<s> [INST] <<SYS>> You are a responsible assistant committed to providing accurate and helpful responses. Avoid sharing harmful or biased content. Clarify any unclear or incorrect questions rather than providing false or misleading information. <</SYS>> What is Antisocial personality disorder and can you explain it in depth? [/INST] Antisocial personality disorder (ASPD or infrequently APD) is a personality disorder characterized by a long-term pattern of disregard of, or violation of, the rights of others as well as a difficulty sustaining long-term relationships. Lack of empathy is often apparent, as well as a history of rule-breaking that can sometimes include law-breaking, a tendency towards substance abuse, and impulsive and aggressive behavior. Antisocial behaviors often have their onset before the age of 8, and in nearly 80% of ASPD cases, the subject will develop their first symptoms by age 11. The prevalence of ASPD peaks in people age 24 to 44 years old, and often decreases in people age 45 to 64 years. In the United States, the rate of antisocial personality disorder in the general population is estimated between 0.5 and 3.5 percent. In a study, a random sampling of 320 newly incarcerated offenders found ASPD was present in over 35 percent of those surveyed.Antisocial personality disorder is defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM), while the equivalent concept of dissocial personality disorder (DPD) is defined in the International Statistical Classification of Diseases and Related Health Problems (ICD); the primary theoretical distinction between the two is that antisocial personality disorder focuses on observable behaviours, while dissocial personality disorder focuses on affective deficits. Otherwise, both manuals provide similar criteria for diagnosing the disorder. Both have also stated that their diagnoses have been referred to, or include what is referred to, as psychopathy or sociopathy. However, some researchers have drawn distinctions between the concepts of antisocial personality disorder and psychopathy, with many researchers arguing that psychopathy is a disorder that overlaps with but is distinguishable from ASPD.

Symptoms and behaviors
Addiction
ASPD is one of the personality disorders most likely to be associated with addiction. This is due to their tendency towards impulsive and reckless decision making, which puts them at risk of developing a substance abuse disorder, prepulse inhibition deficiency, misuse of oral administrations, drug overdoses, blood-borne diseases, shorter periods of abstinence, drug use at earlier ages, aggressive behavior, impulsivity, frequent illegal drug use, drug injections, and difficult interpersonal relationships. Substance abuse problems are far more common amongst people with ASPD who live in rural environments rather than urban ones. There are also gender differences between men and women in regard to substance abuse. Men who abuse substances are far more likely to have ASPD than women, who are more likely to have a mood disorder. The relationship between substance abuse and ASPD can be affected by other personality disorders. For example, one of the previously mentioned studies found that 27.6% of participants who had ASPD and alcohol abuse had more than one personality disorder. Heroin, methamphetamine, opiates, alcohol, nicotine, cannabis, polydrugs, cocaine, and crack cocaine are some prevalent drugs amongst people with ASPD. Alongside substance abuse, patients with ASPD are more likely to develop a gambling addiction.

Impulsivity
Antisocial personality disorder has been associated with higher levels of impulsivity, suicidality,  and irresponsible behavior. Usually resulting in heightened levels of aggressive behavior, domestic violence, illegal drug use, pervasive anger, and violent crimes.  This behavior usually has negative effects on their education, relationships, or job.  Alongside this, risky sexual behavior such as having multiple sexual partners, seeing prostitutes, inconsistently using condoms, trading sex for drugs, and frequent anal sex is also common. Their impulsive behavior will usually jeopardize their own safety and the safety of others.

Emotions
The violent and impulsive behavior present in ASPD has been correlated with chronic boredom. Other studies have found that people with ASPD tend to describe emotions with ambivalence, and experience emotions such as happiness and fear less clearly than others. They may also experience negative emotions such as anger and frustration more frequently and clearly than other emotions. People with ASPD can have difficulty mentalizing, or understanding the mental state of others. They also may display a perfectly intact theory of mind, or the ability to attribute a mental state to oneself and others, but an impaired ability to understand how another individual may be affected by an aggressive action. These factors possibly contribute to their aggressive and criminal behavior as well as their empathy deficits. Despite this they may be adept at social cognition, or the ability to process and store information about other people, which can contribute to an increased ability to manipulate others.

Criminality
People with ASPD tend to experience more convictions, spend more time in jail, and are more likely to be charged with almost any crime. However, assault and other violent crimes are the most common charges. This disorder is also prominent among prisoner populations. Alongside other conduct problems, many people with ASPD had conduct disorder in youth, a disorder characterized by a pervasive pattern of violent, criminal, defiant, and anti-social behavior. Fire-setting and the destruction of others property is also a behavior commonly associated with ASPD and impulsivity. Fire starters with ASPD tend to have a history of robbery, harassment, threatening, blackmail, and difficulty fulfilling promises.

Limited Empathy or Remorse
People with ASPD may experience a limited capacity for empathy and can be more interested in benefiting themselves regardless of the expense it has on others. They may have no regard for morals, social norms, and the rights and feelings of others. People with Antisocial personality disorder may have difficulties in sustaining and maintaining relationships, and some have difficulty entering them. Interpersonal relationships often revolve around the exploitation and abuse of others. People with ASPD may display arrogance, think lowly and negatively of others, and have limited remorse for their harmful actions and have a callous attitude towards those they have harmed. Although behaviors vary in degree, individuals with this personality disorder will typically have limited compunction in exploiting others in harmful ways for their own gain or pleasure, and frequently manipulate and deceive other people. While some do so through a façade of superficial charm, others do so through intimidation and violence. It is possible that people with ASPD may have intact cognitive empathy, but with a deficient theory of mind. Studies have found that people with ASPD have difficulty understanding others emotions and mental states. It also may be possible that people with ASPD do not lack empathy but are less inclined to use it.

Comorbidity
ASPD commonly coexists with the following conditions:

When combined with alcoholism, people may show frontal function deficits on neuropsychological tests greater than those associated with each condition. Alcohol use disorder is likely caused by lack of impulse and behavioral control exhibited by antisocial personality disorder patients. The rates of ASPD tends to register around 40–50% in male alcohol and opiate addicts. However, it is important to remember this is not a causal relationship, but rather a plausible consequence of cognitive deficits as a result of ASPD.

Causes
Personality disorders are seen to be caused by a combination and interaction of genetic and environmental influences. Genetically, it is the intrinsic temperamental tendencies as determined by their genetically influenced physiology, and environmentally, it is the social and cultural experiences of a person in childhood and adolescence encompassing their family dynamics, peer influences, and social values. People with an antisocial or alcoholic parent are considered to be at higher risk. Fire-setting, and cruelty to animals during childhood are also linked to the development of antisocial personality. The condition is more common in males than in females, and among incarcerated populations.

