Antisocial pathways associated with substance use disorders: characterizing etiological underpinnings and implications for treatment

- Substance use disorders (SUDs) are common in those high on antisocial traits.
- Several antisocial pathways confer risk for SUDs, but due to distinct etiologies.
- An 'antisocial-only' pathway involves affective reactivity and executive dysfunction.
- A 'psychopathy' pathway involves a failure of attention to integrate emotion and behavior.
- Interventions must target the unique underlying mechanisms associated with SUD.

The association between substance use disorders (SUDs) and crime is one of the most reliable themes in the SUDs literature. While SUDs undoubtedly contribute to crime, there is also good evidence that specific clinical syndromes place individuals at higher risk for SUDs. Of relevance, two subtypes of individuals, 'antisocial-only' and 'psychopathic,' are at elevated risk for SUDs. The former, which includes conduct disorder and antisocial personality disorder, involves a failure to regulate affective reactions, which overwhelms inhibitory controls. The latter, which includes antisocial behavior plus callous-unemotional traits and psychopathy, involves a failure of attention to adequately integrate affective experiences to guide behavioral control. We describe how these potentially divergent etiologies can inform personalized treatments.