Antisocial Personality Disorder in Primary Care Patients With Somatization Disorder G. Richard Smith, Jr., Jacqueline M. Golding, T. Michael Kashner, and Kathryn Rost Antisocial personality disorder and somatization disorder (SD) have been associated in previous research conducted primarily in patients from the mental health setting. We tested the hypothesis that patients with SD from the primary care setting had less likelihood of having comorbid antisocial personality disorder in a sample of 118 patients with SD. Two methods for diagnosing antisocial personality disorder were used: the Diagnostic Interview Schedule (DIS) and the Structured Clinical Interview for DSM-III-R, axis II (SCID-II). Eight percent of the women and between 18% and 25% (depending on the method used) of the men had antisocial personality, a prevalence rate that clearly exceeds the rate found in the general population. However, in clinical work, only one in 10 women and one in six men with SD will have antisocial personality disorder. These findings are consistent with the shared biological substrate hypothesized for the two disorders. Copyright 0 1991 by W.B. Saunders Company
A
NTISOCIAL PERSONALITY DISORDER and antisocial behavior have been associated with somatization disorder (SD) and its nosologic forerunners, Briquet’s syndrome and hysteria. Previous research on this association has typically assessed psychiatric patients.‘-6 Because we hypothesized that psychiatric problems might differ in patients who receive care in the speciality mental health sector compared with patients receiving care from primary care providers,’ we examined this association in two samples of primary care patients. Table 1 summarizes the literature reporting clinical assessment of both SD (or hysteria and Briquet’s syndrome) and antisocial personality disorder. Rates of antisocial personality disorder among persons with SD vary widely, ranging from 3.6%” to 63.0%.” In contrast, the prevalence of antisocial personality disorder in general populations typically ranges from 2.1% to 3.6%,9 with a rate of 0.4% in one community survey” and a rate of 3.3% in a sample consisting mostly of relatives of psychiatric patients.” When only psychiatric outpatients with SD are considered, rates range from 3.6% to 16.7%, with higher rates among psychiatric patients described as refractory (53.1%),4 inpatients ’ (25.0%),5 and felons (63.0%).8 Community residents’ rates are near the low end of the range reported for psychiatric outpatients. It is not surprising that persons with greater overall disturbance and those who are
From the Centers for Mental Healthcare Research, Department of Psychiatry and Behavioral Sciences, Vniversi~ of Arkansas for Medical Sciences, Little Rock, AR; the Veterans Administration Health Services Research and Development Field Program for Mental Health, Little Rock, AR; and the Western Consortium for Public Health, Berkeley, CA. Supported by grants from the Robert Wood Johnson Foundation (No. 12142) and from the National Institute of Mental Health (No. I ROI MH46090). G.R.S. was also supported by a Research Scientist Development Award, Level IIfrom NIMH (No. lKO2MH-00843). Address reprint requests to G. Richard Smith, Jr., M.D., University of Arkansas for Medical Science, Department of Psychiatry, 4301 WMarkham St-Slot 554, Little Rock, AR 72205-7199. Copyright 0 1991 by W B. Saunders Company 0010-440X19113204-0002$03.00/0 Comprehensive
Psychiatry, Vol. 32, No. 4 (July/August),
1991: pp 367-372
367
368
SMITH ET AL
Table 1.
Previous Reports of Antisocial Personality Disorder as a Comorbid Condition in Patients With SD (or Briquet’s Syndrome)
Investigator
Sample
Gender
Cloninger, 1970’ Cloninger, 1986t’ Cloninger, 1986t’
Felons Psychiatric outpatients Psychiatric outpatients with 8 or more somatization symptoms Psychiatric outpatients Refractory psychiatric patients Psychiatric inpatients Psychiatric outpatients Community residents
F F M
Guze,l971*’ Lilienfeld, l9864 Liskow, 19865 Liskow, 19866 Swartz, in pressZ3
F M&F F F M&F
SD
No. With Antisocial Personality (%)
27 83 38
17 (63.0) 3 (3.6) 5 (13.2)
39 49 16 78 25$
3 26 4 13 1*
(7.7) (53.1) (25.0) (16.7) (5.4)
*Reports that represent the same patient sample. tAntisocial personality assessed as a primary research diagnosis at 4- to 12-year follow-up. *Raw numbers estimated by present authors from weighted percentages.
