662 Personality Disorders
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 environm ent influences the risk of devel-
oping a personality disorder and related psychopathology.
Culture-Related Diagnostic Issues
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 stra tegy. In assessing antisocial traits, it is helpful for the clinician to
consider the social and economic co ntext in which the behaviors occur.
Gender-Related Diagnostic Issues
Antisocial personality disorder is much more common in males than in females. There has
been some concern that antisocial persona lity disorder may be underdiagnosed in fe-
males, particularly because of the emphasis on  aggressive items in the definition of con-
duct disorder.
Differential Diagnosis
The diagnosis of antisocial personality disorder is not given to individuals younger than
18 years and is given only if there is a histor y 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 antiso cial personality disorder are not met.
Substance use disorders. When antisocial behavior in an adult is associated with a
substance use disorder, the diagnosis of antisoci al 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