Antisocial Personality Disorder 2010


Antisocial Personality Disorder

Family Personality Disorder (Cluster B)

Definition a personality disorder in which the person (usually a man) exhibits a lack of conscience for wrongdoing, even toward friends and family members. May be aggressive and ruthless or a clever con artist. (p 655) [1]

Antisocial Personality Disorder is a condition characterized by persistent disregard for, and violation of, the rights of others that begins in childhood or early adolescence and continues into adulthood. Deceit and manipulation are central features of this disorder. For this diagnosis to be given, the individual must be at least 18, and must have had some symptoms of Conduct Disorder (i.e., delinquency) before age 15. This disorder is only diagnosed when these behaviors become persistent and very disabling or distressing. [2]

Symptoms
Anyone over age 15 is considered to have antisocial personality disorder if three or more of the following are noticeable:
(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 [3]

In addition to an objective psychosocial and criminal history, the following steps may be useful in assessing the antisocial client:
  • Taking a thorough family history.
  • Finding out whether the client set fires as a child, abused animals, or was a bed-wetter.
  • Taking a thorough sexual history that includes questions about animals and objects. Asking about any unusual or out-of-the-ordinary sexual experiences may serve as a lead-in and as a means to gauge how the client responds to questions about such personal areas.
  • Taking a history of the client's ability to bond with others. Counselors can ask, "Who was your first best friend?" "When was the last time you saw him or her?" "Do you know how he or she is?" "Is there any authority figure who has ever been helpful to you?"
  • Asking questions to find out about possible parasitic relationships and taking a history of exploitation of self and others. In this context, parasitic refers to a relationship in which one person uses and manipulates another until the first has gotten everything he or she wants, then abandons the relationship.
  • Taking a history of head injuries, fighting, and being hit. It may be useful to refer for neuropsychological testing.
  • Testing urine for recent substance use.
  • HIV testing. [11]

Antisocial Personality Disorder 2010 - The Neuron[10]

Causes
Like all personality disorders, and also most mental disorders, antisocial personality disorder tends to be the result of a combination of biologic/genetic and environmental factors.

Although there are no clear biological causes for this disorder, research on the possible biologic risk factors for developing antisocial personality disorder indicates that the part of the brain that is primarily responsible for learning from one's mistakes and for responding to sad and fearful facial expressions (the amygdala) tends to be smaller and respond less robustly to the happy, sad, or fearful facial expressions of others. That lack of response may have something to do with the lack of empathy that antisocial individuals tend to have with the feelings, rights, and suffering of others. While some individuals may be more vulnerable to developing antisocial personality disorder as a result of their particular genetic background, that is thought to be a factor only when the person is also exposed to life events such as abuse or neglect that tend to put the person at risk for development of the disorder. Similarly, while there are some theories about the role of premenstrual syndrome (PMS) and other hormonal fluctuations in the development of antisocial personality disorder, the disorder can, so far, not be explained as the direct result of such abnormalities.

Other conditions that are thought to be risk factors for antisocial personality disorder include substance abuse, attention deficit hyperactivity disorder (ADHD), or a reading disorder. Theories regarding the life experiences that put people at risk for antisocial personality disorder provide important clues for its prevention. Examples of such life experiences include a history of childhood physical, sexual, or emotional abuse; neglect; deprivation or abandonment; associating with peers who engage in antisocial behavior; or a parent who is either antisocial or alcoholic. [4]

Antisocial Personality Disorder 2010 - The Neuron[9]

Treatments

Another very common question asked is, can antisocial personality disorder be cured? While it can be quite resistant to change, research shows there are a number of effective treatments for this disorder. For example, teenagers who receive therapy that helps them change the thinking that leads to their maladaptive behavior (cognitive behavioral therapy) has been found to significantly decrease the incidence of repeat antisocial behaviors. On the other hand, attempting to treat antisocial personality disorder like other conditions is not often effective. For example, programs that have tried to use a purely reflective (insight-oriented) approach to treating depression or eating disorders in persons with antisocial personality disorder often worsen rather than improve outcomes in those individuals. In those cases, a combination of firm but fair programming that emphasizes teaching the antisocial personality disorder individuals skills that can be used to live independently and productively within the rules and limits of society has been more effective. While medications do not directly treat the behaviors that characterize antisocial personality disorder, they can be useful in addressing conditions that co-occur with this condition. Specifically, depressed or anxious individuals who also have antisocial personality disorder may benefit from antidepressants, and those who exhibit impulsive anger may improve when given mood stabilizers.
Antisocial patients who seek help (or are referred) can be offered evaluation and treatment as outpatients. Patients can be offered an array of services, including neuropsychological assessment, individual psychotherapy, medication management, and family or marital counseling. [5]