identified as having engaged in antisocial behavior have higher rates of the disorder. The one sample that includes gender comparisons shows a much higher rate for men (13.2%) than women (3.6%),2 and the other patient sample that includes men has one of the highest rates (53.1%).4 These data suggest that antisocial personality is more common among male SD patients than female SD patients. This observation is consistent with the gender difference in general populations, in which 3.9% to 5.9% of men, compared with 0.5% to 1.5% of women, have antisocial personality disorder.‘,” Other evidence suggests an association of the two disorders. Robins found that 20 of 76 girls referred to a child guidance clinic between the ages of 12 and 16 because of antisocial behavior received a diagnosis of hysteria as adults.13 Spalt reported rates of antisocial personality among college students with hysteria, using self-report measures to make both diagnoses.14 Thirteen (22.8%) of 57 women and 14 (34.1%) of 41 men with hysteria had definite, probable, or suspected antisocial personality disorder. Cloninger et al. have postulated that antisocial personality disorder and SD arise from a common genetic substrate, with SD being its female manifestation and antisocial personality disorder being its male expression.‘,” This hypothesis stems from the observations that (1) antisocial personality disorder is relatively rare in women, whereas SD is relatively rare in me#; (2) the two disorders occur in the same families”~‘“; and (3) multifactorial analyses implicate similar genetic and environmental factorsI for both disorders. The gender difference in the two disorders has also been attributed to perceptual bias in diagnosis. When men and women were described as having the same symptoms, women were more likely to be seen as having hysteria, whereas men were equally likely to be perceived as having hysteria or antisocial personality.” This study suggested that hysterical and antisocial personality disorders were masculine- and feminine-typed versions, respectively, of a disorder characterized by egocentricity, lack of capacity for love, or poverty of affective
369
ASP IN PRIMARY CARE SOMATIZATION DISORDER
reactions. The generalizability of these results to SD depends on its similarity to hysterical personality disorder. Despite SD’s historical roots in hysteria, this relationship may not be correct. METHODS Two samples of patients with SD were studied. Sample 1 consisted of 36 women and nine men. Sample 2 consisted of 62 women and 11 men. Both samples were recruited as part of treatment intervention studies. Study patients were referred from primary care physicians who had been contacted and notified of our interest in patients with multiple unexplained somatic complaints. Additionally, 46% of patients in sample 2 were self-referred after hearing about the ongoing treatment studies on a television news program or responding to advertisements in a local newspaper for patients with multiple unexplained somatic complaints. All self-referrals had primary care physicians. The presence of SD was determined by a research psychiatrist using a semistructured interview. The interview paid special attention to all items that form the diagnostic criteria for hysteria or Briquet’s syndrome as defined by the Feighner criteria and the Research Diagnostic Criteria, as well as symptoms that comprise the criteria for DSM-III and DSM-III-R SD. If there was any question concerning whether a symptom was medically explained, the patient’s medical record was reviewed before the decision to count the symptom as positive. Only patients meeting DSM-III-R criteria are included in this analysis. In sample 2, the diagnosis of antisocial personality disorder was made using two methods: the National Institute of Mental Health Diagnostic Interview Schedule (DIS)“‘and the Structured Clinical Interview for DSM-III-R Personality Disorder (SCID-II).2’ In sample 1, only the DIS was used (the SCID-II was not available at that time). The DIS was administered by trained research assistants; version 3 was used for sample 1 and version 3A for sample 2. There are no differences between versions 3 and 3A for antisocial personality disorder. DIS diagnoses were made using computer algorithms obtained from its developers. The DIS was administered on the same day as the psychiatrist’s interview. One year later, all patients still in sample 2, 11 men and 59 women, were also administered the SCID-II.” The SCID-II was administered by one of two research psychiatrists. At the time of the evaluation, the psychiatrists had the diagnostic profile of the patient from the DIS and a completed DSM-III-R personality questionnaire. This questionnaire is a self-report questionnaire developed by its authors to precede the SCID-II. The SCID-II was scored by hand and by computer, with no discrepancies between the two methods of scoring. In this study, DIS diagnoses are by DSM-III criteria. DSM-III-R criteria were not available at the time this aspect of the study was completed. SCID-II diagnoses are by DSM-III-R criteria, the criteria set for which the interview was developed. The differences between the two criteria are relatively small and involve the criteria for making the diagnosis of conduct disorder. Also, the absence of guilt or remorse was added to the DSM-III-R criteria.