Genetic
Research into genetic associations in antisocial personality disorder suggests that ASPD has some or even a strong genetic basis. Prevalence of ASPD is higher in people related to someone with the disorder. Twin studies, which are designed to discern between genetic and environmental effects, have reported significant genetic influences on antisocial behavior and conduct disorder.In the specific genes that may be involved, one gene that has seen particular interest in its correlation with antisocial behavior is the gene that encodes for monoamine oxidase A (MAO-A), an enzyme that breaks down monoamine neurotransmitters such as serotonin and norepinephrine. Various studies examining the genes relationship to behavior have suggested that variants of the gene that results in less MAO-A being produced, such as the 2R and 3R alleles of the promoter region, have associations with aggressive behavior in men. The association is also influenced by negative experience in early life, with children possessing a low-activity variant (MAOA-L) who experience such maltreatment being more likely to develop antisocial behavior than those with the high-activity variant (MAOA-H). Even when environmental interactions (e.g. emotional abuse) are controlled for, a small association between MAOA-L and aggressive and antisocial behavior remains.The gene that encodes for the serotonin transporter (SCL6A4), a gene that is heavily researched for its associations with other mental disorders, is another gene of interest in antisocial behavior and personality traits. Genetic associations studies have suggested that the short "S" allele is associated with impulsive antisocial behavior and ASPD in the inmate population. However, research into psychopathy find that the long "L" allele is associated with the Factor 1 traits of psychopathy, which describes its core affective (e.g. lack of empathy, fearlessness) and interpersonal (e.g. grandiosity, manipulativeness) personality disturbances. This is suggestive of two different forms, one associated more with impulsive behavior and emotional dysregulation, and the other with predatory aggression and affective disturbance, of the disorder.Various other gene candidates for ASPD have been identified by a genome-wide association study published in 2016. Several of these gene candidates are shared with attention-deficit hyperactivity disorder, with which ASPD is comorbid. Furthermore, the study found that those who carry four mutations on chromosome 6 are 50 percent more likely to develop antisocial personality disorder than those who do not.

Physiological
Hormones and neurotransmitters
Traumatic events can lead to a disruption of the standard development of the central nervous system, which can generate a release of hormones that can change normal patterns of development.
Aggressiveness and impulsivity are among the possible symptoms of ASPD. Testosterone is a hormone that plays an important role in aggressiveness in the brain.  For instance, criminals who have committed violent crimes tend to have higher levels of testosterone than the average person.  The effect of testosterone is counteracted by cortisol which facilitates the cognitive control of impulsive tendencies.One of the neurotransmitters that has been discussed in individuals with ASPD is serotonin, also known as 5HT. A meta-analysis of 20 studies found significantly lower 5-HIAA levels (indicating lower serotonin levels), especially in those who are younger than 30 years of age.While it has been shown that lower levels of serotonin may be associated with ASPD, there has also been evidence that decreased serotonin function is highly correlated with impulsiveness and aggression across a number of different experimental paradigms. Impulsivity is not only linked with irregularities in 5HT metabolism, but may be the most essential psychopathological aspect linked with such dysfunction. Correspondingly, the DSM classifies "impulsivity or failure to plan ahead" and "irritability and aggressiveness" as two of seven sub-criteria in category A of the diagnostic criteria of ASPD.Some studies have found a relationship between monoamine oxidase A and antisocial behavior, including conduct disorder and symptoms of adult ASPD, in maltreated children.

Neurological
Antisocial behavior may be related to head trauma. Antisocial behavior is associated with decreased grey matter in the right lentiform nucleus, left insula, and frontopolar cortex.  Increased volumes have been observed in the right fusiform gyrus, inferior parietal cortex, right cingulate gyrus, and post central cortex.Intellectual and cognitive ability is often found to be impaired or reduced in the ASPD population. Contrary to stereotypes in popular culture of the "psychopathic genius", antisocial personality disorder is associated with both reduced overall intelligence and specific reductions in individual aspects of cognitive ability. These deficits also occur in general-population samples of people with antisocial traits and in children with the precursors to antisocial personality disorder.People that exhibit antisocial behavior tend to demonstrate decreased activity in the prefrontal cortex.  The association is more apparent in functional neuroimaging as opposed to structural neuroimaging. The prefrontal cortex is involved in many executive functions, including behavior inhibitions, planning ahead, determining consequences of action, and differentiating between right and wrong. However, some investigators have questioned whether the reduced volume in prefrontal regions is associated with antisocial personality disorder, or whether they result from co-morbid disorders, such as substance use disorder or childhood maltreatment. Moreover, it remains an open question whether the relationship is causal, i.e., whether the anatomical abnormality causes the psychological and behavioral abnormality, or vice versa.Cavum septi pellucidi (CSP) is a marker for limbic neural maldevelopment, and its presence has been loosely associated with certain mental disorders, such as schizophrenia and post-traumatic stress disorder. One study found that those with CSP had significantly higher levels of antisocial personality, psychopathy, arrests and convictions compared with controls.

Environmental
Family environment
Many studies suggest that the social and home environment has contributed to the development of antisocial behavior. The parents of these children have been shown to display antisocial behavior, which could be adopted by their children. A lack of parental stimulation and affection during early development leads to high levels of cortisol with the absence of balancing hormones such as oxytocin which disrupts and overloads the childs stress response systems, which is thought to lead to underdevelopment of the childs brain that deals with emotion, empathy and ability to connect to other humans on an emotional level. According to Dr. Bruce Perry in his book The Boy Who Was Raised as a Dog, "the [infants developing] brain needs patterned, repetitive stimuli to develop properly. Spastic, unpredictable relief from fear, loneliness, discomfort, and hunger keeps a babys stress system on high alert. An environment of intermittent care punctuated by total abandonment may be the worst of all worlds for a child."

Cultural influences
The sociocultural perspective of clinical psychology views disorders as influenced by cultural aspects; since cultural norms differ significantly, mental disorders such as ASPD are viewed differently. Robert D. Hare has suggested that the rise in ASPD that has been reported in the United States may be linked to changes in cultural mores, the latter serving to validate the behavioral tendencies of many individuals with ASPD.: 136  While the rise reported may be in part merely a byproduct of the widening use (and abuse) of diagnostic techniques, given Eric Bernes division between individuals with active and latent ASPD – the latter keeping themselves in check by attachment to an external source of control like the law, traditional standards, or religion – it has been suggested that the erosion of collective standards may indeed serve to release the individual with latent ASPD from their previously prosocial behavior.: 136–7 There is also a continuous debate as to the extent to which the legal system should be involved in the identification and admittance of patients with preliminary symptoms of ASPD. Controversial clinical psychiatrist Pierre-Édouard Carbonneau suggested that the problem with legal forced admittance is the rate of failure when diagnosing ASPD. He contends that the possibility of diagnosing and coercing a patient into prescribing medication to someone without ASPD, but is diagnosed with ASPD, could be potentially disastrous. But the possibility of not diagnosing ASPD and seeing a patient go untreated because of a lack of sufficient evidence of cultural or environmental influences is something a psychiatrist must ignore; and in his words, "play it safe".

