Mental Health: Global Challenges Journal

https://reference-global.com/journal/MHGCJ

ISSN 2612-2138

THE PARADOX OF CHILDHOOD CUMULATIVE

ADVERSITY IN ANTISOCIAL PERSONALITY DISORDER:

RECONSIDERING TRAUMA-INFORMED APPROACHES IN

CARCERAL SETTINGS

Ahmed Rady

1,2

, Celia Rupaire

1,3

, Manuel Bermejo

, Jerome Lacoste

1, 4

SMPR Centre Hospitalier Universitaire CHU de Martinique, DOM, France

Alexandria University School of Medicine, Egypt

Centre Hospitalier Maurice Despinoy, DOM, France

UR PSYCOMADD, Paris Saclay University, Villejuif, France

Abstract

Introduction and Purpose:

High levels of Adverse Childhood Experiences (ACEs), is often

associated with Antisocial Personality Disorder (ASPD) psychopathology. Our study investigates if

childhood adversities directly manifest through the dimensions of emotion regulation,

psychopathy, impulsivity, and aggression. Dimensions that are commonly addressed in carceral

settings.

Methodology: A retrospective study conducted in a carceral setting. We analysed records of

male inmates with a clinical diagnosis of ASPD who consulted the prison psychiatric service from

January to June 2025. Records with comorbid Borderline Personality

Disorder (BPD) or active

psychosis were excluded and only included medical records

incorporating the relevant

psychometric evaluations, the Difficulties in Emotion

Regulation Scale (DERS), Psychopathy

Checklist-Revised (PCL-R), Levenson Self-

Report Psychopathy Scale (LSRP), Barratt Impulsiveness

Scale (BIS-11), and Buss-Perry Aggression Questionnaire

(BPAQ). Participants were stratified into

High (ACE≥4) and Low (ACE <4) cumulative adversity groups.

Results: The final sample comprised (N=47) participants. No statistically significant differences

were found between the High and Low cumulative adversity groups on the total scores of the

DERS (p=0.11), PCL-R (p=0.63), LSRP (p=0.55), BIS-

11 (p=0.19), and BPAQ (p=0.64). ACE

correlation with those psychological dimensions did not reach significance.

Conclusion:

Within a pure ASPD sample, a higher load of childhood adversity was not

associated with greater deficits in emotion regulation, impulsivity, or overall aggression. This

dissociation suggests that the phenotypic expression of ASPD in adulthood may represent a final

common etiologic pathway, not necessarily associated with severity of childhood adversities.

The findings invite reconsideration of current models and open insights to investigate the utility of

integrating trauma-specific, explorative

therapies to address deeply seated pathological

schemas not addressed by classical Interventions with focus on the measured dimensions.

Keywords

Mental Health, Antisocial Personality Disorder, Childhood Psychotrauma, Adverse Childhood

Experiences, Emotion Regulation, Forensic Psychiatry, Trauma-focused

Address for correspondence:

Ahmed Rady, SMPR – Dispositif Psychiatrique de l’

USMP, Centre Hospitalier

Universitaire CHU de Martinique, DOM, France

E-mail: ahmed.rady@chu-martinique.fr

This work is licensed under a Creative Commons Attribution- 4.0 International

License (CC BY 4.0).

©Copyright: Rady et al, 2026

Publisher: Paradigm (De Gruyter)

DOI: https://doi.org/10.56508/mhgcj.v9i1.338

Submitted for

publication: 02

December 2025

Revised: 05 January

2026

Accepted for

publication: 06

February 2026

Mental Health: Global Challenges Journal

https://reference-global.com/journal/MHGCJ

ISSN 2612-2138

Introduction

Antisocial Personality Disorder (ASPD) represents

a severe and pervasive pattern of disregard for

the rights of others, including traits of

deceitfulness, impulsivity, irritability, recklessness,

and an evident lack of empathy (WHO, 2024). It’s

a highly prevalent psychopathology in carceral

settings, with a prevalence rate ranging 40-60%

of male prison inmates, making it a critical

mental health concern for forensic psychiatry

according to a systemic review analyzing 62

surveys (Fazel and Danesh, 2002). The etiology of

ASPD is complex and multifaceted, involving a

complexed interplay of genetic predispositions,

neurobiological vulnerabilities, and particular

environmental triggers in Bio-Psycho-Social model

(Jansen, 2022).

Among the documented environmental

factors, comes the exposure to childhood

Adversity as one of the major and replicated risk

factors (Lobbestael et al, 2010). The Adverse

Childhood Experiences (ACE) study and

subsequent research have compellingly revealed

a strong, dose-response relationship model

between the number of ACEs, including abuse,

neglect, and household dysfunction and

subsequent negative outcomes later in adult life.