RESULTS Tables 2 and 3 present rates of antisocial personality disorder in patients with SD. Diagnoses of antisocial personality disorder are based on the DIS in Table 2, and on the SCID-II in Table 3. Depending on sample and diagnostic instrument,
Table 2.
SD Patients Who Have Comorbid Antisocial Personality Disorder by the DIS Sample 1 (N = 45)
Women (n = 98) Men (n = 21) Total (n = 118)
4/36 (11.1%) 3/9 (33.3%) 7/45 (15.6%)
Sample 2 (N = 73)
Total (N = 118)
4/62 (6.5%) 2/l 1 (18.2%) 6/73 (8.2%)
8/98 (8.2%) 5/20 (25.0%) 13/118 (11.0%)
370
SMITH ET AL
Table 3.
SD Patients Who Have Comorbid Antisocial Personality Disorder by the SCID-II
Women (n = 59) Men (n = 11) Total (n = 70)
Sample 1
Sample 2 (N = 70)
NA NA NA
5/59 (8.5%) 2/11 (18.2%) 7170 (10.0%)
6.5%to 11.1% of women and 18.2% to 33.3% of men have antisocial personality disorder. We conducted two additional sets of analyses to identify demographic and clinical correlates of antisocial personality disorder in this population. In the first set, the two samples were pooled, before examining correlates of antisocial personality as diagnosed by the DIS. These analyses took advantage of the greater statistical power available in the pooled sample. The second set of analyses used only data from sample 2, and involved identifying correlates of antisocial personality as diagnosed by the DIS, the SCID-II, and either (i.e., persons meeting either set of criteria were considered to be positive for antisocial personality). When the two samples were pooled, men were significantly more likely than women to meet DSM-III criteria for antisocial personality (25.0% v 8.2%, P < .05, Fisher’s exact test, two-tailed). Race, socioeconomic status, and age were unrelated to antisocial personality. Analysis of clinical characteristics consisted of estimating the prevalence of antisocial personality in persons who did versus did not report each DSM-III-R symptom of SD, and who reported at least one versus none of each symptom group (gastrointestinal, pain, sexual, and cardiorespiratory symptoms; pseudoneurologic symptoms were omitted, because all patients had at least one symptom in this group). Because 31 individual somatization symptoms were examined, one to two significant differences would be expected by chance alone. This analysis showed that persons with amnesia were more likely (6.7% v 20.0%, P < .05, Fisher’s exact test) and those with difficulty swallowing were less likely (17.9% v 4.4%, P < .05, Fisher’s exact test) to meet criteria for antisocial prsonality. No symptom groups were associated with antisocial personality. In the analysis of sample 2 only, married persons were less likely than the currently unmarried to meet SCID-II (22.2% v 2.3%, P < .05, Fisher’s exact test) and either (20.0% v 2.2%, P < .05, Fisher’s exact test) criteria for antisocial personality. No other demographic characteristics were associated with antisocial personality. When clinical characteristics were considered, persons with difficulty swallowing were less likely to meet SCID-II criteria (18.8% v 2.6%, P < .05, Fisher’s exact test), those with fainting or loss of consciousness were less likely to meet DIS criteria (13.2% v 2.4%, P < .05, Fisher’s exact test), and those with seizures or convulsions were more likely to meet SCID-II criteria (6.6% v 33.3%, P < .05%, Fisher’s exact test). Because 93 tests of individual symptoms were conducted (of which 62 were independent), three to five significant differences would be expected by chance.
