aggressive tendencies show in about 72% of all male patients diagnosed with aspd. about 29% of the men studied with aspd also showed a prevalence of pre-meditated aggression. based on the evidence in the study, the researchers concluded that aggression in patients with aspd is mostly impulsive, though there are some long-term evidences of pre-meditated aggressions. it often occurs that those with higher psychopathic traits will exhibit the pre-meditated aggressions to those around them. over the course of a patient's life with aspd, he or she can exhibit this aggressive behavior and harm those close to him or her. additionally, many people (especially adults) who have been diagnosed with aspd become burdens to their close relatives, peers, and caretakers. harvard medical school recommends that time and resources be spent treating victims who have been affected by someone with aspd, because the patient with aspd may not respond to the administered therapies. in fact, a patient with aspd may only accept treatment when ordered by a court, which will make their course of treatment difficult and severe. because of the challenges in treatment, the patient's family and close friends must take an active role in decisions about therapies that are offered to the patient. ultimately, there must be a group effort to aid the long-term effects of the disorder. epidemiology the estimated lifetime prevalence of aspd amongst the general population falls within 1 to 4%, skewed towards men with 6% and 2% women. as seen in two north american studies and two european studies, aspd is more commonly seen in men than in women, with men three to five times more likely to be diagnosed with aspd than women. the prevalence of aspd is even higher in selected populations, like prisons, where there is a preponderance of violent offenders. it has been found that the prevalence of aspd among prisoners is just under 50%. similarly, the prevalence of aspd is higher among patients in alcohol or other drug (aod) use treatment programs than in the general population, suggesting a link between aspd and aod use and dependence. as part of the epidemiological catchment area (eca) study, men with aspd were found to be three to five times more likely to excessively use alcohol and illicit substances than those men without aspd. while aspd occurs more often in men than women, there was found to be increased severity of this substance use in women with aspd. in a study conducted with both men and women with aspd, women were more likely to misuse substances compared to their male counterparts. homelessness is also common amongst people with aspd. a study on 31 youths of san francisco and 56 youths in chicago found that 84% and 48% of the homeless met the diagnostic criteria for aspd respectively. another study on the homeless found that 25% of participants had aspd. individuals with aspd are at an elevated risk for suicide. some studies suggest this increase in suicidality is in part due to the association between suicide and symptoms or trends within aspd, such as criminality and substance use. offspring of people with aspd are also at risk. some research suggests that negative or traumatic experiences in childhood, perhaps as a result of the choices a parent with aspd might make, can be a predictor of delinquency later on in the child's life. additionally, with variability between situations, children of a parent with aspd may face consequences of delinquency if they're raised in an environment in which crime and violence is common. suicide is a leading cause of death among youth who display antisocial behavior, especially when mixed with delinquency. incarceration, which could come as a consequence of actions from a person with aspd, is a predictor for suicide ideation in youth. history the first version of the dsm in 1952 listed sociopathic personality disturbance. this category was for individuals who were considered "...ill primarily in terms of society and of conformity with the prevailing milieu, and not only in terms of personal discomfort and relations with other individuals." there were four subtypes, referred to as "reactions": antisocial, dyssocial, sexual, and addiction. the antisocial reaction was said to include people who were "always in trouble" and not learning from it, maintaining "no loyalties", frequently callous and lacking responsibility, with an ability to "rationalize" their behavior. the category was described as more specific and limited than the existing concepts of "constitutional psychopathic state" or "psychopathic personality" which had had a very broad meaning; the narrower definition was in line with criteria advanced by hervey m. cleckley from 1941, while the term sociopathic had been advanced by george partridge in 1928 when studying the early environmental influence on psychopaths. partridge discovered the correlation between antisocial psychopathic disorder and parental rejection experienced in early childhood. the dsm-ii in 1968 rearranged the categories and "antisocial personality" was now listed as one of ten personality disorders but still described similarly, to be applied to individuals who are: "basically unsocialized", in repeated conflicts with society, incapable of significant loyalty, selfish, irresponsible, unable to feel guilt or learn from prior experiences, and who tend to blame others and rationalize. the manual preface contains "special instructions" including "antisocial personality should always be specified as mild, moderate, or severe." the dsm-ii warned that a history of legal or social offenses was not by itself enough to justify the diagnosis, and that a "group delinquent reaction" of childhood or adolescence or "social maladjustment without manifest psychiatric disorder" should be ruled out first. the dyssocial personality type was relegated in the dsm-ii to "dyssocial behavior" for individuals who are predatory and follow more or less criminal pursuits, such as racketeers, dishonest gamblers, prostitutes, and dope peddlers. (dsm-i classified this condition as sociopathic personality disorder, dyssocial type). it would later resurface as the name of a diagnosis in the icd manual produced by the who, later spelled dissocial personality disorder and considered approximately equivalent to the aspd diagnosis. the dsm-iii in 1980 included the full term antisocial personality disorder and, as with other disorders, there was now a full checklist of symptoms focused on observable behaviors to enhance consistency in diagnosis between different psychiatrists ('inter-rater reliability'). the aspd symptom list was based on the research diagnostic criteria developed from the so-called feighner criteria from 1972, and in turn largely credited to influential research by sociologist lee robins published in 1966 as "deviant children grown up". however, robins has previously clarified that while the new criteria of prior childhood conduct problems came from her work, she and co-researcher psychiatrist patricia o'neal got the diagnostic criteria they used from lee's husband the psychiatrist eli robins, one of the authors of the feighner criteria who had been using them as part of diagnostic interviews. the dsm-iv maintained the trend for behavioral antisocial symptoms while noting "this pattern has also been referred to as psychopathy, sociopathy, or dyssocial personality disorder" and re-including in the 'associated features' text summary some of the underlying personality traits from the older diagnoses. the dsm-5 has the same diagnosis of antisocial personality disorder. the pocket guide to the dsm-5 diagnostic exam suggests that a person with aspd may present "with psychopathic features" if he or she exhibits "a lack of anxiety or fear and a bold, efficacious interpersonal style".