The risk to biological relatives of females with the disorder tends to be higher than the risk to biological relatives of males with the disorder. Biological relatives of individuals with this disorder are also at increased risk for somatic symptom disorder and substance use disorders. Within a family that has a member with antisocial personality disorder, males more often have antisocial personality disorder and substance use disorders, whereas fe- males more often have somatic symptom disorder. However, in such families, there is an increase in prevalence of all of these disorders in both males and females compared with the general population. Adoption studies indicate that both genetic and environmental factors contribute to the risk of developing antisocial personality disorder. Both adopted and biological children of parents with antisocial personality disorder have an increased risk of developing antisocial personality disorder, somatic symptom disorder, and sub- stance use disorders. Adopted-away children resemble their biological parents more than their adoptive parents, but the adoptive family environment inﬂuences the risk of devel- oping a personality disorder and related psychopathology.
Antisocial personality disorder appears to be associated with low socioeconomic status and urban settings. Concerns have been raised that the diagnosis may at times be misap— plied to individuals in settings in which seemingly antisocial behavior may be part of a protective survival strategy. In assessing antisocial traits, it is helpful for the clinician to consider the social and economic context in which the behaviors occur.
Antisocial personality disorder is much more common in males than in females. There has males, particularly because of the emphasis on aggressive items in the definition of con- duct disorder.
The diagnosis of antisocial personality disorder is not given to individuals younger than 18 years and is given only if there is a history of some symptoms of conduct disorder be- fore age 15 years. For individuals older than 18 years, a diagnosis of conduct disorder is given only if the criteria for antisocial personality disorder are not met.
Substance use disorders. When antisocial behavior in an adult is associated with a substance use disorder, the diagnosis of antisocial personality disorder is not made unless the signs of antisocial personality disorder were also present in childhood and have con- tinued into adulthood. When substance use and antisocial behavior both began in childhood and continued into adulthood, both a substance use disorder and antisocial personality disorder should be diagnosed if the criteria for both are met, even though some antisocial acts may be a consequence of the substance use disorder (e.g., illegal selling of drugs, thefts to obtain money for drugs).
Schizophrenia and bipolar disorders. Antisocial behavior that occurs exclusively dur- ing the course of schizophrenia or a bipolar disorder should not be diagnosed as antisocial personality disorder.
Other personality disorders. Other personality disorders may be confused with antiso- cial personality disorder because they have certain features in common. It is therefore im- portant to distinguish among these disorders based on differences in their characteristic features. However, if an individual has personality features that meet criteria for one or more personality disorders in addition to antisocial personality disorder, all can be diag- nosed. Individuals with antisocial personality disorder and narcissistic personality disor- der share a tendency to be tough-minded, glib, superficial, exploitative, and lack empathy.