From a forensic perspective, they are more prone

to criminal behavior, violence, and the

development of ASPD (Felitti et al, 2019; Hughes

et al, 2017).

From a neurodevelopmental perspective,

chronic early-life stress can induce structural and

functional changes in key brain regions, including

the prefrontal cortex, dorsolateral and

ventromedial aspects, responsible for executive

control and impulse regulation, the amygdala,

involved in threat detection and fear, and the

anterior cingulate cortex, implicated in error

processing and empathy (Teicher and Samson,

2016; McCrory et al, 2011). This continuous

exposure to stress during early developmental

stages can interfere with the development of

healthy emotional and behavioral regulation

abilities, with tendencies towards externalization

behaviors (Van der Kolk, 2014). Given this

established link, an intuitive hypothesis would

suggest that among individuals who have

developed ASPD, those with a cumulative

adversity would exhibit a more severe and

impairing form of the disorder. This could manifest

as more severe deficits in emotion regulation, a

core difficulty implicated in reactive aggression

and impulsivity (Gratz and Roemer, 2004); higher

levels of psychopathy, particularly the secondary

variant characterized by emotional dysregulation,

impulsivity, reactive anger and expectedly

reflects on the scores of self-reported measures

of impulsivity and aggression (Hicks et al, 2010).

We formulate our research hypothesis in easy

wording, the null hypothesis H0: Once the

diagnostic threshold for ASPD is reached, its

phenotypic severity is independent of cumulative

adversity; The alternative hypothesis H1: Higher

ACE load is associated with proportional greater

impairment in emotion regulation, impulsivity,

aggression, and psychopathy traits.

However, the clinical reality within forensic

populations suggests a more complex pattern of

interaction. The psychological architecture of

ASPD, which may overlap with but is distinct from

psychopathy, can be characterized by significant

emotional numbing, detachment, and

alexithymia (Hare, 2003; Hemming et al, 2021).

It’s noteworthy that psychopathy construct is

fundamentally based on the existence of two

sub-factors affective-interpersonal factor and

impulsivity-antisocial life styles. It’s a broader

dimensional rather than categorical diagnosis

and it englobes antisocial personality disorder as

well as other diagnosis as narcissistic and

borderline personality disorders (Wall et al, 2015;

Strickland et al, 2020).

It is a coherent hypothesis that for some

individuals, a high adversity burden contributes to

the development of ASPD through a process of

adaptive emotional blunting, resulting in a

personality structure where the subjective

experience of emotional dysregulation is

markedly attenuated, even if disruptive

behavioral mode persists. This observation

creates a paradox where the hypothesized

etiological agent childhood adversity does not

necessarily correlate with the severity of self-

reported or clinically rated psychopathy

symptoms in adulthood (Wolf, 2025).

Furthermore, the dominant approach of

psychological intervention in many prison systems

remains, globally, anchored to cognitive-

behavioral therapy (CBT) models (Thekkumkara et

al, 2022). These programs, such as reasoning

and rehabilitation programs, primarily focus on

modifying present cognitive distortions,

enhancing problem-solving skills, and developing

goal-oriented behavioral control. While they show

modest efficacy in reducing recidivism (Valizadeh

et al, 2020). They largely operate on a present-

focused mode, deliberately avoiding deep

exploration of past traumatic experiences. This

therapeutic gap is particularly salient, in the light

of the high prevalence of childhood traumatic

adversities in offender population (Beaudry et al,

2021).

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ISSN 2612-2138

Purpose

The present study aims to dissect this complex

relationship within a unique and rigorously defined

clinical sample: incarcerated men with a primary

diagnosis of ASPD, without comorbid disorders

that could confound results as active psychosis or

Borderline Personality Disorder (BPD).

Methodology

A retrospective cross-sectional study was

conducted by reviewing the computerized

medical records of the psychiatric service within

the Centre Pénitentiaire de Ducos, the principal

detention and correctional facility in Martinique,

Overseas department of France. The study period

spanned from January to June 2025. We

screened all clinical records of male inmates

who had received a formal diagnosis of ASPD

from a staff psychiatrist, based on established

ICD-11 diagnostic criteria (ICD11 Code F602)

(WHO, 2024). To ensure a homogeneous sample

and minimize confounding diagnostic bias in

analysis, we applied strict exclusion criteria: any

comorbid diagnosis of Borderline Personality

Disorder (BPD) (ICD11 Code F603) due to its

shared features of impulsivity and emotional

dysregulation but different etiological pathways,

or any active psychotic disorder (ICD11 Codes

F20-29) as schizophrenia and schizoaffective

disorder. The final sample comprised 47

participants, who were subsequently categorized

into two groups based on their score on the

Adverse Childhood Experiences (ACE)

questionnaire.

