The Textbook of Antisocial Personality Disorder, edited by Donald Black, MD, and Nathan Kolla MD, PhD, delivers on its title. It is a comprehensive twenty-four-chapter textbook on antisocial personality disorder. It is easy to read yet covers everything from the historical description of antisocial personality disorder to modern advances like biomarkers and functional MRIs. The contributors are faculty in institutions across the world, including forensic psychiatrists and psychologists as well as researchers in fields like translational medicine and brain imaging.
The introduction section of the book, written by the editors, is particularly poignant. It points out how antisocial personality disorder (ASPD), characterized by a patient’s “recurrent—typically lifelong—misbehavior”, is “psychiatry’s forgotten disorder.” Despite its high societal cost, it is given minimal research funding; it is often viewed as “untreatable.” The editors aptly describe this as a cynical view, one that is “premature because of the lack of relevant treatment research” (p xvi).
The book’s twenty-four chapters are divided into four parts. Part I provides the foundation, tracing the history of our modern notion of ASPD. Readers are led through past eras, starting with the eighteenth-century notion of “moral insanity” in England. Readers are reminded about the variability of how this disorder has historically been viewed: clinically versus as a social label. This part of the book also covers more recent efforts to formally classify antisocial behavior, including that found through iterations of the Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Statistical Classification of Diseases and Related Health Problems (ICD).
Part II of the book addresses relevant clinical concepts, including epidemiology, clinical symptoms, and comorbid conditions. The authors, in this section as throughout the book, thread a sense of objectivity and compassion into their well-cited recitation of the literature. For instance, they remind the reader that “most antisocial individuals are not criminals” (p 40). They also caution that despite the association between ASPD and malingering, clinicians should “be cautious and avoid assuming that all patients with ASPD are exaggerating symptoms” (p 66).
Through a series of eleven chapters, Part III delves into the etiology and pathophysiology of the disorder. The first chapter details the natural history and course, including childhood onset, typical improvement with age, and improved outcomes when accompanied by variables like marriage. The subsequent ten chapters provide a plethora of studies spanning topics from social theories of causation to biomarkers and imaging. These chapters are dense, but crucial. Included studies are well summarized and organized in a format that will be of assistance to clinicians and future researchers. The choice of studies serves to remind the reader of the simultaneous relevance of environmental and biological factors in the development and presentation of ASPD.
Part IV of the textbook bridges theory with practice, discussing psychosocial and pharmacological management strategies. These chapters are informative, with tables of relevant studies and findings. The table in the pharmacology chapter helpfully includes specific medications studied as well as dosages and outcomes. The authors convey a clear sense of caution regarding both the design of past studies and the associated limited evidence regarding efficacy. The last chapter in this section, chapter 19, is written by one of the editors, Donald Black. Dr. Black reminds clinicians that we ourselves can act as a barrier to care for individuals with ASPD, by our hesitancy in making the diagnosis, challenges with countertransference reactions, and “therapeutic gloom.”
The final section of the book focuses on special populations and situations, including children, women, sexual offenders, and individuals in the criminal justice system. This section closes with the book’s final chapter, chapter 24, which attempts to provide some hope: “Prevention of Antisocial Personality Disorder.” The authors in this chapter saliently point out that ASPD is the only personality disorder for which the DSM requires a childhood onset for diagnosis. They note that this core criteria, and ASPD’s natural history and progression, makes it a key target for public health interventions (and the lofty goal of preventing ASPD).
The Textbook of Antisocial Personality Disorder is a must have for forensic psychiatrists. It also deserves a place in psychiatric residency and forensic fellowship libraries. The editors have brought together a wealth of data in a well-organized book. Furthermore, they have addressed this highly stigmatized and understudied disorder with a sense of compassion and hope.
Footnotes
Disclosures of financial or other potential conflicts of interest: None.
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