Conduct disorder
While antisocial personality disorder is a mental disorder diagnosed in adulthood, it has its precedent in childhood. The DSM-5s criteria for ASPD require that the individual have conduct problems evident by the age of 15. Persistent antisocial behavior, as well as a lack of regard for others in childhood and adolescence, is known as conduct disorder and is the precursor of ASPD. About 25–40% of youths with conduct disorder will be diagnosed with ASPD in adulthood.Conduct disorder (CD) is a disorder diagnosed in childhood that parallels the characteristics found in ASPD and is characterized by a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate norms are violated. Children with the disorder often display impulsive and aggressive behavior, may be callous and deceitful, and may repeatedly engage in petty crime such as stealing or vandalism or get into fights with other children and adults. This behavior is typically persistent and may be difficult to deter with threat or punishment. Attention deficit hyperactivity disorder (ADHD) is common in this population, and children with the disorder may also engage in substance use. CD is differentiated from oppositional defiant disorder (ODD) in that children with ODD do not commit aggressive or antisocial acts against other people, animals, and property, though many children diagnosed with ODD are subsequently re-diagnosed with CD.Two developmental courses for CD have been identified based on the age at which the symptoms become present. The first is known as the "childhood-onset type" and occurs when conduct disorder symptoms are present before the age of 10 years. This course is often linked to a more persistent life course and more pervasive behaviors, and children in this group express greater levels of ADHD symptoms, neuropsychological deficits, more academic problems, increased family dysfunction, and higher likelihood of aggression and violence. The second is known as the "adolescent-onset type" and occurs when conduct disorder develops after the age of 10 years. Compared to the childhood-onset type, less impairment in various cognitive and emotional functions are present, and the adolescent-onset variety may remit by adulthood. In addition to this differentiation, the DSM-5 provides a specifier for a callous and unemotional interpersonal style, which reflects characteristics seen in psychopathy and are believed to be a childhood precursor to this disorder. Compared to the adolescent-onset subtype, the childhood-onset subtype, especially if callous and unemotional traits are present, tends to have a worse treatment outcome.

Diagnosis
DSM-5
Section II
The main text of fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) defines antisocial personality disorder as being characterized by at least three of the following traits:

Failure to conform to social norms and laws, indicated by repeatedly engaging in illegal activities.
Deceitfulness, indicated by continuously lying, using aliases, or conning others for personal gain and pleasure.
Exhibiting impulsivity or failing to plan ahead.
Irritability and aggressiveness, indicated by repeatedly getting into fights or physically assaulting others.
Reckless behaviors that disregard the safety of others.
Irresponsibility, indicated by repeatedly failing to consistently work or honor financial obligations.
Lack of remorse after hurting or mistreating another person.In order to be diagnosed with antisocial personality disorder under the DSM-5, one must be at least 18 years old, show evidence of onset of conduct disorder before age 15, and antisocial behavior cannot be explained by schizophrenia or bipolar disorder.

Section III (Alternative Model of Personality Disorders)
In response to criticisms of the extant (Section II/DSM-IV) criteria for personality disorders, including their discordance with current models in the scientific literature, high comorbidity rate, overuse of some categories and underuse of others, and overwhelming use of the personality disorder-not otherwise specified (PD-NOS) diagnosis, the DSM-5 Workgroup on personality disorders devised a dimensional model, wherein categoric personality diagnoses reflect extreme variations of normal personality traits.
In response to criticisms of the extant Section II/DSM-IV criteria for ASPD, namely its failure to capture the interpersonal and affective features of psychopathy, new criteria were proposed.In addition to the new criteria, the individual must be at least 18 years old, the traits must cause dysfunction or distress, and should not be better explained by another mental disorder, the pathophysiological effects of a substance, or a persons cultural or social background. Also included as a "with psychopathic traits" specifier modelled after the Fearless Dominance scale of the Psychopathic Personality Inventory, defined by low Anxiousness and Withdrawal and high Attention-Seeking. Researchers have also proposed the inclusion of Grandiosity and Restricted Affectivity to better capture psychopathy.

Psychopathy
Psychopathy is commonly defined as a personality disorder characterized partly by antisocial behavior, a diminished capacity for empathy and remorse, and poor behavioral controls. Psychopathic traits are assessed using various measurement tools, including Canadian researcher Robert D. Hares Psychopathy Checklist, Revised (PCL-R). "Psychopathy" is not the official title of any diagnosis in the DSM or ICD; nor is it an official title used by other major psychiatric organizations. The DSM and ICD, however, state that their antisocial diagnoses are at times referred to (or include what is referred to) as psychopathy or sociopathy.American psychiatrist Hervey Cleckleys work on psychopathy formed the basis of the diagnostic criteria for ASPD, and the DSM states ASPD is often referred to as psychopathy. However, critics argue ASPD is not synonymous with psychopathy as the diagnostic criteria are not the same, since criteria relating to personality traits are emphasized relatively less in the former. These differences exist in part because it was believed such traits were difficult to measure reliably and it was "easier to agree on the behaviors that typify a disorder than on the reasons why they occur".Although the diagnosis of ASPD covers two to three times as many prisoners than the diagnosis of psychopathy, Robert Hare believes the PCL-R is better able to predict future criminality, violence, and recidivism than a diagnosis of ASPD. He suggests there are differences between PCL-R-diagnosed psychopaths and non-psychopaths on "processing and use of linguistic and emotional information", while such differences are potentially smaller between those diagnosed with ASPD and without. Additionally, Hare argued confusion regarding how to diagnose ASPD, confusion regarding the difference between ASPD and psychopathy, as well as the differing future prognoses regarding recidivism and treatability, may have serious consequences in settings such as court cases where psychopathy is often seen as aggravating the crime.Nonetheless, psychopathy has been proposed as a specifier under an alternative model for ASPD. In the DSM-5, under "Alternative DSM-5 Model for Personality Disorders", ASPD with psychopathic features is described as characterized by "a lack of anxiety or fear and by a bold interpersonal style that may mask maladaptive behaviors (e.g., fraudulence)". Low levels of withdrawal and high levels of attention-seeking combined with low anxiety are associated with "social potency" and "stress immunity" in psychopathy.: 765  Under the specifier, affective and interpersonal characteristics are comparatively emphasized over behavioral components. Research suggests that, even without the "with psychopathic traits" specifier, these Section III criteria accurately capture the affective-interpersonal features of psychopathy, though the specifier increases coverage of the Interpersonal and Lifestyle facets of the PCL-R.

Millons Subtypes
Theodore Millon suggested 5 subtypes of ASPD. However, these constructs are not recognized in the DSM and ICD.

Elsewhere, Millon differentiates ten subtypes (partially overlapping with the above) – covetous, risk-taking, malevolent, tyrannical, malignant, disingenuous, explosive, and abrasive – but specifically stresses that "the number 10 is by no means
special ... Taxonomies may be put forward at levels that are more coarse or more fine-grained.": 223