Measures and Psychometric Properties

Data were extracted from the standardized

psychological assessments proposed and

administered during clinical consultations upon

initial evaluation at the psychiatric service.

Cumulative Adversity

The Adverse Childhood Experiences (ACE)

Questionnaire is a 10-item self-report tool that

assesses exposure to categories of childhood

maltreatment and household dysfunction before

the age of 18 (Felitti et al, 2019). It covers

emotional, physical, and sexual abuse;

emotional and physical neglect; and household

challenges such as substance abuse, mental

illness, and incarceration of a relative. Each

affirmative response scores one point, yielding a

total score from 0 to 10. The ACE is a widely

validated instrument with good test-retest

reliability (Hughes et al, 2017). The cut-off score of

4, used to define our High Cumulative Adversity

group (ACE ≥4), is well-established in the literature

as a threshold associated with a steep increase in

the risk for multiple poor health and social

outcomes (Yu et al, 2022). In our Unit, the

validated French version was used (Tarquinio

Camille et al, 2023).

Emotion Regulation:

The Difficulties in Emotion Regulation Scale

(DERS) is a 36-item self-report questionnaire that

provides a comprehensive assessment of

emotion dysregulation (Gratz and Roemer, 2004).

Participants rate items on a 5-point Likert scale. It

yields a total score and six subscale scores: Non-

Acceptance of Emotional Responses, Difficulty

Engaging in Goal-Directed Behavior, Impulse

Control Difficulties, Lack of Emotional Awareness,

Limited Access to Emotion Regulation Strategies,

and Lack of Emotional Clarity. The DERS has

excellent psychometric properties, with a

reported Cronbach's alpha of 0.93 for the total

score and subscale alphas ranging from 0.80 to

0.89 (Gratz and Roemer, 2004). In our Unit, the

validated French version was used (Dan-Glauser

and Scherer, 2012). In our study Cronbach’s

alpha was 0.83.

Clinician rated psychopathy:

The Psychopathy Checklist-Revised (PCL-R) is

the gold standard 20-item clinical construct

rating scale for the assessment of psychopathy in

forensic populations (Hare, 2003). It is completed

based on a semi-structured interview and a

thorough review of supporting file information. It

provides a total score (range 0-40) and two factor

scores: Factor 1 (Interpersonal/Affective traits:

glibness, grandiosity, deceitfulness, lack of

empathy/remorse) and Factor 2

(Lifestyle/Antisocial traits: impulsivity, irresponsibility,

need for stimulation, early behavioral problems).

The PCL-R has extensive evidence for its reliability

and predictive validity, with inter-rater reliability

coefficients consistently reported above 0.85

(Hare, 2020). In the present study, the validated

French version was used (Cote and Hodgins,

1991).

Self-rated psychopathy:

The Levenson Self-Report Psychopathy Scale

(LSRP) is a 26-item self-report measure designed

to assess primary and secondary psychopathy

traits in community and incarcerated samples

(Levenson et al, 1995). It uses a 4-point Likert

scale (disagree strongly to agree strongly) and

provides a total score, a Primary Psychopathy

score (reflecting a selfish, uncaring, and

manipulative interpersonal style), and a

Secondary Psychopathy score (reflecting

impulsivity, poor behavioral control, and self-

defeating life strategies). The scale has

demonstrated adequate internal consistency,

Mental Health: Global Challenges Journal

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ISSN 2612-2138

with Cronbach's alphas reported around 0.82 for

the primary scale and 0.63 for the secondary

scale (Levenson et al, 1995; Brinkley et al, 2001).

In our study, the validated French version was

applied (Savard et al, 2014).

Impulsivity:

The Barratt Impulsiveness Scale (BIS-11) is a 30-

item self-report questionnaire that is the most

widely used measure of trait impulsivity (Patton,

1995). Items are rated on a 4-point scale. It

generates a total score and three second-order

factor scores: Attentional Impulsiveness (inability

to focus attention and cognitive instability), Motor

Impulsiveness (tendency to act on the spur of the

moment), and Non-Planning Impulsivity (lack of

sense of the future and forethought). The BIS-11

has good internal consistency, with a total score

Cronbach's alpha typically around 0.83 (Patton,

1995). The validated French version was applied

(Gélinas et al, 2015).

