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Ask the Mental Health Expert Archives 2001-2004

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PTSD and Antisocial Personality Disorder

Q. Have there been any research to establish a possible causal relationship between posttraumatic stress disorder (PTSD) from war trauma and antisocial personality disorder? If so, can you help me locate these studies?

A. I think the short answer to your question, as I understand it, is "no". But let me sort things out a bit first. There is a difference between antisocial behavior (e.g., forging checks, stealing, assaulting people, etc.) and antisocial personality disorder (APD). The latter--by definition--is a nearly life-long disturbance in personality, characterized by "?a pervasive pattern of disregard for, and violation of, the rights of others occurring since age 15 years?"

So, if I understand your question correctly, it might be phrased as follows: "Is there any research that shows a causal link between pre-existing APD (prior to combat experience or war-related trauma), and subsequent development of post-traumatic stress disorder (PTSD)?"

Resnick et al (J Clin Psychol 1989 Nov;45(6):860-6) carried out a study of 118 Vietnam-era veterans to determine the relationship between number of preadult and adult antisocial behaviors, level of combat exposure, and development of combat-related post-traumatic stress disorder (PTSD). They found that combat exposure level was related significantly to PTSD symptomatology, whereas number of preadult antisocial behaviors was not.

This would seem to argue against the causal link between pre-existing APD and subsequent combat-related PTSD. However, both combat exposure level and preadult antisocial behaviors were related significantly to number of adult antisocial behaviors. This suggested to the researchers that, "?trauma may play a role in the development and/or maintenance of adult antisocial behaviors observed in some Vietnam veterans."

Another study (Sierles et al, Am J Psychiatry 1983 Sep;140(9):1177-9) examined 25 combat veterans hospitalized for treatment of posttraumatic stress disorder and found that co-morbidity was common. Fourteen patients (56%) met operationally defined criteria for one additional diagnosis, five (20%) for two additional diagnoses, and two (8%) for three additional diagnoses.

The coexisting syndromes included alcoholism, drug dependence, APD, somatization disorder, endogenous depression, and organic mental syndrome. These data, of course, don't tell us what caused what; and clinically, it's often hard to determine that. More generally, there is epidemiologic evidence of an association between APD and anxiety disorders, including PTSD.

Specifically, in one community sample of adults aged 15-54, social phobia and post-traumatic stress disorder were both associated with significantly increased odds of APD, after adjusting for differences in sociodemographic characteristics and other psychiatric comorbidity (Goodwin & Hamilton, Psychiatry Res 2003 Feb 15;117(2):159-66).

The bottom line: there seems to be some correlation between PTSD and APD, but it's not clear precisely which way the "causal arrow" is traveling.

October 2003

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