Treatment
ASPD is considered to be among the most difficult personality disorders to treat. Rendering an effective treatment for ASPD is further complicated due to the inability to look at comparative studies between psychopathy and ASPD due to differing diagnostic criteria, differences in defining and measuring outcomes and a focus on treating incarcerated patients rather than those in the community. Because of their very low or absent capacity for remorse, individuals with ASPD often lack sufficient motivation and fail to see the costs associated with antisocial acts. They may only simulate remorse rather than truly commit to change: they can be seductively charming and dishonest, and may manipulate staff and fellow patients during treatment. Studies have shown that outpatient therapy is not likely to be successful, but the extent to which persons with ASPD are entirely unresponsive to treatment may have been exaggerated.Most treatment done is for those in the criminal justice system to whom the treatment regimes are given as part of their imprisonment. Those with ASPD may stay in treatment only as required by an external source, such as parole conditions. Residential programs that provide a carefully controlled environment of structure and supervision along with peer confrontation have been recommended. There has been some research on the treatment of ASPD that indicated positive results for therapeutic interventions.
Psychotherapy, also known as "talk" therapy, has been found to help treat patients with ASPD. Schema therapy is also being investigated as a treatment for ASPD. A review by Charles M. Borduin features the strong influence of multisystemic therapy (MST) that could potentially improve this issue. However, this treatment requires complete cooperation and participation of all family members. Some studies have found that the presence of ASPD does not significantly interfere with treatment for other disorders, such as substance use, although others have reported contradictory findings.Therapists working with individuals with ASPD may have considerable negative feelings toward patients with extensive histories of aggressive, exploitative, and abusive behaviors. Rather than attempt to develop a sense of conscience in these individuals, which is extremely difficult considering the nature of the disorder, therapeutic techniques are focused on rational and utilitarian arguments against repeating past mistakes. These approaches would focus on the tangible, material value of prosocial behavior and abstaining from antisocial behavior. However, the impulsive and aggressive nature of those with this disorder may limit the effectiveness of this form of therapy.The use of medications in treating antisocial personality disorder is still poorly explored, and no medications have been approved by the FDA to specifically treat ASPD. A 2020 Cochrane review of studies that explored the use of pharmaceuticals in ASPD patients, of which eight studies met the selection criteria for review, concluded that the current body of evidence was inconclusive for recommendations concerning the use of pharmaceuticals in treating the various issues of ASPD. Nonetheless, psychiatric medications such as antipsychotics, antidepressants, and mood stabilizers can be used to control symptoms such as aggression and impulsivity, as well as treat disorders that may co-occur with ASPD for which medications are indicated.

Prognosis
According to professor Emily Simonoff of the Institute of Psychiatry, Psychology and Neuroscience, there are many variables that are consistently connected to ASPD, such as: childhood hyperactivity and conduct disorder, criminality in adulthood, lower IQ scores and reading problems. The strongest relationship between these variables and ASPD are childhood hyperactivity and conduct disorder. Additionally, children who grow up with a predisposition of ASPD and interact with other delinquent children are likely to later be diagnosed with ASPD. Like many disorders, genetics play a role in this disorder but the environment holds an undeniable role in its development.
Boys are almost twice as likely to meet all of the diagnostic criteria for ASPD than girls (40% versus 25%) and they will often start showing symptoms of the disorder much earlier in life. Children that do not show symptoms of the disease through age 15 will almost never develop ASPD later in life. If adults exhibit milder symptoms of ASPD, it is likely that they never met the criteria for the disorder in their childhood and were consequently never diagnosed. Overall, symptoms of ASPD tend to peak in late teens and early twenties, but can often reduce or improve through age 40.ASPD is ultimately a lifelong disorder that has chronic consequences, though some of these can be moderated over time. There may be a high variability of the long-term outlook of antisocial personality disorder. The treatment of this disorder can be successful, but it entails unique difficulties. It is unlikely to see rapid change especially when the condition is severe. In fact, past studies revealed that remission rates were small, with up to only 31% rates of improvement instead of remittance. As a result of the characteristics of ASPD (e.g., displaying charm in effort of personal gain, manipulation), patients seeking treatment (mandated or otherwise) may appear to be "cured" in order to get out of treatment. According to definitions found in the DSM-5, people with ASPD can be deceitful and intimidating in their relationships. When they are caught doing something wrong, they often appear to be unaffected and unemotional about the consequences. Over time, continual behavior that lacks empathy and concern may lead to someone with ASPD taking advantage of the kindness of others, including his or her therapist.Without proper treatment, individuals with ASPD could lead a life that brings about harm to themselves or others. This can be detrimental to their families and careers. Those with ASPD lack interpersonal skills (e.g., lack of remorse, lack of empathy, lack of emotional-processing skills). As a result of the inability to create and maintain healthy relationships due to the lack of interpersonal skills, individuals with ASPD may find themselves in predicaments such as divorce, unemployment, homelessness and even premature death by suicide. They also see higher rates of committed crime, reaching peaks in their late teens and often committing higher-severity crimes in their younger ages of diagnoses. Comorbidity of other mental illnesses such as depression or substance use disorder is prevalent among patients with ASPD. People with ASPD are also more likely to commit homicides and other crimes. Those who are imprisoned longer often see higher rates of improvement with symptoms of ASPD than others who have been imprisoned for a shorter amount of time.According to one study, 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 patients 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 patients 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
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 childs life. Additionally, with variability between situations, children of a parent with ASPD may face consequences of delinquency if theyre 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 </s>


<s> [INST] <<SYS>> You are a responsible assistant committed to providing accurate and helpful responses. Avoid sharing harmful or biased content. Clarify any unclear or incorrect questions rather than providing false or misleading information. <</SYS>> What is Cutaneous focal mucinosis and can you explain it in depth? [/INST]  </s>


<s> [INST] <<SYS>> You are a responsible assistant committed to providing accurate and helpful responses. Avoid sharing harmful or biased content. Clarify any unclear or incorrect questions rather than providing false or misleading information. <</SYS>> What is Argininosuccinic aciduria and can you explain it in depth? [/INST] Argininosuccinic aciduria is an inherited disorder that causes the accumulation of argininosuccinic acid (also known as "ASA") in the blood and urine. Some patients may also have an elevation of ammonia, a toxic chemical, which can affect the nervous system. Argininosuccinic aciduria may become evident in the first few days of life because of high blood ammonia, or later in life presenting with "sparse" or "brittle" hair, developmental delay, and tremors.
An infant with argininosuccinic aciduria may seem lethargic or be unwilling to eat, have poorly controlled breathing rate or body temperature, experience seizures or unusual body movements, or go into a coma. Complications from argininosuccinic aciduria may include developmental delay and mental retardation. Progressive liver damage, skin lesions, and brittle hair may also be seen. Immediate treatment and lifelong management (following a strict diet and using appropriate supplements) may prevent many of these complications.
Occasionally, an individual may inherit a mild form of the disorder in which ammonia accumulates in the bloodstream only during periods of illness or other stress.

Genetics
Mutations in the ASL gene cause argininosuccinic aciduria. Argininosuccinic aciduria belongs to a class of genetic diseases called urea cycle disorders. The urea cycle is a sequence of reactions in the cells of the liver. It processes excess nitrogen, generated when protein is used by the body, to make a compound called urea that is excreted by the kidneys.In argininosuccinic aciduria, the enzyme argininosuccinate lyase, involved in the conversion of arginino succinate to arginine within the urea cycle, is damaged or missing. The urea cycle cannot proceed normally, and nitrogen accumulates in the bloodstream in the form of ammonia. Ammonia is especially damaging to the nervous system, so argininosuccinic aciduria causes neurological problems as well as eventual damage to the liver.This condition is inherited in an autosomal recessive pattern, which means two copies of the gene in each cell are altered. Most often, the parents of an individual with an autosomal recessive disorder are carriers of one copy of the altered gene but do not show signs and symptoms of the disorder.

