39.

ANTISOCIAL PERSONALITY DISORDER

Elissa M. Bail, M.D., and Robin A. MtCann, Ph.D

1. What is antisocial personality disorder?

Clues to a diagnosis of antisocial personality disorder include (1) a high frequency of behaviors that violate rules or the rights of others and (2) a cognitive style characterized by lack of motivation to understand the world from any point of view except ones own. To meet criteria for the diagnosis of antisocial personality disorder, such behaviors must begin i n childhood (before age 15 years) and persist through adulthood. Childhood behaviors that violate rules or the rights of others include frequent lying, stealing, and physical fights; fire setting and other destruction of property; and cruelty to people or animals. For adults such behaviors include impulsivity, consistent failure to follow through with occupational and family commitments, frequent lying, and lack of remorse. Examples of such characters in literature and film include Fagin in Dickens Oliver Twist,the Benefactor in Dickens David Copperfield, and the title characters in Bonnie and Clyde. The specific criteria for the DSM IV1 diagnosis are presented below: A. There is a pervasive pattern of disregard for and violation of the rights of others occurring since aye 15, as indicated by 3 or more of the following: 1. failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest. 2. deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure. 3. impulsivity or failure to plan ahead. 4. irritability and aggressiveness, as indicated by repeated physical fights or assaults. 5. reckless disregard for safety of self or others. 6. consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations. 7. lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another. B. The individual is at least 18 years. C. There is evidence of conduct disorder with onset before age 15 years. D. Occurrence of antisocial behavior is not exclusively during the course of schizophrenia or a manic episode. From American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC, American Psychiatric Association, 1994, with permission. Antisocial personality disorder, as currently conceptualized in DSM IV, is a quantitative (behaviorally anchored) rather than qualitative (trait- or predisposition-based) diagnosis. However, it is important to recognize the difference between specific antisocial acts and the chronic maladaptative pattern of antisocial behavior that characterizes the patient with antisocial personality disorder. For example, most adolescents have committed the following illegal activities at least once: driving a car without a license, skipping school, fist fighting, stealing, drinking alcohol, or using marijuana. Similarly, many adults have committed some of the following illegal or hurtful behaviors: lying, use of marijuana and other illegal drugs, extramarital affairs, failure to provide child support, and spouse and child abuse. In a randomly sampled survey, 25% of married individuals reported that their spouse had physically abused them in the past year. Despite a few behaviors that particularly distinguish the antisocial individual (vagrancy, the use of aliases, impulsivity, and a poor marital history), the differentiation between antisocial personality disorder and normative legal and social violations is largely quantitative. Individuals with antisocial personality disorder, beginning in childhood, consistently

I98

An ti social Personality Disorder

I99

and inflexibly commit a higher frequency of antisocial behaviors resulting in maladaptive social or occupational functioning. The credo of the individual with antisocial personality disorder can be summarized as I believe; therefore, it is so. Such individuals are 100% certain of the veracity of their viewpoint, 100% certain that because they want something, they should receive it. They are 100% certain that because they believe that a particular rule is silly, they need not follow it. Because they believe that they can avoid negative consequences, they are 100% certain that they will not happen. Because they believe that another is not worthy of respect, they feel 100% justified in denigrating the person. The high frequency of antisocial behaviors may be maintained by this egocentric cognitive style, notable for a lack of motivation to understand events from any other point of view. Such individuals do not think about how others perceive them and are not concerned about the effect of their behavior on others. Qualities such as empathy, remorse, reliability, and sincerity depend on understanding events from the vantage of others. The antisocial individuals low motivation to understand anothers point of view may account for his or her limited ability to demonstrate empathy, remorse, sincerity, or reliability.