Aggressiveness:

The Buss-Perry Aggression Questionnaire (BPAQ)

is a 29-item self-report measure that assesses four

dimensions of aggression (Buss and Perry, 1992).

Items are rated on a 5-point scale. The subscales

are: Physical Aggression (e.g., "I get into fights a

lot"), Verbal Aggression (e.g., "I often find myself

disagreeing with people"), Anger (e.g., "I have

trouble controlling my temper"), and Hostility (e.g.,

"I am suspicious of overly friendly strangers"). The

BPAQ has demonstrated good reliability and

construct validity, with internal consistency

coefficients for its subscales ranging from 0.72 to

0.85 (Buss and Perry, 1992). In our study, the

validated French version was used (Bouchard,

2007).

It's worth mentioning that all our sample

included in their records at least one event of a

violent act or violation of internal carceral

regulations leading to a disciplinary measure. This

criterion represents an objective support for the

dimension of aggressiveness assessed by the

above mentioned psychometric tool.

Statistical Analysis

Data analysis was performed using SPSS

Statistics version, 26.0. Descriptive statistics

(means, standard deviations) were computed for

all demographic and clinical variables.

Independent samples t-tests were used to

compare the High and Low cumulative adversity

groups on all continuous outcome variables

(DERS, PCL-R, LSRP, BIS-11, and BPAQ total and

subscale scores). Pearson bivariate correlation

was used to assess the correlation between the

quantitative variables as score of all

psychometric measures used in the study.

Convergent validity and scale coherence in our

sample using the correlation of score of each

subscale with the corrected total (sum of other

subscales). Intercorrelation between subscales

were done to assess discriminant validity. The

assumption of homogeneity of variances were

verified using Levene's Test. A p-value of < 0.05

was considered statistically significant for all

analyses.

Ethical considerations

The study was approved by the Institutional

Research Board IRB of Centre Hospitalier

Universitaire CHU de Martinique under 2025/045.

All patients were signing a non-opposition to use

their anonymous data for clinical research at the

French University hospitals when registering on the

medical records system.

Results

Descriptive statistics of the sample

The final sample consisted of (N=47) male

participants with a primary diagnosis of ASPD. The

High Cumulative Adversity group (ACE ≥ 4)

contained (n=25) individuals, and the Low

Cumulative Adversity group (ACE < 4) contained

(n=22) individuals. The sample (N=47) showed a

mean age of 32.4 ± 8.59 (years). Scores on the

diverse psychometric dimensions were as follows:

ACE (3.94 ± 2.25), DERS (92.43 ± 26.41), BIS

(66.66 ± 9.67), PCL (31.72 ± 3.62), LSRP (61.77 ±

11.26) and BPAQ (94.96 ± 15.92) (Table 1).

Inferential statistics and comparative

analysis

Emotion Regulation (DERS), There was no

significant difference in the overall emotion

dysregulation between the two groups (p=0.11).

Among the subscales, only Lack of Emotional

Clarity approached but didn’t reach significance

(p=0.06). As for Psychopathy (PCL-R and LSRP),

The groups did not differ on the total scores of the

clinician-rated PCL-R (p=0.63) or the self-reported

LSRP (p=0.55). A significant but mild difference

was found only on the LSRP Primary Psychopathy

subscale (p=0.03).

Lastly both Impulsivity (BIS-11) and Aggression

(BPAQ), No significant differences were found for

total impulsivity (p=0.19) or its subcomponents.

Similarly, total aggression scores did not differ

(p=0.64), this non-significance extended to its

four sub-dimensions. (Table 2).

Correlation bivariate analysis

Bivariate Pearson correlation analysis revealed

no statistical significant correlation between score

of (ACE) and all psychometric measures of

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psychopathy, emotional regulation, Impulsivity or

Aggressiveness. (Table 3).

Due to the null results in our study, we

assessed some psychometric properties of the

psychometric measures.