Diagnosis
Diagnosis is based mainly on clinical findings and laboratory test results. Plasma concentrations of ammonia (>150 μmol/L) and citrulline (200-300 μmol/L) are elevated. Elevated levels of argininosuccinic acid (5-110 μmol/L) in the plasma or urine are diagnostic. Molecular genetic testing confirms diagnosis. Newborn screening for ASA is available in the U.S. and parts of Australia, and is considered in several European countries

Treatment
During an acute hyperammonemic episode, oral proteins must be avoided and intravenous (I.V.) lipids, glucose and insulin (if needed) should be given to promote anabolism. I.V. nitrogen scavenging therapy (with sodium benzoate and/or sodium phenylacetate) should normalize ammonia levels, but if unsuccessful, hemodialysis is recommended. Long-term management involves dietary protein restriction as well as arginine supplementation. In those with frequent episodes of metabolic decompensation or with hyperammonemia even when following a protein-restricted diet, daily oral nitrogen scavenging therapy may be successful. Orthotopic liver transplantation offers long-term relief of hyperammonemia but does not seem to sufficiently correct neurological complications. Arterial hypertension can be treated by restoring nitric oxide deficiency

Prognosis
Due to the rarity of the disease, it is hard to estimate mortality rates or life expectancy. One 2003 study which followed 88 cases receiving two different kinds of treatment found that very few persons lived beyond age 20 and none beyond age 30.

Incidence
Argininosuccinic aciduria occurs in approximately 1 in 70,000 live births. Many patients can now be detected on the newborn screen if their blood citrulline is elevated.

References
Literature
Kleijer WJ, Garritsen VH, Linnebank M, Mooyer P, Huijmans JG, Mustonen A, Simola KO, Arslan-Kirchner M, Battini R, Briones P, Cardo E, Mandel H, Tschiedel E, Wanders RJ, Koch HG (2002). "Clinical, enzymatic, and molecular genetic characterization of a biochemical variant type of argininosuccinic aciduria: prenatal and postnatal diagnosis in five unrelated families". J Inherit Metab Dis. 25 (5): 399–410. doi:10.1023/A:1020108002877. PMID 12408190. S2CID 11129281.
Lee B, Goss J (2001). "Long-term correction of urea cycle disorders". J Pediatr. 138 (1 Suppl): S62–71. doi:10.1067/mpd.2001.111838. PMID 11148551.
Reid Sutton V, Pan Y, Davis EC, Craigen WJ (2003). "A mouse model of argininosuccinic aciduria: biochemical characterization". Mol Genet Metab. 78 (1): 11–6. doi:10.1016/S1096-7192(02)00206-8. PMID 12559843.
Scaglia F, Brunetti-Pierri N, Kleppe S, Marini J, Carter S, Garlick P, Jahoor F, OBrien W, Lee B (2004). "Clinical consequences of urea cycle enzyme deficiencies and potential links to arginine and nitric oxide metabolism". J Nutr. 134 (10 Suppl): 2775S–2782S, discussion 2796S–2797S. doi:10.1093/jn/134.10.2775S. PMID 15465784. Full text
Stadler S, Gempel K, Bieger I, Pontz BF, Gerbitz KD, Bauer MF, Hofmann S (2001). "Detection of neonatal argininosuccinate lyase deficiency by serum tandem mass spectrometry" </s>


<s> [INST] <<SYS>> You are a responsible assistant committed to providing accurate and helpful responses. Avoid sharing harmful or biased content. Clarify any unclear or incorrect questions rather than providing false or misleading information. <</SYS>> What is Pulmonary atresia with ventricular septal defect and can you explain it in depth? [/INST] Pulmonary atresia with ventricular septal defect is a rare birth defect characterized by pulmonary valve atresia occurring alongside a defect on the right ventricular outflow tract.It is a type of congenital heart disease/defect, and one of the two recognized subtypes of pulmonary atresia, the other being pulmonary atresia with intact ventricular septum.

Signs and symptoms
The condition consists of atresia affecting the pulmonary valve and a hypoplastic right ventricular outflow tract. The ventricular septal defect doesnt impede the in and outflowing of blood in the ventricular septum, which helps it form during fetal life.The spectrum of symptoms exhibited by children with this condition depends on the severity of the condition, while some barely show symptoms, others might develop complications such as congestive heart failure.In symptomatic children, symptoms become apparent soon after birth, these usually consist of the following:
Cyanosis
Breathing difficulties
Feeding difficulties
Exhaustion while being fed
Heart murmur
Excessive daytime sleepiness
Sticky skinOther features can occur alongside this birth defect, including other congenital anomalies such as polydactyly, microcephaly, congenital hearing loss (sensorineural type), renal agenesis, dextrocardia, etc.The condition has been called a severe form of Tetralogy of Fallot.If deformed blood vessels coming from the thoracic aorta appear alongside this condition, the phenotype is renamed to pulmonary atresia with ventricular septal defect and major aortopulmonary collaterals.

Complications
Children with this condition are at a higher risk of developing the following complications:
Failure to thrive
Recurrent chest infections
Endocarditis
Epilepsy
Stroke
Arrhythmia
Heart failure
Premature deathChildren whose PAVSD is caused by DiGeorge syndrome (also known as 22q11.2 deletion syndrome) are more likely to suffer from the post-surgical complications (especially respiratory ones) associated with surgeries that treat this defect.Women with PAVSD are at a slightly higher risk of being infertile and having miscarriages or children with a congenital heart defect.Airway hyperresponsiveness is a commonly seen co-morbidity among those afflicted with PAVSD.

Pathogenesis
Pulmonary atresia in PAVSD takes place during the first 8 weeks of fetal life, when the pulmonary valve that is supposed to form, fails to form, this doesnt allow blood to flow through the pulmonary artery from the right ventricle. The ventricular septal defect associated with PAVSD lets the right ventricule form.In some cases of PAVSD, major aortopulmonary collateral arteries develop; in a normal fetus, these arteries usually develop but then start deteriorating after pulmonary arteries grow, in fetuses with PAVSD, the pulmonary arteries dont develop, and this gives a chance to the major aortopulmonary collateral arteries to develop fully.

Pathophysiology
The mildest variant of pulmonary atresia with ventricular septal defect involves pulmonary atresia with normally developed main pulmonary artery and branch pulmonary arteries, the blood that flows to the lungs from the right side of the heart goes to the left side of the heart through the ventricular septum which then flows through the patent ductus arteriosus. The most severe variant involves the presence of severely hypoplastic main pulmonary arteries and branch pulmonary arteries, alongside agenesis of the patent ductus arteriosus. Blood flow to the lungs comes from various dysplastic (malformed) blood vessels from the thoracic aorta called major aortapulmonary collateral arteries, these blood vessels narrow down as time goes on.

Causes
Although this birth defect is congenital, the exact cause is unknown, and it may vary between children with the condition, the following factors have been known to influence the risk of a baby being born with the condition:

Genetics
The molecular genetics of this condition isnt known in most people with PA(VSD), however, there have been candidate genes found to be possibly implicated in the pathogenesis of this condition:
DNAH10
DST
FAT1
HMCN1
HNRNPC
TEP1
TYK2
NDRG4
TBX5
NKX2.5
GATA4There have also been copy number variants described in the medical literature as associated with PA(VSD):
Deletion in chromosome 16p11.2
Deletion in chromosome 5q35.3
Deletion in chromosome 5p13.1
Deletion in chromosome 22q11.2
Deletion in chromosome 15q11.2
Deletion in chromosome 8p23.2
Deletion in chromosome 17p13.2
Duplication in chromosome 5q14.1
Duplication in chromosome 10p13A 1998 study done in Britain revealed that children with a mother who had a congenital heart defect (including PAVSD) had a higher risk of being born with a congenital heart defect themselves than those whose father had a congenital heart defect.