2. List clues for the general practitioner that he or she is treating a patient with antisocial personality disorder. Such clues include physical, historical, and interpersonal characteristics of the patient and the practitioners response to the patient. Physical characteristics of the patient include (1 ) multiple tattoos, especially jail-house tattoos, which generally are of poor quality and completed by nonprofessional tattoo artists or the patient; and (2) biker or otherwise nonconformist appearance modeled after groups known to approve or sanction violence or disregard for the rights of others. Historical characteristics include ( 1 ) multiple injuries or scars not explained by occupation or involvement in sports and (2) unstable lifestyle. Interpersonal characteristics include an ingratiating interaction style, (2) entitled attitude with frequent demands, (3) superficial charm with overall functioning and level of success well below the level anticipated on the basis of perceived level of intelligence, (4) references in the interview to prison time or use of prison slang (e.g., the man, snitches, hooch, the joint), ( 5 ) unsolicited statements that Im telling you the truth, doc! and (6) statements suggesting a pattern of projecting blame onto others. Examples of such statements include, Yeah, doc, those doctors in the pen, theyre not like you, they dont know what theyre doing. They never told me I shouldnt drink . . . smoke . . . or yeah, they really screwed up or yeah, those fast food restaurants, they really ought to be sued by somebody . . . it is theirfault we all got this cholesterol problem. The practitioners responses often include: 1. A perception that the patients complaints or requests are manipulative, including an uncomfortable feeling that the patient is seeking drugs. Suggestive evidence includes an unusual degree of knowledge about pain medication, a request for specific addictive medication, vague responses to questions about prior treatment providers, or subjective complaints justifying addictive medication without supportive physical findings. 2. Suspicion that the patient is not being truthful about the medical history. This suspicion may be based on inconsistencies in the patients report, vague answers to many questions, or an irritable, defensive response to detailed questioning. None of these clues are pathognomonic for the diagnosis of antisocial personality disorder. They are sufficiently suggestive to warrant particular notice and consideration of more detailed questioning, special precautions, or external validation of history before implementing treatment.
3. How common is antisocial personality disorder? Antisocial personality disorder is the only personality disorder studied in recent large-scale U.S. surveys: the Epidemiologic Catchment Area (ECA) study, and the National Comorbidity Survey (NCS). The prevalence of antisocial personality disorder in these studies was 2.4% and 3.5%, respectively. In the National Comorbidity Study, 5.8% of men and 1.2% of women met criteria for antisocial personality disorder.

200

Antisocial Personality Disorder

4. What is a psychopath? What is a sociopath? Are these terms synonymous with antisocial personality disorder? What is the diagnostic reliability of antisocial personality disorder? Often, the terms psychopath, sociopath, and antisocial personality disorder are loosely used synonymously. This is unfortunate as it fosters poor communication and poor diagnostic reliability. Historically, the terms psychopath and sociopath referred to persons who not only exhibited bad behavior, but suffered from a disorder characterized by deficits in empathy and an inability to manage interpersonal relationships. Factor-analytic studies suggest two separate elements in psychopathy: criminality and pathologic inteipersonallaffective behavior. Hares Psychopathy Checklist measures both elements. When both elements are considered, only 10-25% of criminals meet diagnostic criteria for psychopathy. In comparison, between two-thirds and three-quarters of male prison populations meet the definition of antisocial personality disorder when DSM IV criteria are used. In other words, psychopaths are probably a more pathologic subset of the broader category of those with antisocial personality disorder. The Cleckley and Hare term psychopath involves a trait-based description of personality. The traits of psychopathy include: superficial charm, irresponsibility, insincerity, lack of remorse, impulsiveness, egocentricity, shallow affect, and a failure to learn from experience. Criteria based on traits are generally less diagnostically reliable. A trait approach requires the diagnostician to determine absolutely the presence or absence of qualities such as irresponsibility and insincerity in an all or none fashion. In actuality, such traits reflect a continuum of behaviors rather than a dichotomy. Psychopathy, as measured by the Hare Psychopathy Checklist-Revised can be reliably assessed, though such reliability requires extensive training, and the test is time consuming. In contrast, the DSM IV criteria are behaviorally anchored, resulting in considerably greater ease in attaining diagnostic reliability. Though it may be difficult to reach agreement on whether a given patient is irresponsible, it is relatively easy to determine whether a person has or has not failed to honor financial obligations or provide child support. Although clinicians can diagnose reliably the presence or absence of a personality disorder, they are not able to distinguish reliably between the different personality disorders. Because of its behavioral anchors, however, the diagnosis of antisocial personality disorder has the highest diagnostic reliability of all personality disorders. 5. Discuss the differential diagnosis of antisocial personality disorder. Antisocial personality disorder must be differentiated from antisocial behavior. Antisocial behavior may be committed intermittently by many people without mental disorders or may be a symptom of another disorder. To differentiate between antisocial behavior and antisocial personality disorder it is necessary to consider whether the patient meets criteria for a personality disorder. Patients must demonstrate a pervasive, enduring, and inflexible antisocial pattern of perceiving, relating to, and thinking about themselves, others, and their environment. Although antisocial personality disorder, not unexpectedly, is represented disproportionately in prison populations, a pattern of criminal behavior (beginning before or after age 15) is insufficient to make the diagnosis. Studies of prison populations have reported prevalence rates of antisocial personality disorder as low as 40% and as high as 75%. Prisoners without antisocial personality disorder may include professional criminals, those involved in organized crime, and one-time offenders. Many such persons clearly disregard the rights of others and may have no remorse for their harmful effects. However, if they are neither aggressive nor impulsive, they probably do not meet criteria for antisocial personality disorder. Criminal or antisocial behavior is commonly associated with substance use disorders. Correlations between the diagnoses of antisocial personality disorder and alcohol or other substance abuse or dependence are statistically significant. The presence of one of the three diagnoses increases the probability of the presence of the others. Despite this association, the diagnosis of antisocial personality disorder should not be given if criminal behavior and other antisocial behavior occur only in the context of addiction. Specific symptoms of antisocial personality disorder are associated with many psychiatric disorders. Patients with schizophrenia, mania, sexual perversions, mental retardation, organic brain syndromes, and other personality disorders (including narcissistic personality disorder) may demonstrate some but not all features of antisocial personality disorder. For example, patients with schizophrenia,