Table 1: Descriptive statistics of the sample for the various psychometric measures (N=47)

Psychometric measure

Mean ± SD

IC95%

AGE

32.4 ± 8.59

[29.94 - 34.86]

ACE

3.94 ± 2.25

[3.3 - 4.58]

DERS

92.43 ± 26.41

[84.88 - 99.98]

BIS

66.66 ± 9.67

[63.9 - 69.43]

PCL

31.72 ± 3.62

[30.69 - 32.76]

LSRP

61.77 ± 11.26

[58.55 - 65]

LSRP – Primary psychopathy

37.91 ± 8.06

[35.61 - 40.21]

LSRP – Secondary psychopathy

23.85 ± 5.11

[22.39 - 25.31]

BPAQ

94.96 ± 15.92

[90.41 - 99.51]

ACE : Adverse Chilhood Experiences ; DERS : Difficulty of Emotions Regulation Scale ; BIS : Barrat Impulsivity

Scale ; PCL : Psychopathy Checklist of Hare ; LSRP : Levenson Self-Report Psychpathy Scale ; BPAQ : Buss

Perry Aggression Questionnaire

Intercorrelation between subscales

The subscales intercorrelations supported the

convergent and discriminant validity of the

psychometric measures, with moderate to large

positive correlations within each scale. The

overall pattern of significant positive correlations

within scales, coupled with generally lower or

non-significant cross-scale correlations (where

reported), aligns with the expected structural

validity of each. It’s noteworthy that non-

significant subscales intercorrelation may be

attributed to the small sample size and lower

power to show significance (Table 4).

Correlation between subscales and corrected

total

Corrected total was calculated as total score

minus that subscale's score. For the DERS, the

subscales Clarity, Impulse Control, Goals, and

Strategies show large correlations (0.75 - 0.76)

with the total corrected score, while Non-

Acceptance shows a medium correlation and

Awareness is N.S., suggesting that Awareness

contributes minimally to the overall DERS total. In

the LSRP, both Primary and Secondary

Psychopathy subscales show medium

correlations with the total corrected score. For the

BIS-11, all subscales (Cognitive and Motor

Impulsivity, Difficult Planning) demonstrated

medium to high positive correlations with the total

corrected score, with Motor Impulsivity showing

the strongest link. Similarly, for the BPAQ, Anger

shows a large correlation with the total corrected

score, Physical Aggression and Hostility show

medium correlations, and Verbal Aggression was

N.S.. Overall, the pattern supports the internal

consistency and convergent validity of most

subscales, while identifying specific subscales

(Awareness in DERS, Verbal Aggression in BPAQ)

that are poorly aligned with their respective total

scores. This later finding may be explained by the

small sample size and low power to detect

significance. (Table 5).

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Table 2. Comparison between groups with high cumulative adversity (≥4) (N=25) and those with low cumulative adversity (<4) (N=22)

Patients with score ≥ 4

High cumulative burden (n=25)

Patients with score < 4

low cumulative burden (n=22)

Student t test

P value

Difficulty in Emotions Regulation Scale DERS

Score total

98.2 ± 29.32

85.86 ± 21.46

-1.63

0.11

Awareness

17.88 ± 5.8

16.18 ± 4.44

-1.12

0.27

Clarity

13.08 ± 5.96

10.36 ± 3.02

-1.93

0.06

Non Acceptance

15.4 ± 6.37

13.64 ± 5.01

-1.04

0.3

Impulse control

15.52 ± 6.84

14.72 ± 6.04

-0.42

0.67

Goals

15.84 ± 5.44

13.5 ± 6.81

-1.31

0.2

Strategies

21.16 ± 8.02

18.04 ± 6.22

-1.48

0.15

Psychopathy Check List of Hare PCL

Score total

31.48 ± 4.19

32 ± 2.91

0.49

0.63

Levenson Self Report Psychopathy LSRP

Score total

60.84 ± 12.77

62.82 ± 9.44

0.6

0.55

Primary psychopathy

36.72 ± 8.89

39.27 ± 6.96

1.08

Secondary psychopathy

24.12 ± 5.59

23.55 ± 4.63

-038

0.71

BARRAT Impulsivity Scale BIS-11

Score total

68.4 ± 10.54

64.68 ± 8.39

-1.33

0.19

Cognitive impulsivity

18.8 ± 3.99

17.32 ± 2.83

-1.45

0.15

Motor Impulsivity

23.64 ± 4.17

22.09 ± 4.06

-1.29

0.2

Difficult planification

25.96 ± 5.11

25.27 ± 4.3

-0.5

0.62

Buss Perry Aggression questionnaire BPAQ

Score total

93.92 ± 16.5

96.14 ± 15.54

0.47

0.64

Physical agressivity

30.36 ± 6.34

33.6 ± 6.79

1.69

0.1

Verbal agressivity

18.52 ± 3.78

17.59 ± 4.34

-0.79

0.44

Anger

21.08 ± 6.93

21.09 ± 4.83

0.01

0.1

Hostility

24.08 ± 6.32

23.86 ±6.21

-0.12

0.9

*p<0.05 ; DERS : Difficulty of Emtions Regulation Scale ; PCL : Psychopathy check list ; LSRP levenson Self Report Psychopathy scale ; BIS : Barrat Impulsivity Scale ; BPAQ : Buss