Syndromes
Some cases of PA(VSD) have been associated with genetic syndromes such as VACTERL association, Alagille syndrome, CHARGE syndrome, trisomy 13, 18, and 21.

Environmental
While congenital heart defects cant be acquired, they can also be caused by environmental factors the mother exposed herself to before and/or during pregnancy, these include:
Smoking
Certain medications (e.g. thalidomide, retinoids, or vitamin A coegers)
Alcohol consumption
Vehicle exhaust components
By-products of disinfectants
Incinerators (proximity)
Agricultural pesticides
Solvents
Landfill sites
Heavy metalsMaternal exposure to carbon monoxide from smoke (e.g. from cigarettes) has been known for having the ability of quickly crossing the placenta into the fetus, which then attaches itself to fetal haemoglobin, leaving a shortage of nutrients and oxygen as a result </s>


<s> [INST] <<SYS>> You are a responsible assistant committed to providing accurate and helpful responses. Avoid sharing harmful or biased content. Clarify any unclear or incorrect questions rather than providing false or misleading information. <</SYS>> What is Extrapyramidal symptoms and can you explain it in depth? [/INST] Extrapyramidal symptoms (EPS) are symptoms that are archetypically associated with the extrapyramidal system of the brains cerebral cortex. When such symptoms are caused by medications or other drugs, they are also known as extrapyramidal side effects (EPSE). The symptoms can be acute (short-term) or chronic (long-term). They include movement dysfunction such as dystonia (continuous spasms and muscle contractions), akathisia (may manifest as motor restlessness), parkinsonism characteristic symptoms such as rigidity, bradykinesia (slowness of movement), tremor, and tardive dyskinesia (irregular, jerky movements). Extrapyramidal symptoms are a reason why subjects drop out of clinical trials of antipsychotics; of the 213 (14.6%) subjects that dropped out of one of the largest clinical trials of antipsychotics (the CATIE trial (Clinical Antipsychotic Trials for Intervention Effectiveness), which included 1460 randomized subjects), 58 (27.2%) of those discontinuations were due to EPS.

Causes
Medications
Extrapyramidal symptoms are most commonly caused by typical antipsychotic drugs that antagonize dopamine D2 receptors. The most common typical antipsychotics associated with EPS are haloperidol and fluphenazine. Atypical antipsychotics have lower D2 receptor affinity or higher serotonin 5-HT2A receptor affinity which lead to lower rates of EPS.Other anti-dopaminergic drugs, like the antiemetic metoclopramide, can also result in extrapyramidal side effects. Short and long-term use of antidepressants such as selective serotonin reuptake inhibitors (SSRI), serotonin-norepinephrine reuptake inhibitors (SNRI), and norepinephrine-dopamine reuptake inhibitors (NDRI) have also resulted in EPS. Specifically, duloxetine, sertraline, escitalopram, fluoxetine, and bupropion have been linked to the induction of EPS.

Non-medication-related
Other causes of extrapyramidal symptoms can include brain damage and meningitis. However, the term "extrapyramidal symptoms" generally refers to medication-induced causes in the field of psychiatry.

Diagnosis
Since it is difficult to measure extrapyramidal symptoms, rating scales are commonly used to assess the severity of movement disorders. The Simpson-Angus Scale (SAS), Barnes Akathisia Rating Scale (BARS), Abnormal Involuntary Movement Scale (AIMS), and Extrapyramidal Symptom Rating Scale (ESRS) are rating scales frequently used for such assessment and are not weighted for diagnostic purposes; these scales can help clinicians weigh the benefit/expected benefit of a medication against the degree of distress which the side effects are causing the patient, aiding in the decision to maintain, reduce, or discontinue the causative medication(s).

Classification
Acute dystonic reactions: painful, muscular spasms of neck, jaw, back, extremities, eyes, throat, and tongue; highest risk in young men.Oculogyric crisis is a kind of acute dystonic reaction that involves the prolonged involuntary upward deviation of the eyes.
Akathisia: A feeling of internal motor restlessness that can present as tension, nervousness, or anxiety. Clinical manifestations include pacing and an inability to sit still.
Pseudoparkinsonism: drug-induced parkinsonism (rigidity, bradykinesia, tremor, masked facies, shuffling gait, stooped posture, sialorrhoea, and seborrhoea; greater risk in the elderly). Although Parkinsons disease is primarily a disease of the nigrostriatal pathway and not the extrapyramidal system, loss of dopaminergic neurons in the substantia nigra leads to dysregulation of the extrapyramidal system. Since this system regulates posture and skeletal muscle tone, a result is the characteristic bradykinesia of Parkinsons.
Tardive dyskinesia: involuntary muscle movements in the lower face and distal extremities; this can be a chronic condition associated with long-term use of antipsychotics.

Treatment
Medications are used to reverse the symptoms of extrapyramidal side effects caused by antipsychotics or other drugs, either by directly or indirectly inhibiting dopaminergic neurotransmission. The treatment varies by the type of the EPS, but may involve anticholinergic agents such as procyclidine, benztropine, diphenhydramine, and trihexyphenidyl, and (rarely) dopamine agonists like pramipexole.If the EPS are induced by an antipsychotic, EPS may be reduced by decreasing the dose of the antipsychotic or by switching from a typical antipsychotic to an (or to a different) atypical antipsychotic, such as aripiprazole, ziprasidone, quetiapine, olanzapine, risperidone, or clozapine. These medications possess an additional mode of action that is believed to mitigate their effect on the nigrostriatal pathway, which means they are associated with fewer extrapyramidal side-effects than "conventional" antipsychotics (chlorpromazine, haloperidol, etc.)

Dystonia
Anticholinergic medications are used to reverse acute dystonia </s>


<s> [INST] <<SYS>> You are a responsible assistant committed to providing accurate and helpful responses. Avoid sharing harmful or biased content. Clarify any unclear or incorrect questions rather than providing false or misleading information. <</SYS>> What is Exhibitionism and can you explain it in depth? [/INST] Exhibitionism is the act of exposing in a public or semi-public context ones intimate parts – for example, the breasts, genitals or buttocks. The practice may arise from a desire or compulsion to expose themselves in such a manner to groups of friends or acquaintances, or to strangers for their amusement or sexual satisfaction, or to shock the bystander. Exposing oneself only to an intimate partner is normally not regarded as exhibitionism. In law, the act of exhibitionism may be called indecent exposure, "exposing ones person", or other expressions.

History
Public exhibitionism by women has been recorded since classical times, often in the context of women shaming groups of men into committing, or inciting them to commit, some public action. The ancient Greek historian Herodotus gives an account of exhibitionistic behaviors from the fifth century BC in The Histories. Herodotus writes that: When people travel to Bubastis for the festival, this is what they do. Every baris carrying them there overflows with people, a huge crowd of them, men and women together. Some of the women have clappers, while some of the men have pipes which they play throughout the voyage. The rest of the men and women sing and clap their hands. When in the course of their journey they reach a community — not the city of their destination, but somewhere else — they steer the bareis close to the bank. Some of the women carry on doing what I have already described them as doing, but others shout out scornful remarks to the women in the town, or dance, or stand and pull up their clothes to expose themselves. Every riverside community receives this treatment.
A case of what appears to be exhibitionism in a clinical sense was recorded in a report by the Commission against Blasphemy in Venice in 1550.In the UK the 4th draft of the revised Vagrancy Act of 1824 included an additional clause or openly and indecently exposing their persons which gave rise to difficulties because of its ill-defined scope. During the course of a subsequent debate on the topic in Parliament, the then Home Secretary, Mr Peel, observed that there was not a more flagrant offence than that of indecently exposing the person which had been carried to an immense extent in the parks...wanton exposure was a very different thing from accidental exposure.The development of new technologies such as smartphones and tablets has permitted some exhibitionists to reorient their methods such as with nude selfies.