Antisocial Personality Disorder

20 I

mental retardation, and organic brain syndromes are likely to demonstrate impaired occupational and parental functioning. All of these disorders are sometimes associated with impulsive acts, including repeated unlawful behavior. Sometimes, such impulsive acts may be associated with lack of remorse. For example, sex offenders may not experience remorse with regard to their sexual victims because of false beliefs that their behavior is not harmful or in fact is desired by the victim. At times, only the absence of symptoms of a conduct disorder as a child clarifies that the patient does not have antisocial personality disorder. 6. What is the cause of antisocial personality disorder? Antisocial personality disorder is likely the result of an interaction among multiple factors, including individual vulnerabilities, particular developmental learning histories, and environmental stressors. Individual vulnerabilities include genetic factors. Twin studies have demonstrated that there is significant heritability involved in criminal behavior. EEG studies have found a high frequency of abnormalities in sociopaths. There are studies which suggest those who develop antisocial personality are born with an uninhibited temperament, lack of normal fearfulness, and a constitutionally based failure to leam from negative experiences. Another biologic factor in psychopathy is possible comorbidity with attention-deficit hyperactivity disorder. About one-third of children with attention-deficit hyperactivity disorder later demonstrate adult criminal behavior. Patterson and others have proposed a developmental theory of antisocial behavior which is enipirically anchored. This theory has generated interventions, primarily prevention, with demonstrated success. Patterson proposes the following learning history: First, parents teach their children antisocial behavior through inappropriate and inconsistent parenting. Inappropriate parenting may occur when the parent positively reinforces the child for antisocial acts. For example, the parent may laugh or praise the child when the child hits another. Inconsistent parenting may occur when the parent negatively reinforces the child. For example, a mother asks her son to clean his room. Like most children, he does not comply immediately, so the mother asks again. The child throws a tantrum. The mother experiences the tantrum as aversive and stops asking him to clean his room. Thus the child is negatively reinforced for his tantrum; in other words, when he throws a tantrum, the mother stops asking him to be responsible. The mother also learns that if she does not ask her child to be responsible, he will not throw a tantrum. The child learns to use aversive behavior to avoid responsibility. The second step in the development of antisocial behavior occurs when the child begins school. The childs aversive behavior leads to a predictable social outcome: the child is rejected. He or she does not follow instructions, is unable to complete a task on time, and does not cooperate with others. The child lacks the skills to do well academically and thus may fail to learn to read or compute math. Such failures have dire consequences for occupational and social future. Step three of the inexorable sequence occurs when after being rejected, the child gravitates toward deviant peer groups. Such peers are likely to provide positive feedback for antisocial behaviors and punishment for prosocial behaviors. Epidemiologic studies have identified clear environmental and social factors which correlate with antisocial personality disorder. Social structures affect the prevalence of personality disorders by lowering or raising the threshold at which other risks influence their development.6Though there are no differences in prevalence of antisocial personality disorder among U.S. racial groups, there are important cross-cultural differences in its prevalence. In east Asian cultures with low comorbid alcoholism, antisocial personality disorder has an unexpectedly low prevalence (0.03-0.14% vs. 2-4% in the U.S.). This difference has been attributed to strong vs. weak family structures. The importance of social factors is further supported by the fact that the prevalence of antisocial personality disorder is increasing dramatically in North America. Both the ECA and NCS studies found that the lifetime prevalence of antisocial personality disorder nearly doubled among young people in 15 years. Such rapid increases in such a short time period can be accounted for by changes in the social environment.