Perry Agression Questionnaire

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Table 3. Correlation between score on Adverse Childhood Experiences (ACE) and other psychological constructs (N=47)

ACE DERS BIS PCL LSRP BPAQ

ACE

DERS

0.26

BIS

0.32

0.37**

PCL

-0.01

0.03

0.37*

LSRP

0.02

0.54***

0.29

0.12

BPAQ

0.01

0.67***

0.43*

0.14

0.63***

*p<0.05 ; **p<0.01 ; ***p<0.001 ; ACE : Adverse Chilhood Experiences ; DERS : Difficulty of Emotions Regulation Scale ; BIS : Barrat Impulsivity Scale ; PCL :

Psychopathy Checklist of Hare ; LSRP : Levenson Self-Report Psychpathy Scale ; BPAQ : Buss Perry Aggression Questionnaire

Table 4. S

ubscales Intercorrelations for the psychometric measures in the study

Difficulty in Emotions Regulation Scale (DERS)

Awareness

Clarity

Non-Acceptance

Impulse control

Goals

Strategies

Awareness

Clarity

0.33*

Non-Acceptance

-0.05

0.46*

Impulse Control

0.27

0.61*

0.26

Goals

0.2

0.58*

0.51*

0.69*

Strategies

0.19

0.67*

0.43*

0.77*

0.67*

Levenson Self-Report Psychopathy Scale (LSRP)

Primary Psychop

Secondary Psychop

Primary Psychop

0.43*

Secondary Psychop

0.43*

Barrat Impulsivity Scale (BIS-11)

Cognitive impulsivity

Motor impulsivity

Difficult planning

Cognitive impulsivity

Motor impulsivity

0.35*

Difficult planning

0.31*

0.53*

Buss Perry Aggression Questionnaire (BPAQ)

Physical Verbal Anger Hostility

Physical

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Verbal

Anger

0.53*

0.23

Hostility

0.26

0.08

0.39*

*p<0.05

Table 5. Correlation between subscales and corrected total score for the psychometric measures used in the study

Difficulty in Emotions Regulation Scale (DERS)

Subscale

Corrected total

IC95%

Interpretation

(per Cohen)

Awareness

0.17

[-0.12, 0.44]

N.S

Clarity 0.76*** [0.6, 0.86] large

Non-Acceptance

0.41**

[0.14, 0.62]

medium

Impulse control

0.75***

[0.59, 0.85]

large

Goals

0.75***

[0.59, 0.85]

large

Strategies

0.76***

[0.6, 0.86]

large

Levenson Self-Report Psychopathy Scale (LSRP)

Primary Psychopathy

0.43**

[0.16, 0.64]

medium

Secondary Psychopathy

0.43**

[0.16, 0.64]

medium

Barrat Impulsivity Scale (BIS-11)

Cognitive Impulsivity

0.38**

[0.1, 0.6]

medium

Motor Impulsivity

0.56***

[0.33, 0.73]

medium

Difficult Planning

0.52***

[0.27, 0.7]

medium

Buss Perry Aggression Questionnaire (BPAQ)

Physical Aggression

0.47***

[0.21, 0.67]

medium

Verbal Aggression

0.22

[-0.072, 0.48]

N.S.

Anger

0.59***

[0.36, 0.75]

large

Hostility

0.35**

[0.07, 0.58]

medium

*p<0.05;**<0.01;***p<0.001; Corrected total = The sum of other subscales (calculated as Total score – Subscale score); The interpretation per Cohen for the subscales of

“Motor Impulsivity” and “Difficult Planning”, are both large instead of medium, because both have value > 0.5.

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Discussion

We hypothesized that if cumulative adversity

exerts a direct, dose-dependent influence, on

the maladaptive functioning within ASPD, the high

load group will demonstrate significantly greater

impairment across all measured psychologic

dimensions. Strikingly, the general lack of

significant differences does not support a simple

dose-dependent model within this severely

affected sample. This could suggest either lack of

quantitative association, where high adversity

burden generates more severe unhealthy

psychological measures, or this association may

still exerting an important effect to etiologically

induce the psychopathology in a rather present /

absence model, where the development of the

disorder itself is, hypothetically the potential

critical threshold. In this later hypothesized model,

additional trauma does not necessarily worsen its

specific phenotypic expression. This finding invites

consideration of profound implications on the

way we conceptualize and treat ASPD in forensic

settings. The dissociation between cumulative

adversity and ASPD phenotype challenges a

straightforward dose-dependent model of

trauma in established ASPD.