Case Study
Notes of first therapy session with Ani Korban, male, 46, diagnosed with Antisocial Personality Disorder (AsPD), or Psychopathy and Sociopathy

Ani was referred to therapy by the court, as part of a rehabilitation program. He is serving time in prison, having been convicted of grand fraud. The scam perpetrated by him involved hundreds of retired men and women in a dozen states over a period of three years. All his victims lost their life savings and suffered grievous and life-threatening stress symptoms.

He seems rather peeved at having to attend the sessions but tries to hide his displeasure by claiming to be eager to "heal, reform himself and get reintegrated into normative society". When I ask him how does he feel about the fact that three of his victims died of heart attacks as a direct result of his misdeeds, he barely suppresses an urge to laugh out loud and then denies any responsibility: his "clients" were adults who knew what they were doing and had the deal he was working on gone well, they would all have become "filthy rich." He then goes on the attack: aren't psychiatrists supposed to be impartial? He complains that I sound exactly like the "vicious and self-promoting low-brow" prosecutor at his trial.

He looks completely puzzled and disdainful when I ask him why he did what he did. "For the money, of course" - he blurts out impatiently and then recomposes himself: "Had this panned out, these guys would have had a great retirement, far better than their meager and laughable pensions could provide." Can he describe his typical "customer"? Of course he can - he is nothing if not thorough. He provides me with a litany of detailed demographics. No, I say - I am interested to know about their wishes, hopes, needs, fears, backgrounds, families, emotions. He is stumped for a moment: "Why would I want to know these data? It's not like I was their bloody grandson, or something!"

Ani is contemptuous towards the "meek and weak". Life is hostile, one long cruel battle, no holds barred. Only the fittest survive. Is he one of the fittest? He shows signs of unease and contrition but soon I find out that he merely regrets having been caught. It depresses him to face incontrovertible proof that he is not as intellectually superior to others as he had always believed himself to be.

Is he a man of his word? Yes, but sometimes circumstances conspire to prevent one from fulfilling one's obligations. Is he referring to moral or to contractual obligations? Contracts he believes in because they represent a confluence of the self-interests of the contracting parties. Morality is another thing altogether: it was invented by the strong to emasculate and enslave the masses. So, is he immoral by choice? Not immoral, he grins, just amoral.

How does he choose his business partners? They have to be alert, super-intelligent, willing to take risks, inventive, and well-connected. "Under different circumstance, you and I would have been a great team" - he promises me as I, his psychiatrist, am definitely "one of the most astute and erudite persons he has ever met." I thank him and he immediately asks for a favor: could I recommend to the prison authorities to allow him to have free access to the public pay phone? He can't run his businesses with a single daily time-limited call and this is "adversely affecting the lives and investments of many poor people." When I decline to do his bidding, he sulks, clearly consumed by barely suppressed rage.

How is he adapting to being incarcerated? He is not because there is no need to. He is going to win his appeal. The case against him was flimsy, tainted, and dubious. What if he fails? He doesn't believe in "premature planning". "One day at a time is my motto." - he says smugly - "The world is so unpredictable that it is by far better to improvise."

He seems disappointed with our first session. When I ask him what his expectations were, he shrugs: "Frankly, doctor, talking about scams, I don't believe in this psycho-babble of yours. But I was hoping to be able finally communicate my needs and wishes to someone who would appreciate them and lend me a hand here." His greatest need, I suggest, is to accept and admit that he erred and to feel remorse, This strikes him as very funny and the encounter ends as it had begun: with him deriding his victims.