ASP IN PRIMARY
CARE SOMATIZATION
DISORDER
371
DISCUSSION
We estimated rates of comorbid antisocial personality disorder among persons with SD who were referred from primary care settings. When the two samples were combined, 8.2% of women and 25.0% of men had antisocial personality disorder. Results were similar using two methods for diagnosing antisocial personality disorder. These rates are much higher than those reported in general populations (0.5% to 1.5% of women, 3.9% to 5.9% of men). These data are consistent with the hypothesized association between antisocial personality disorder and SD. Rates of antisocial personality disorder among women in the present samples are well within the range found in previous studies of female psychiatric outpatients. Rates in men are higher than the rate found in the one previous study of men with SD (25% or 18% in the present study compared with 13.2% in Cloninger et al.‘). However, that study examined primary research diagnoses at follow-up, rather than concurrent psychiatric comorbidity. Thus, these data provide no support for the contention that the manifestations of these psychiatric disorders in primary care patients are substantially different from those seen in psychiatric settings. The excess of men with antisocial personality disorder resembles findings from general populations.9”’ The unmarried, particularly those who had never married, appeared to be at higher risk for antisocial personality. Individual somatization symptoms or symptom groups were unrelated to the prevalence of antisocial personality disorder when adjustments were made for multiple statistical tests. Our attempts to identify correlates of antisocial personality in this population reflect the problems inherent in multiple statistical tests in the small sample necessitated by the rareness of SD. Three main conclusions can be drawn from this study. First, there are much greater rates of antisocial personality disorder in primary care patients with SD than would be expected in a general population. Second, in a clinical setting, only one in 10 women and one in six men with SD will have antisocial personality disorder. It is possible that the association of antisocial personality with SD represents the well-documented propensity for psychiatric disorders in general to co-occur with one another.22 Also, additional analyses suggest that antisocial personality disorder is no more common than most other personality disorders in this sample of patients with SD. It occurs less often than four other personality disorders, and equally often as two other personality disorders among men with SD, but is more common than the remaining four personality disorders in this group. Similarly, among women, the frequency of antisocial personality ranks eighth of 11 personality disorders. Finally, these data are consistent with a shared biological substrate for SD and antisocia1 personality disorder with possible sex-linked expression. They are also consistent with the hypothesis that the two disorders share social-environmental antecedents. ACKNOWLEDGMENT The authors would like to express their appreciation to Carla Baltz, Dawn Neal, Debbie Cindy Mosley, and Martha Mobbs without whose efforts this research would not be possible.
Hodges,
372
SMITH ET AL
REFERENCES 1. Cloninger CR, Guze SB: Psychiatric illness and female criminality: The role of sociopathy and hysteria in the antisocial woman. Am J Psychiatry 127:303-311,197O 2. Cloninger CR, Martin RL, Guze SB, et al: A prospective follow-up and family study of somatization in men and women. Am J Psychiatry 143:873-8781986 3. Guze SB, Woodruff RA Jr, Clayton PJ: Hysteria and antisocial behavior: Further evidence of an association. Am J Psychiatry 127:957-960, 1971 4. Lilienfeld SO, VanValkenburg C, Larntz K, et al: The relationship of histrionic personality disorder to antisocial personality and somatization disorders. Am J Psychiatry 143:718-722, 1986 5. Liskow B, Penick EC, Powell BJ, et al: Inpatients with Briquet’s syndrome: Presence of additional psychiatric syndromes and MMPI results. Compr Psychiatry 27:461-470, 1986 6. Liskow B, Othmer E, Penick EC, et al: Is Briquet’s syndrome a heterogeneous disorder? Am J Psychiatry 143:626-69,1986 7. Brown FW, Golding JM, Smith GR Jr: Psychiatric comorbidity in primary care somatization disorder. Psychosom Med 52:445-451,199l 8. Cloninger CR, Guze SB: Female criminals: Their personal, familial, and social backgrounds. Arch Gen Psychiatry 