The development of ASPD may represent a

final common pathway or a diagnostic threshold

that, once reached, exhibits a ceiling effect on

certain psychological measures (Glenn et al,

2013). Our sample, by design, consisted of

individuals who had already developed severe

and prisoned antisocial behavior. Within this

group, the additional dose of childhood adversity

may not manifest proportionally with more severe

deficits on the assessed psychologic dimensions.

The psychological machinery of ASPD, the

impulsivity, the emotional deficits, the

aggressiveness sound to operate at a consistently

high pathological level, forming, a more or less,

stable personality structure that is somehow

dissociated from the quantitative load of its past

adversities (DeLisi et al, 2019). This aligns with

personality disorder theory, which posits that once

maladaptive patterns are generated, they

become self-perpetuating, driven more by

internal personality dynamics than by their original

triggers in a vicious circle model (Smits et al,

2024). Though this theory of final common

pathway is a hypothetical possibility, but our

cross-sectional design is yet limited with regards

the ability to present this theory as established

conclusion.

The significant finding of higher self-reported

primary psychopathy in the low adversity group

provides an interesting finding, subject to debate.

This supports longstanding theories of a primary

variant of psychopathy with a stronger biological

and temperamental basis, as low fearfulness and

blunted affect, which may be less dependent on

severe environmental trauma for its expression, so

in simple terms, not a particularly trauma-sensitive

subtype (Jansen, 2022; Viding and McCrory,

2019). In this model, the core poverty of empathy

traits is a pre-existing vulnerability.

Conversely, the individuals in the high trauma

group may have developed their antisocial

pathology more directly through the internalizing

pathways of emotional confusion and

dysregulation as suggested by the tendency in

the DERS Clarity subscale, even if the final

behavioral outcome ASPD and incarceration is

phenotypically similar they may still be

etiologically heterogeneous (Kimonis et al, 2012).

The assessment tools themselves may be

limited in capturing the specific sequelae of

trauma in this population. The DERS, for instance,

measures conscious awareness and strategies for

managing emotion. In high-trauma ASPD, the

defensive structure may involve profound

emotional numbing, dissociation, or alexithymia

that these scales do not fully catch (Hemming et

al, 2021; Bach et al, 2022). What shows in results

as a lack of clarity, the only significantly

associated subscale, could be the reflecting a

disconnection from internal states, a survival

pathological coping strategy that becomes a

personality trait (Wolf, 2025).

Modern neurobiological models offer a

framework for understanding this dissociation.

Early life adversity can lead to hyper-reactivity of

the amygdala and hypoactivity of the prefrontal

cortex, creating a brain predisposed to threat

hypersensitivity and poor behavioral inhibition

(Teicher and Samson, 2016; Herzog et al, 2020).

However, in some individuals, particularly those

who develop the primary psychopathic variant,

the stress response system may be characterized

by hypo-reactivity, leading to a lack of anxiety

and fearlessness in the face of punishment (Blair,

2013). This biological dichotomy could underpin

the different pathways to ASPD, explaining why

trauma load does not have systematically the

same effect. Furthermore, epigenetic

mechanisms, where trauma modifies the level of

gene expression without changing the DNA

sequence, can create long lasting modulation in

stress regulation and social behavior. It is possible

that the mere presence of a certain level of

trauma triggers these epigenetic changes, and

the resulting phenotype then follows its own

developmental course, again in a sort of

automated pilot mode (Moreira et al, 2022).

Implications for Forensic Mental Health

The clinical implications of these findings are

substantial. The current paradigm in many

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ISSN 2612-2138

carceral settings heavily relies on CBT-based

programs that target cognitive distortions,

problem-solving skills, and future-oriented

behavioral control (Thekkumkara et al, 2022;

Valizadeh et al, 2020). While these programs

have value in managing surface-level behaviors,

our results indicate that they are fundamentally

incomplete because they systematically fail to

address the foundational role of childhood

trauma. If cumulative adversity does not directly

correlate with current symptom severity, it is a

fallacy to believe that treating the symptoms

alone will resolve the underlying trauma.

Conversely, ignoring the past adversities may

mean missing the core etiological wound around

which the personality disorder is structured

(Levenson et al, 2020).

We therefore suggest a paradigm shift in

therapeutic strategy. The high prevalence of CEs

in this population is not a historical footnote; it is a

central clinical reality that could benefit from

direct and specific intervention (Gaber et al,

2025). Forensic mental health services could

consider embracing trauma-informed care (TIC)

principles, which recognize the pervasive impact

of trauma and create environments of safety and

empowerment. Beyond this philosophical shift,

specific therapeutic modalities could be

explored (Seitanidou et al, 2024).