Psychological aspects
The term exhibitionist was first used in 1877 by French physician and psychiatrist Charles Lasègue. Various earlier medical-forensic texts discuss genital self-exhibition, however.When exhibitionistic sexual interest is acted on with a non-consenting person or interferes with a persons quality of life or normal functioning, it can be diagnosed as exhibitionistic disorder in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5). The DSM states that the highest possible prevalence for exhibitionistic disorder in men is 2% to 4%. It is thought to be much less common in women. In a Swedish survey, 2.1% of women and 4.1% of men admitted to becoming sexually aroused from the exposure of their genitals to a stranger.A research team asked a sample of 185 exhibitionists, "How would you have preferred a person to react if you were to expose your privates to him or her?" The most common response was "Would want to have sexual intercourse" (35.1%), followed by "No reaction necessary at all" (19.5%), "To show their privates also" (15.1%), "Admiration" (14.1%), and "Any reaction" (11.9%) </s>


<s> [INST] <<SYS>> You are a responsible assistant committed to providing accurate and helpful responses. Avoid sharing harmful or biased content. Clarify any unclear or incorrect questions rather than providing false or misleading information. <</SYS>> What is Trichostasis spinulosa and can you explain it in depth? [/INST]  </s>


<s> [INST] <<SYS>> You are a responsible assistant committed to providing accurate and helpful responses. Avoid sharing harmful or biased content. Clarify any unclear or incorrect questions rather than providing false or misleading information. <</SYS>> What is Sibling rivalry and can you explain it in depth? [/INST] Sibling rivalry is a type of competition or animosity among siblings, whether blood-related or not.
Siblings generally spend more time together during childhood than they do with parents. The sibling bond is often complicated and is influenced by factors such as parental treatment, birth order, personality, and people and experiences outside the family. Sibling rivalry is particularly intense when children are very close in age and of the same gender and/or where one or both children are intellectually gifted.

Throughout the lifespan
According to observational studies by Judith Dunn, children are sensitive from the age of one year to differences in parental treatment. From 18 months, siblings can understand family rules and know how to comfort and be kind to each other. By the age of 3, children have a sophisticated grasp of social rules, can evaluate themselves in relation to their siblings, and know how to adapt to circumstances within the family.Sibling rivalry often continues throughout childhood and can be very frustrating and stressful to parents. Adolescents fight for the same reasons younger children fight, but they are better equipped to physically, intellectually, and emotionally hurt and be intellectually and emotionally hurt by each other. Physical and emotional changes cause pressures in the teenage years, as do changing relationships with parents and friends. Fighting with siblings as a way to get parental attention may increase in adolescence. One study found that the age group 10 to 15 reported the highest level of competition between siblings.Sibling rivalry can continue into adulthood, and sibling relationships can change dramatically over the years. Events, such as a parent’s illness, may bring siblings closer together, whereas marriage may drive them apart, particularly if the in-law relationship is strained. Approximately one-third of adults describe their relationship with siblings as rivalrous or distant. However, rivalry often lessens over time. At least 80 percent of siblings over the age of 60 enjoy close ties.

Causes
According to Kyla Boyse from the University of Michigan, each child in a family competes to define who it is as an individual and wants to show that it is separate from its siblings.  Children may feel they are getting unequal amounts of their parents’ attention, discipline, and responsiveness. Children fight most in families where there is neither any understanding that fighting is not an acceptable way to resolve conflicts nor any alternative way of handling such conflicts; in families in which physical fighting is forbidden but no method of non-physical conflict resolution (e.g., verbal argument) is permitted, the conversion and accumulation of everyday disputes into long-simmering hostilities can have an effect nearly as corrosive.  Stress in the parents’ and children’s lives can create more conflict and increase sibling rivalry. Some research indicates that changes in the weather can increase the likelihood of children exhibiting deviant behavior.

Other psychological approaches
Alfred Adler saw siblings as "striving for significance" within the family and felt that birth order was an important aspect of personality development. In fact, psychologists and researchers today endorse the influence of birth order, as well as age and gender constellations, on sibling relationships. However, parents are seen as capable of having an important influence on whether they are competitive or not.David Levy introduced the term "sibling rivalry" in 1941, claiming that for an older sibling "the aggressive response to the new baby is so typical that it is safe to say it is a common feature of family life." Researchers today generally endorse this view, noting that parents can ameliorate this response by being vigilant to favoritism and by taking appropriate preventative steps. In fact, the ideal time to lay the groundwork for a lifetime of supportive relationships between siblings is during the months prior to the new babys arrival.

Prevention
Parents can reduce the opportunity for rivalry by refusing to compare or typecast their children, planning fun family activities together, and making sure each child has enough time and space of their own. They can also give each child individual attention, encourage teamwork, refuse to hold up one child (such as the oldest) as a role model for the others (such as the younger children), and avoid favoritism. Teaching the children positive ways to ask for attention from parents when they need it can also make it less likely that they will resort to aggressive attention-getting strategies. Eileen Kennedy-Moore notes that this remedy also requires that parents "catch children being good" by responding to childrens kind, helpful, and creative bids for attention. Additionally, by being proactive about teaching children emotional intelligence, problem solving skills, negotiation skills, and encouraging them to look for win-win solutions, parents can help children resolve conflicts that arise as a normal part of growing up together in the same household. A concerted effort by parents to reduce competitiveness while nurturing bonding can further help alleviate sibling rivalry.
However, according to Sylvia Rimm, although sibling rivalry can be reduced, it is unlikely to be entirely eliminated. In moderate doses, rivalry may be a healthy indication that each child is assertive enough to express his or her differences with other siblings.Vernon Weihe suggests that four criteria should be used to determine if questioned and/or questionable behavior is rivalry or sibling abuse. First, given that children use different conflict-resolution tactics during various developmental stages, one must rule out the possibility that the questioned behavior is in fact age-appropriate for the child exhibiting it. Second, one must determine whether the behavior is an isolated incident or instead part of an enduring pattern: abuse is, by definition, a long-term pattern rather than occasional disagreements. Third, one must determine if there is an "aspect of victimization" to the behavior: rivalry tends to be incident-specific, reciprocal, and obvious to others, while abuse is characterized by secrecy and an imbalance of power. Fourth, one must determine the goal of the questioned and/or questionable behavior: while rivalry is motivated entirely or primarily by aspects of a childs self-interest in which the interests of others, including the childs rival, do not play a role, in scenarios featuring abuse, the perpetrators ultimate interests tend to include domination, humiliation, or at least embarrassment of the victim.