7. What is the prognosis for the patient with antisocial personality disorder? Impairment is the rule, although it may range from mild to severe. Not uncommonly, professionals or laypersons refer to various prominent persons, such as politicians, as sociopaths. Sociopathic qualities such as disregard for the truth and lack of remorse are perhaps present in many

202

Antisocial Personality Disorder

individuals drawn to positions of national recognition or power. However, economic or political success is unlikely if a person truly meets criteria for antisocial personality disorder. Characteristics of antisocial personality disorder such as early onset, related impairment in educational achievement, impulsivity, and aggression generally preclude success. Impairment due to the disorder is frequently severe. Typically, such individuals fail to become independent, experiencing years of institutionalization, usually penal rather than medical. Although estimates vary, such individuals appear significantly more likely to die prematurely as a result of suicide, homicide, or complications of drug or alcohol abuse. Although people who meet criteria for antisocial personality disorder are at risk of early death, the prognosis for those who live to middle-age is somewhat encouraging. Spontaneous improvement with age appears to be the rule rather than the exception. In the ECA study, there was a striking decrease in the prevalence after age 44. In a large follow-up study, fewer than 10% met criteria for antisocial personality disorder 29 years after initial hospitalization. The vast majority has ongoing impairments, particularly in interpersonal relationships. The most consistent improvements are in criminal behavior. The prognosis for the psychopathic subset of antisocial personality disorders appears more grim. The psychopaths are significantly more likely to recidivate than non-psychopathic antisocials.

8. What kind of difficulties do professionals have with patients diagnosed with antisocial personality disorder? Health care professionals frequently experience the following problems with patients diagnosed with antisocial personality disorder: (1) difficulty in collecting reliable history, (2) difficulty in managing the patient, (3) conflict between responsibility to the patient and responsibility to society, and (4) because of the conflict, negative feelings such as anger, boredom, and hopelessness. The dishonesty of patients with antisocial personality disorder makes it difficult to collect reliable history. Inconsistency or vagueness is a clue that the patient may be lying. Nonverbal cues include stammering, short answers, hesitations, excessive blinking, dilated pupils, and excessive touching of clothing. The patient is likely to blame the clinician who questions inconsistencies (e.g., arent you listening? you heard that wrong, I didnt say that, or use your head, doc). In such situations, straightforward delineation of the costs and benefits of presenting an accurate history is useful. Patients with antisocial personality disorder respond best to an approach based on self-interest. Fortunately, they typically have the capacity and motivation to discuss honestly their physical history (in contrast to social or occupational history). Keys to the second difficulty, difficulty in management, include the following: I . It is the patients responsibility to deal with the consequences of antisocial behavior. 2. The clinician must set clear expectations regarding acceptable behavior. 3. The clinician must take a nonjudgmental stance and objectively help the patient to consider the costs and benefits of his or her behavior to self. For example, the patient may wish to consider whether the benefits of denigrating nursing staff (reduction in tension) outweigh the costs (probable reduction in care). Given the patients difficulty appreciating any point of view other than his or her own, it is more effective to emphasize the effects on self than on others. The health care provider also may experience conflict between responsibility to the patient and responsibility to the patients dependents or society. Informing the patient of the limits of confidentiality at the onset of treatment helps to ameliorate such problems. For example, the patient should be informed that the clinician will be unable to maintain confidentiality if the patient threatens to harm self or others, or reveals plans to commit a crime. Similarly, the patient should be informed that the clinician is unable to maintain confidentiality if the patient reports physical abuse or neglect of a child or, in some states, an elderly person. Before breaking confidentiality, the clinician is well advised to consult. Consultation not only provides information but also enables the clinician to wear one rather than multiple hats. For example, in the case of mandated reporting of child abuse, by consulting with specialists in psychiatry and social work the clinician avoids the potentially conflicting roles of investigator, therapist, and physician. Data indicating that hospital personnel report less than 50% of child abuse cases suggest a conflict between medical and social responsibilities.