Explorative Modalities like Schema Therapy,

developed for personality disorders, are ideally

suited to address the early maladaptive

schemas, as mistrust/abuse, emotional

deprivation and defectiveness, that originate in

adverse childhoods (Pilkington et al, 2021). These

therapies directly target the emotional and

relational patterns formed in response to trauma,

aiming to heal them at their root. Evidence-

based treatments for trauma, such as Eye

Movement Desensitization and Reprocessing

(EMDR) (Shapiro, 2014) and Narrative Exposure

Therapy (NET) (Elbert et al, 2022), adapted for

complex trauma and forensic populations,

warrant empirical investigation in this population.

These therapies may help the individual process

and integrate fragmented and distressing

traumatic memories, reducing their power to

drive maladaptive behaviors in the present. It’s

noteworthy that our therapeutic suggestions are

based on the high prevalence of childhood

adversity among individuals with ASPD, but were

not assessed in the present study.

Approaches like Dialectical Behavior Therapy

(DBT) (Rostamzadeh et al, 2024) and Acceptance

and Commitment Therapy (ACT) (Byrne and

Cullen, 2024), while focused on the present time,

incorporate mindfulness and distress tolerance

skills that are crucial for managing the emotional

dysregulation that can emerge when trauma is

processed. They may serve as a vital preparatory

and concurrent treatment to explorative work.

Implementing such a model in a prison setting is

challenging, requiring trained staff, institutional

buy-in, and a long-term perspective. However,

the potential payoff is a more profound and

sustainable change, moving beyond mere

recidivism reduction to genuine psychological

rehabilitation (Coleman et al, 2024).

Limitations and Future Directions

This study has several limitations. Its

retrospective and cross-sectional nature prevents

any causal inference. The sample was all-male

and from a single prison in a specific cultural

context (French Caribbean), which may limit

generalizability. While we excluded major

comorbidities, we did not control for other factors

like substance use disorders or depression, which

could influence the results. The reliance on a

specific cut-off score for the ACE, while standard,

may have obscured more nuanced relationships.

Additionally, the study's moderate sample size

(N=47) may have limited statistical power to

detect small to medium effect sizes. The reliance

on retrospective data and standardized

assessments, while necessary, may not capture

the full complexity of trauma sequelae or the

most severe variants of ASPD, as our sample

included only inmates who consulted psychiatric

services and had complete psychometric data.

The high mean of psychopathy scale and the

welling to pass an extensive battery of

psychometric scales add a selection bias to the

profile of patients included in the analysis. The

retrospective research model limits control over

assessment timing and rater consistency. Future

research should employ longitudinal designs,

larger and more diverse samples (including

females), and more nuanced measures of

trauma (e.g., type, timing, perceived impact).

Incorporating neurobiological markers (e.g.,

cortisol levels, fMRI) could also help elucidate the

different pathways linking trauma to ASPD. Most

importantly, empirical trials are needed to directly

test the efficacy of trauma-focused interventions

(e.g., Schema Therapy, EMDR, NET) specifically in

populations with ASPDs.

Conclusion

In conclusion, within a homogeneous group of

incarcerated men with ASPD, a higher load of

childhood trauma was not associated with more

severe deficits in emotion regulation, impulsivity,

or aggression. This dissociation highlights that the

psychological presentation of ASPD is not a

simple reflection of cumulative adversity but

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ISSN 2612-2138

rather a complex, potentially multi-determined

endpoint. The single finding of elevated primary

psychopathy in the low trauma group

underscores the existence of distinct etiological

pathways. The results serve as a powerful

reminder that to effectively rehabilitate individuals

with ASPD, correctional mental health services

must look beyond present behaviors and directly

address the ghosts of a traumatic past. This invites

consideration of a fundamental shift from purely

cognitive-behavioral management to an

integrated, trauma-informed model that

incorporates explorative, schema-focused, and

trauma-processing therapies. Only by confronting

the foundational wounds of the past can we

hope to foster genuine and lasting change in this

challenging population.

Funding statement

The authors declare that this research did not

receive any specific grant from funding agencies

in the public, commercial, or not-for-profit

sectors. The publication fee was covered by the

authors.

Conflict of interest

The authors have no relevant financial or

nonfinancial conflict of interests to disclose.

Acknowledgment

To administrative, nursing and other

paramedical staff of the Service Médico-

Psychologique Régional SMPR, UF2101, Centre

Pénitentiaire de Ducos.

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