • 78% for rape • 61% for habitual aggression • 49% for pedophiles • 15% of criminals committing single violent act • 3% of the general population • Damage is typically in the prefrontal area

22. Prefrontal Cortex • Frontal Lobe: Orbitofrontal Cortex (OF) • poor impulse control • explosive, aggressive outbursts • lack of interpersonal sensitivity • Frontal Lobe: Ventromedial (vm) Prefrontal • judgment, awareness of socially appropriate conduct, assessing consequences

23. Prefrontal Cortex • Antisocial/Violent Behavior • Reduced activation related to impulsive aggressive acts • Psychopaths • Increased activation during emotionally challenging tasks

24. Corpus Callosum • Structural abnormalities • Social, autonomic, and emotional impairment • “faulty wiring”

25. Amygdala • Arousal • Controls Autonomic Responses Associated with Fear • Emotional Responses

26. Hippocampus • Hippocampal impairments • Affect dysregulation • Poor contextual fear conditioning

27. Psychopathic Traits • Enlarged corpus callosum • Reduced posterior hippocampus volume • Exaggerated right > left anterior hippocampus asymmetry • Reduced prefrontal gray volume

28. Psychopaths • Increased prefrontal white matter in deceitful/cunning/manipulative behavior • Reduced amygdala volume in violent offenders with high psychopathy scores • Reduced prefrontal gray volume with psychopathy factors

29. APD – Violent Behavior • Reduced prefrontal gray matter • Reduced temporal lobe volume • Reduced posterior hippocampal volumes • Increased collosal volume • No amygdala differences

30. Treatment

31. Messina et al (2003) • Background • Literature unclear whether ASPD is predictive of substance abuse treatment responsivity • Hypotheses for ASPD patients • CBT, CM, & CBT + CM > MM • CBT < CM < CBT + CM • CM effects decrease significantly during post-treatment

32. Procedure • 120 MM patients randomly assigned to CBT, CM, CBT + CM, or MM • 16 weeks of treatment • Outcome measures • Urine samples • Attendance

33. Results In-Treatment • ASPD significantly and positively related to treatment responsivity • All conditions better than control for ASPD, but not for non-ASPD • ASPD patients in CM condition significantly more likely to be abstinent during treatment than CBT condition. No diff between CM and CBT + CM. • ASPD CM > non-ASPD CM

34. Results Post-Treatment • ASPD CM - highest level of abstinence • ASPD: CM, CBT, & CBT + CM > MM • Non ASPD: No between group differences

37. Digiuseppe • Proposed components of effective tx for anger management: • Therapeutic alliance • Motivation for change • Manage physiological arousal • Cognitive change • Behavior change • Relapse Prevention

38. Secondary targets • Manage impulsive behavaiors • Forgiveness • Systemic interventions • Rebuilding relationships • Environmental supports • Treatment manuals

39. Treatment for Psychopathy • Therapeutic Communities • Lower recidivism for non-psychopaths and higher recidivism for psychopaths (violent) • Did the new skills actually aide the psychopaths in manipulating others? • CBT • Inconclusive • In one study psychopaths rated as showing the most improvement after tx were the most likely to re-offend. Why?