Antisocial Personality Disorder

203

The above difficulties may result in the fourth difficulty: the health professional may experience negative feelings such as anger, boredom, hopelessness, and hatred toward the patient. Whereas it is the patients responsibility to deal with the consequences of his or her behavior, the provider must deal appropriately with her or his own feelings. The clinicians perusal of police reports may result in anger, fear, or horror. Some clinicians avoid reading police reports for fear that such feelings may prevent them from providing adequate care. As a result of the marked tendency of patients with antisocial personality disorder to project blame and responsibility, the clinician may experience guilt, impotence, and hopelessness. It is important, particularly for the introspective health care provider, to study the patients behavior, not his or her own. Finally, it is important to recognize that feelings of apathy or boredom may shield more intense feelings. Signs that clinicians may be acting out their feelings inappropriately include forgetting appointments and other commitments, colluding with staff in denigrating the patient, colluding with the patient in denigrating staff, giving the patient special consideration, or giving the patient less than appropriate consideration.

9. What are the guidelines for management of medical conditions in patients with antisocial personality disorder? 1. Err on the side of caution. If anyone (clinician, spouse, colleague, or support personnel) expresses concern about personal safety, whether based on clearcut logic or gut feeling, evaluate the patient with a chaperone present. 2. The clinician at times will be required to evaluate patients in restraints or chains. The patient should be evaluated as thoroughly as possible with restraints in place. If adequate assessment is not possible, adequate security personnel should be obtained before removal of restraints and completion of physical examination. The clinician should defer security assessment decisions to security personnel. The clinician must not try to be a hero. 3. The clinician should consider a diagnosis of malingering (exaggeration or complete fabrication of symptoms for secondary gain). For example, the patient may wish to avoid work, military conscription, or prison time or to obtain financial gain, disability payments, or drugs. Clinicians should ask themselves, Why is this patient in my office right now? What does this patient really want? 4. The clinician should be cautious in prescribing medication and avoid prescription of addictive medications when possible. When such medications are prescribed, the clinician must be explicit and write out exactly how much is to be dispensed-e.g., dispense 4 (four). The clinician must think, Is this written in such a way that the patient could alter what the pharmacy dispenses? No refills should be specified. If the clinician follows a patient with antisocial personality disorder or antisocial symptoms, precise amounts should be prescribed from visit to visit. The patient should be notified that the clinician will not provide extra prescriptions if they are lost, stolen, or accidentally flushed down the toilet.

CONTROVERSY
10. Is antisocial personality disorder a treatable condition? Against: 1. Prior comprehensive, costly programs in which offenders were diverted to secure treatment facilities rather than prison demonstrated no sufficient improvement or decrease in recidivism to warrant the cost to society. In fact, in one study (Rice, et al.) a psychopathic subset actually demonstrated increased violent recidivism after receiving treatment, in contrast to the non-psychopathic antisocial individuals who demonstrated a decrease in violent recidivism. 2. Psychiatric or psychological treatment of individuals with antisocial personality disorder is a poor allocation of financial and social resources. 3. Psychiatric or psychological treatment of incarcerated individuals is coercive, unethical, and unconstitutional. For: 1. Previous treatment outcome studies of patients with antisocial personality disorder involve significant methodologic problems: ( 1 ) Few outcome studies identified subjects by DSM-I11 or