23:554-558,197O 9. Karno M, Hough RL, Burnam MA, et al: Lifetime prevalence of specific psychiatric disorders among Mexican Americans and non-Hispanic whites in Los Angeles. Arch Gen Psychiatry 44:695-701, 1987 10. Reich J, Yates W, Nduaguba M: Prevalence of DSM-III personality disorders in the community. Sot Psychiatry Psychiatr Epidemio124: 12-16,1989 11. Zimmerman M, Coryell W: DSM-III personality disorder diagnoses in a nonpatient sample. Demographic correlates and comorbidity. Arch Gen Psychiatry 46:682-689,1989 12. Robins LN, Helzer JE, Weissman MM, et al: Lifetime prevalence of specific psychiatric disorders in three sites. Arch Gen Psychiatry 41:949-958,1984 13. Robins L: Deviant Children Grown Up. Baltimore, MD, Williams & Wilkins, 1966 14. Spalt L: Hysteria and antisocial personality. A single disorder? J Nerv Ment Dis 168:456-464. 1980 15. Cloninger CR, Reich T, Guze SB: The multifactorial mode1 of disease transmission, III: Familial relationship between sociopathy and hysteria (Briquet’s syndrome). Br J Psychiatry 127:23-32,197s 16. Swartz M, Landerman R, George L, et al: Somatization disorder, in Robins LN, Regier D (eds): Psychiatric Disorders in America. New York, NY, Free Press, 1990 17. Cloninger CR, Guze SB: Psychiatric illnesses in the families of female criminals: A study of 288 first-degree relatives. Br J Psychiatry 122:697-703,1973 18. Woerner PI, Guze SB: A family and marital study of hysteria. Br J Psychiatry 114:161-168, 1968 19. Warner R: The diagnosis of antisocial and hysterical personality disorders: An example of sex bias. J Nerv Ment Dis 166:839-845,197s 20. Robins LN, Helzer JE, Croughan J, et al: National Institute of Mental Health Diagnostic Interview Schedule. Arch Gen Psychiatry 38:381-389,198l 21. Spitzer RL, Williams JBW, Gibbon M: Structured clinical interview for DSM-III-R personality disorder. New York, NY, Biometrics Research Department, New York State Psychiatric Institute, 1988 22. Boyd JH, Burke JD, Gruenberg E, et al: Exclusion criteria of DSM-III: A study of co-occurrence of hierarchy-free syndromes. Arch Gen Psychiatry 41:983-989,1984
A
NTISOCIAL PERSONALITY DISORDER and antisocial behavior have been associated with somatization disorder (SD) and its nosologic forerunners, Briquet’s syndrome and hysteria. Previous research on this association has typically assessed psychiatric patients.‘-6 Because we hypothesized that psychiatric problems might differ in patients who receive care in the speciality mental health sector compared with patients receiving care from primary care providers,’ we examined this association in two samples of primary care patients. Table 1 summarizes the literature reporting clinical assessment of both SD (or hysteria and Briquet’s syndrome) and antisocial personality disorder. Rates of antisocial personality disorder among persons with SD vary widely, ranging from 3.6%” to 63.0%.” In contrast, the prevalence of antisocial personality disorder in general populations typically ranges from 2.1% to 3.6%,9 with a rate of 0.4% in one community survey” and a rate of 3.3% in a sample consisting mostly of relatives of psychiatric patients.” When only psychiatric outpatients with SD are considered, rates range from 3.6% to 16.7%, with higher rates among psychiatric patients described as refractory (53.1%),4 inpatients ’ (25.0%),5 and felons (63.0%).8 Community residents’ rates are near the low end of the range reported for psychiatric outpatients. It is not surprising that persons with greater overall disturbance and those who are
From the Centers for Mental Healthcare Research, Department of Psychiatry and Behavioral Sciences, Vniversi~ of Arkansas for Medical Sciences, Little Rock, AR; the Veterans Administration Health Services Research and Development Field Program for Mental Health, Little Rock, AR; and the Western Consortium for Public Health, Berkeley, CA. Supported by grants from the Robert Wood Johnson Foundation (No. 12142) and from the National Institute of Mental Health (No. I ROI MH46090). G.R.S. was also supported by a Research Scientist Development Award, Level IIfrom NIMH (No. lKO2MH-00843). Address reprint requests to G. Richard Smith, Jr., M.D., University of Arkansas for Medical Science, Department of Psychiatry, 4301 WMarkham St-Slot 554, Little Rock, AR 72205-7199. Copyright 0 1991 by W B. Saunders Company 0010-440X19113204-0002$03.00/0 Comprehensive
Psychiatry, Vol. 32, No. 4 (July/August),
1991: pp 367-372
367
368
SMITH ET AL
Table 1.