Animals
Sibling rivalry is common among various animal species, in the form of competition for food and parental attention. An extreme type of sibling rivalry occurs when young animals kill their siblings. For example, a black eagle mother lays two eggs, and the first-hatched chick pecks the younger one to death within the first few days. In the blue-footed booby, there is always the emergence of a brood hierarchy. The dominant chick will attack the subordinate one in times of food scarcity, often pecking it repeatedly or driving it from the nest. Among spotted hyenas, sibling competition begins as soon as the second cub is born, and 25% of cubs are killed by their siblings.Sibling relationships in animals are not always competitive. For example, among wolves, older siblings help to feed and guard the young.

Famous instances
In religion
The Book of Genesis in the Bible contains several examples of sibling rivalry: the story of Cain and Abel tells of one brothers jealousy after God appears to favour his sibling, and the jealousy ultimately leads to murder. Esau was jealous of his brother Jacobs inheritance and blessing; sisters Leah and Rachel compete for the love of Jacob; Josephs brothers are so jealous that they effectively sell him into slavery. These stories are also present in the Quran.
Another example is provided in the myth of Romulus and Remus, wherein twin brothers Romulus and Remus fight for control over Rome, and which ends with the death of Remus at the hands of his brother.

In folk and fairy tales
Sibling rivalry, bitter jealousy, and envy are notable in several fairy tales around the world. In some tales, the jealousy escalates to outright murder of the successful sibling.
Some tale types, according to the Aarne-Thompson-Uther Index, heavily feature sibling and step-sibling rivalry as part of the plot:

ATU 301, "The Three Stolen Princesses" or "Jean de lOurs": a hero, born with strong powers, descends to an underworld realm to rescue three princesses. He sends the three maidens to the upper realm with the help of his brothers (or companions), but they cut the rope and trap him in the subterranean realm.
ATU 361, "Bearskin": a man makes a deal with devil: must not pray or bathe for a certain number of years. Later, the man meets a father with his three daughters; only the youngest sister promises to marry the man. After the time is up, the man grooms himself and goes to meet his bride, explaining the whole story. Her sisters seethe with rage and explode with jealousy; the devil takes two souls, instead of one.
ATU 403, "The Black and the White Bride": a woman, dispised by her (step)family, marries a prince. Later, her step-mother conspires to replace the woman with her (step)sibling.
ATU 432, "The Bird Lover" or "The Prince as Bird": a maiden is visited at night by a bird, which is a prince in disguise. Her family  begin to suspect something and set up a trap by her window: they put spikes (nails, broken glass, thorns) to hurt the bird. The bird prince thinks her beloved betrayed him and flees, which prompts the heroine to seek him in parts unknown.
ATU 480, "The Kind and Unkind Girls" or "The Spinning-Woman by the Spring": two sisters or stepsisters, one diligent and the other lazy, meet a supernatural entity in the woods or in a magical realm. The diligent sibling acts kindly and obeys the entitys orders, and is rewarded; the lazy one disobeys and is punished.
ATU 510A, "Cinderella": the heroine is maltreated by her stepmother and stepsiblings.
ATU 511, "One-Eye, Two-Eyes, and Three-Eyes": two women (the first one-eyed and the other three-eyed) mistreat their sibling, a woman with two eyes.
ATU 530, "The Princess on the Glass Hill": a father sends his three sons to guard his crops or to hold a vigil on his grave. The older ones disobey and/or feel frightened, so they send their youngest brother, whom they call a fool or stupid, to fulfill their fathers orders. The foolish brother acquires three magical horses and uses them to reach a princess atop a glass hill for three times.
ATU 530A, "The Pig With Golden Bristles": as a continuation of the story of The Glass Mountain, after the wedding, the tsar/king sends his sons-in-law on a quest for some creatures with marvellous attributes. The older brothers want to go on the quest to impress their father-in-law and further humiliate their youngest brother.
ATU 550, "The Golden Bird": a king sends his three sons to find the golden bird and bring it home. The older ones fail, but the youngest is successful, capturing the bird and a horse and bringing with him a maiden as his wife. Spurred by intense jealousy, they murder their sibling or toss them in a ditch and take the prizes of the quest for themselves.
ATU 551, "The Water of Life": a king is dying or blind, so he sends his sons for a magical cure (a magical bird, the water of life, etc.), which can only be found in a distant realm, in the hands of a princess or maiden. The youngest is successful and returns with the prize, but his brothers drop him in a ditch. The youngest prince survives and returns incognito to the city. The foreign maiden comes after the person who stole her property.
ATU 554, "The Grateful Animals": in some variants, the youngest brother protects or helps three animals of different species, much to his brothers chagrin, who wanted to hunt them. When the three brothers are assigned tasks by a king, the youngest accomplishes the feats with the animals help.
ATU 707, "The Dancing Water, the Singing Apple, and the Speaking Bird": one night, the prince (king, tsar, sultan) hears three sisters talking, the youngest promising that, if she were to marry the king, would bear him children (twins, triplets) with wonderful attributes. Her sisters are married to lowly officials or servants of the kings court and, bearing an intense jealousy toward the newly crowned queen, decide to get rid of the royal children.
ATU 709, "Snow White": in some regional variants of the tale type, the rivalry isnt between mother and daughter or between step-mother and step-daughter. Instead, it is the heroines older sisters who get jealous over the youngests beauty and charm and conspire to kill her.
ATU 780, "The Singing Bone": a person murders their sibling (brother or sister) and buries them in a shallow grave. A tree sprouts from it. Its wood is used to create an instrument (fiddle, violin, flute) that reveals the murder.

In literature
A number of Shakespeares plays display the incidences of sibling rivalry. King Lear provokes rivalry among his three daughters by asking them to describe their love for him; in the same play, Edmund contrives to force his half-brother Edgar into exile. In The Taming of the Shrew, sisters Kate and Bianca are shown fighting bitterly. In Richard III, the title character is at least partially motivated by rivalry with his brother, King Edward. In As You Like It, there is obvious sibling rivalry and antagonism between Orlando and Oliver, and also between Duke Frederick and Duke Senior.
Most adaptations of Sherlock Holmes depict sibling rivalry with his brother, Mycroft Holmes.
In John Steinbecks East of Eden, the brothers Cal and Aron Trask are counterparts to Cain and Abel of the Bible story.
A Song of Ice and Fire contains numerous examples, such as that between Stannis Baratheon and Renly Baratheon. After their eldest brother Robert Baratheons death they contend for the Iron Throne, Stannis finally killing Renly through dark magic on the night before Renly intends to kill Stannis in battle, though it is left unclear whether he is aware of his role in Renlys death. The history of Westeros also contains "The Dance of the Dragons", in which Princess Rhaenyra Targaryen and her half-brother Aegon II Targaryen fought over the Iron Throne after their Father Viserys I Targaryens death, Aegon eventually killing Rhaenyra, but being poisoned shortly after, leading to Rhaenyras son Aegon III becoming king.

In film and television
Sibling rivalry is a common theme in media that features child characters, reflecting the importance of this issue in early life. These issues can include jealousy on the birth of a new baby, different sibling roles, frequent arguments, competitiveness for mothers affection, and tensions between step-siblings.
Adult siblings can also be portrayed with a rivalrous relationship, often a continuation of childhood conflicts. Situation comedies exploit this to comic effect. Sibling relationships may be shown as alternately loving and argumentative. Brothers or sisters in a similar line of work may display professional rivalry </s>