204

Antisocial Personality Disorder

DSM-111-R criteria; (2) no studies in which diagnostic criteria were well-defined employed nontreated control group; and (3) although expert opinion supporting the lack of benefit of individual psychodynamic treatment is pervasive, no information in the literature addresses outcome for patients with antisocial personality disorder treated with other modalities for an extended time in a forensic setting. Schizophrenia does not respond to psychodynamic psychotherapy but is generally agreed to be a treatable condition. Depression does not generally improve with psychoanalysis but often responds to cognitive therapy, antidepressant medication, or a combination of the two. Studies of treatment outcome with conduct-disordered children, who may potentially become adults with antisocial personality disorder, suggest that antisocial personality disorder can be prevented. Parent-management training, cognitive therapy, and court-diversion appear to be promising approaches. In summary, conclusions about the treatability of antisocial personality disorder are premature; it is as scientifically valid to say that such patients are treatable as it is to say that they are not. 2. Patients with antisocial personality disorder have a significant risk of early death but also a good chance of spontaneous remission (or at least substantial improvement) if they live till age 30 or 35. At a minimum, this observation supports crisis intervention strategies aimed at decreasing the risk of early death and minimizing negative effects of antisocial behaviors on both the patient and others. 3. For unclear reasons, the standard for psychiatric medical conditions appears to equate treatment with cure. Diabetes mellitus, coronary artery disease, and chronic obstructive pulmonary disease are only three of the many medical disease that are treatable (i.e., morbidity and mortality can be reduced by medical interventions) but not currently curable.Accurate assessment of treatability of antisocial personality disorder requires clear definition of the target symptoms to be reduced or relieved. Target symptoms may include prevention or treatment of violent death, aggression, substance abuse, impulsivity, or concomitant major mental disorders. Individuals with antisocial personality disorder have a 5-50-fold increased risk of experiencing concurrent mania, schizophrenia, and alcohol or drug abuse. Prognosis is improved by treatment of concurrent anxiety and depression. Treatment of such disorders may prolong life and decrease personal and societal damage while awaiting possible spontaneous remission.
BIBLIOGRAPHY
1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC, American Psychiatric Association, 1994. 2. Beck AT, Freeman A: Cognitive Therapy of Personality Disorders. New York, Guilford Press, 1990. 3. Cleckley H: The Mask of Sanity, 5th ed. St. Louis, Mosby, 1976. 4. Frances AJ, Hales RE (eds): American Psychiatric Association Annual Review, vol. 5. Washington, DC, American Psychiatric Press, 1986. 5. Hare RD: Psychopathy: A clinical construct whose time has come. Criminal Justice Behavior 23:25-54, 1996. 6. Kessler CR, McGonagle KA, Zhao S, et al: Lifetime and 12-month prevalence of DSM-lIIR psychiatric disorders in the United States. Arch Gen Psychiatry 51 :8-19, 1994. 7. Paris J: A hiopsychosocial model of psychopathy (227-287). In Millon, et a1 (eds): Psychopathy. New York, Guilford Press, 1998. 8. Patterson GR, DeBaryshe BD, Ramsey E: A developmental perspective on antisocial behavior. Am Psycho1 44:329-335, 1989. 9. Rice ME, Harris GT, Cormier CA: An evaluation of a maximum security therapeutic community for psychopaths and other mentally disordered offenders. Law Hum Behav 16:399412, 1992. 10. Schubert DS, Wolf AW, Patterson MB, et al: A statistical evaluation of the literature regarding the associations among alcoholism, drug abuse, and antisocial personality disorder. Int J Addict 23:797-808, 1988. I 1. Treatment outlines for antisocial personality disorder. The Quality Assurance Project. Aust N Z J Psychiatry 2.5541-547, 1991. 12. Widiger TA, Corbitt EM, Millon TM: Antisocial personality disorder. APA Rev Psychiatry 11:63-79, 1992.