Previous Reports of Antisocial Personality Disorder as a Comorbid Condition in Patients With SD (or Briquet’s Syndrome)
Investigator
Sample
Gender
Cloninger, 1970’ Cloninger, 1986t’ Cloninger, 1986t’
Felons Psychiatric outpatients Psychiatric outpatients with 8 or more somatization symptoms Psychiatric outpatients Refractory psychiatric patients Psychiatric inpatients Psychiatric outpatients Community residents
F F M
Guze,l971*’ Lilienfeld, l9864 Liskow, 19865 Liskow, 19866 Swartz, in pressZ3
F M&F F F M&F
SD
No. With Antisocial Personality (%)
27 83 38
17 (63.0) 3 (3.6) 5 (13.2)
39 49 16 78 25$
3 26 4 13 1*
(7.7) (53.1) (25.0) (16.7) (5.4)
*Reports that represent the same patient sample. tAntisocial personality assessed as a primary research diagnosis at 4- to 12-year follow-up. *Raw numbers estimated by present authors from weighted percentages.
identified as having engaged in antisocial behavior have higher rates of the disorder. The one sample that includes gender comparisons shows a much higher rate for men (13.2%) than women (3.6%),2 and the other patient sample that includes men has one of the highest rates (53.1%).4 These data suggest that antisocial personality is more common among male SD patients than female SD patients. This observation is consistent with the gender difference in general populations, in which 3.9% to 5.9% of men, compared with 0.5% to 1.5% of women, have antisocial personality disorder.‘,” Other evidence suggests an association of the two disorders. Robins found that 20 of 76 girls referred to a child guidance clinic between the ages of 12 and 16 because of antisocial behavior received a diagnosis of hysteria as adults.13 Spalt reported rates of antisocial personality among college students with hysteria, using self-report measures to make both diagnoses.14 Thirteen (22.8%) of 57 women and 14 (34.1%) of 41 men with hysteria had definite, probable, or suspected antisocial personality disorder. Cloninger et al. have postulated that antisocial personality disorder and SD arise from a common genetic substrate, with SD being its female manifestation and antisocial personality disorder being its male expression.‘,” This hypothesis stems from the observations that (1) antisocial personality disorder is relatively rare in women, whereas SD is relatively rare in me#; (2) the two disorders occur in the same families”~‘“; and (3) multifactorial analyses implicate similar genetic and environmental factorsI for both disorders. The gender difference in the two disorders has also been attributed to perceptual bias in diagnosis. When men and women were described as having the same symptoms, women were more likely to be seen as having hysteria, whereas men were equally likely to be perceived as having hysteria or antisocial personality.” This study suggested that hysterical and antisocial personality disorders were masculine- and feminine-typed versions, respectively, of a disorder characterized by egocentricity, lack of capacity for love, or poverty of affective
369
ASP IN PRIMARY CARE SOMATIZATION DISORDER
reactions. The generalizability of these results to SD depends on its similarity to hysterical personality disorder. Despite SD’s historical roots in hysteria, this relationship may not be correct. METHODS Two samples of patients with SD were studied. Sample 1 consisted of 36 women and nine men. Sample 2 consisted of 62 women and 11 men. Both samples were recruited as part of treatment intervention studies. Study patients were referred from primary care physicians who had been contacted and notified of our interest in patients with multiple unexplained somatic complaints. Additionally, 46% of patients in sample 2 were self-referred after hearing about the ongoing treatment studies on a television news program or responding to advertisements in a local newspaper for patients with multiple unexplained somatic complaints. All self-referrals had primary care physicians. The presence of SD was determined by a research psychiatrist using a semistructured interview. The interview paid special attention to all items that form the diagnostic criteria for hysteria or Briquet’s syndrome as defined by the Feighner criteria and the Research Diagnostic Criteria, as well as symptoms that comprise the criteria for DSM-III and DSM-III-R SD. If there was any question concerning whether a symptom was medically explained, the patient’s medical record was reviewed before the decision to count the symptom as positive. Only patients meeting DSM-III-R criteria are included in this analysis. In sample 2, the diagnosis of antisocial personality disorder was made using two methods: the National Institute of Mental Health Diagnostic Interview Schedule (DIS)“‘and the Structured Clinical Interview for DSM-III-R Personality Disorder (SCID-II).2’ In sample 1, only the DIS was used (the SCID-II was not available at that time). The DIS was administered by trained research assistants; version 3 was used for sample 1 and version 3A for sample 2. There are no differences between versions 3 and 3A for antisocial personality disorder. DIS diagnoses were made using computer algorithms obtained from its developers. The DIS was administered on the same day as the psychiatrist’s interview. One year later, all patients still in sample 2, 11 men and 59 women, were also administered the SCID-II.” The SCID-II was administered by one of two research psychiatrists. At the time of the evaluation, the psychiatrists had the diagnostic profile of the patient from the DIS and a completed DSM-III-R personality questionnaire. This questionnaire is a self-report questionnaire developed by its authors to precede the SCID-II. The SCID-II was scored by hand and by computer, with no discrepancies between the two methods of scoring. In this study, DIS diagnoses are by DSM-III criteria. DSM-III-R criteria were not available at the time this aspect of the study was completed. SCID-II diagnoses are by DSM-III-R criteria, the criteria set for which the interview was developed. The differences between the two criteria are relatively small and involve the criteria for making the diagnosis of conduct disorder. Also, the absence of guilt or remorse was added to the DSM-III-R criteria.
RESULTS Tables 2 and 3 present rates of antisocial personality disorder in patients with SD. Diagnoses of antisocial personality disorder are based on the DIS in Table 2, and on the SCID-II in Table 3. Depending on sample and diagnostic instrument,
Table 2.
SD Patients Who Have Comorbid Antisocial Personality Disorder by the DIS Sample 1 (N = 45)
Women (n = 98) Men (n = 21) Total (n = 118)
4/36 (11.1%) 3/9 (33.3%) 7/45 (15.6%)
Sample 2 (N = 73)
Total (N = 118)
4/62 (6.5%) 2/l 1 (18.2%) 6/73 (8.2%)
8/98 (8.2%) 5/20 (25.0%) 13/118 (11.0%)
370
SMITH ET AL
Table 3.
SD Patients Who Have Comorbid Antisocial Personality Disorder by the SCID-II
Women (n = 59) Men (n = 11) Total (n = 70)
Sample 1
Sample 2 (N = 70)
NA NA NA
5/59 (8.5%) 2/11 (18.2%) 7170 (10.0%)
6.5%to 11.1% of women and 18.2% to 33.3% of men have antisocial personality disorder. We conducted two additional sets of analyses to identify demographic and clinical correlates of antisocial personality disorder in this population. In the first set, the two samples were pooled, before examining correlates of antisocial personality as diagnosed by the DIS. These analyses took advantage of the greater statistical power available in the pooled sample. The second set of analyses used only data from sample 2, and involved identifying correlates of antisocial personality as diagnosed by the DIS, the SCID-II, and either (i.e., persons meeting either set of criteria were considered to be positive for antisocial personality). When the two samples were pooled, men were significantly more likely than women to meet DSM-III criteria for antisocial personality (25.0% v 8.2%, P < .05, Fisher’s exact test, two-tailed). Race, socioeconomic status, and age were unrelated to antisocial personality. Analysis of clinical characteristics consisted of estimating the prevalence of antisocial personality in persons who did versus did not report each DSM-III-R symptom of SD, and who reported at least one versus none of each symptom group (gastrointestinal, pain, sexual, and cardiorespiratory symptoms; pseudoneurologic symptoms were omitted, because all patients had at least one symptom in this group). Because 31 individual somatization symptoms were examined, one to two significant differences would be expected by chance alone. This analysis showed that persons with amnesia were more likely (6.7% v 20.0%, P < .05, Fisher’s exact test) and those with difficulty swallowing were less likely (17.9% v 4.4%, P < .05, Fisher’s exact test) to meet criteria for antisocial prsonality. No symptom groups were associated with antisocial personality. In the analysis of sample 2 only, married persons were less likely than the currently unmarried to meet SCID-II (22.2% v 2.3%, P < .05, Fisher’s exact test) and either (20.0% v 2.2%, P < .05, Fisher’s exact test) criteria for antisocial personality. No other demographic characteristics were associated with antisocial personality. When clinical characteristics were considered, persons with difficulty swallowing were less likely to meet SCID-II criteria (18.8% v 2.6%, P < .05, Fisher’s exact test), those with fainting or loss of consciousness were less likely to meet DIS criteria (13.2% v 2.4%, P < .05, Fisher’s exact test), and those with seizures or convulsions were more likely to meet SCID-II criteria (6.6% v 33.3%, P < .05%, Fisher’s exact test). Because 93 tests of individual symptoms were conducted (of which 62 were independent), three to five significant differences would be expected by chance.
ASP IN PRIMARY
CARE SOMATIZATION
DISORDER
371
DISCUSSION
We estimated rates of comorbid antisocial personality disorder among persons with SD who were referred from primary care settings. When the two samples were combined, 8.2% of women and 25.0% of men had antisocial personality disorder. Results were similar using two methods for diagnosing antisocial personality disorder. These rates are much higher than those reported in general populations (0.5% to 1.5% of women, 3.9% to 5.9% of men). These data are consistent with the hypothesized association between antisocial personality disorder and SD. Rates of antisocial personality disorder among women in the present samples are well within the range found in previous studies of female psychiatric outpatients. Rates in men are higher than the rate found in the one previous study of men with SD (25% or 18% in the present study compared with 13.2% in Cloninger et al.‘). However, that study examined primary research diagnoses at follow-up, rather than concurrent psychiatric comorbidity. Thus, these data provide no support for the contention that the manifestations of these psychiatric disorders in primary care patients are substantially different from those seen in psychiatric settings. The excess of men with antisocial personality disorder resembles findings from general populations.9”’ The unmarried, particularly those who had never married, appeared to be at higher risk for antisocial personality. Individual somatization symptoms or symptom groups were unrelated to the prevalence of antisocial personality disorder when adjustments were made for multiple statistical tests. Our attempts to identify correlates of antisocial personality in this population reflect the problems inherent in multiple statistical tests in the small sample necessitated by the rareness of SD. Three main conclusions can be drawn from this study. First, there are much greater rates of antisocial personality disorder in primary care patients with SD than would be expected in a general population. Second, in a clinical setting, only one in 10 women and one in six men with SD will have antisocial personality disorder. It is possible that the association of antisocial personality with SD represents the well-documented propensity for psychiatric disorders in general to co-occur with one another.22 Also, additional analyses suggest that antisocial personality disorder is no more common than most other personality disorders in this sample of patients with SD. It occurs less often than four other personality disorders, and equally often as two other personality disorders among men with SD, but is more common than the remaining four personality disorders in this group. Similarly, among women, the frequency of antisocial personality ranks eighth of 11 personality disorders. Finally, these data are consistent with a shared biological substrate for SD and antisocia1 personality disorder with possible sex-linked expression. They are also consistent with the hypothesis that the two disorders share social-environmental antecedents. ACKNOWLEDGMENT The authors would like to express their appreciation to Carla Baltz, Dawn Neal, Debbie Cindy Mosley, and Martha Mobbs without whose efforts this research would not be possible.
Hodges,
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