CENTER ON BEHAVIORAL MEDICINE
ADDITIONAL MATERIALRELATED PAPERS
by the author to reproduce this paper:
Antisocial Personality Disorder
Antisocial personality disorder is highly complex in the multiple behaviors it encompasses as well as in the successful treatment. The simplified descriptions of this disorder given by the DSM-IV-TR states as followed. “The essential feature of antisocial personality disorder is a pervasive pattern of disregard for, and violation of, the rights of others that begins in early childhood or early adolescence and continues into adulthood.” (p.701) The purpose of this paper is to provide a definition of antisocial personality disorder with an inclusion of the signs and symptoms as outlined in the DMS-IV. In addition, the physiological, psychological, and sociological factors underlying the causation as well as treatment approaches will be included.
Antisocial personality disorder adheres to a time line that begins in childhood and extends to around the fourth decade of life.” At this juncture” the symptoms that meet criteria begin to diminish including criminal activity and substance abuse. The prevalence for antisocial personality disorder effects 3% of males and 1% of females in community samples. In clinical settings with consideration of the population characteristics, the prevalence has a 3% to 30% range. These numbers increase when applied to institutions such as drug treatment facilities, prisons, and forensic settings. (DSM-IV-TR, 2003, p. 704)
Considerations made while diagnosing antisocial personality disorder must include culture, age, and gender features. Those diagnosed are commonly from urban areas maintaining a low socioeconomic status. Clinicians must carefully factor for antisocial behavior being a basic survival need in respect to living conditions. Some individuals may have in error, been diagnosed with antisocial personality disorder as the social norms within their ecological system for means of survival had been overlooked. This disorder is only diagnosed after eighteen years, and diagnosed in males more often than females. This differentiation maybe linked to the aggressive behavior emphasis in conduct disorder. (DSM-IV-TR, p. 704)
The DSM-IV-TR indicates that antisocial personality disorder presents the familial patterns as indicated here. The prevalence of the disorder in first-degree biological relatives exceeds the occurrence that is seen in general population studies. This number increases exponentially for biological family members of a female with the diagnosis, in their potential risk, than if a male is diagnosed. When a family member is diagnosed with antisocial personality, it is highly probable another family member has been diagnosed with a substance-related disorder (often male), or a Somatization disorder (often female). Family studies show an increase for all three diagnoses of males and females than in the general population studies.
Adoption studies have revealed the implications environmental and biological factors have on antisocial personality disorder, somatization disorder, and substance-related disorders. Biological and adopted children show a greater prevalence of being diagnosed with the three disorders when the parents have antisocial personality disorder. Children that have biological parents with antisocial personality disorder, but were adopted into another family exhibit the genetic disorder characteristics of the biological parents. However, the environmental influences of the adoptive family will affect if the child will develop one of the three related disorders.
Those persons with antisocial personality disorder frequently have a substance-related disorder and it is often assumed the two disorders will coexist. Approximately 84% of people diagnosed with antisocial personality disorder also have a history of substance abuse. (Doweiko, H., 2002, p. 40) Antisocial personality disorder shows a higher potential for those diagnosed to present substance-related disorders that all other personality disorders. When diagnosing antisocial personality disorders with a differential diagnosis of substance-related abuse specific attention must be given to the onset of all underlying symptoms. This is because those qualifying criteria for antisocial personality disorder often reflect the behaviors of individuals who abuse alcohol and drugs.
While difficult to assess without controversy, a fundamental commonality between antisocial personality disorder and substance-related disorders is shared in the nature of both disorders. Alcoholics Anonymous, and later adopted by Narcotics Anonymous, attribute symptoms of disorder to a spiritual disease. “From it all forms of spiritual disease, for we have been not only mentally and physically ill, we have been spiritually sick.” (Alcoholics Anonymous, 2005) This analysis coincides with the long-standing beliefs of the psychology of antisocial personality disorder. Descriptions of individuals with the disorder include similar points such as, “have an underdeveloped conscience.” (Papilia, D., 1988, p. 591) More recently, research in social psychology acknowledges problems of conscience, and includes moral implications.
From a social standpoint, an extreme deviant act can justify or desensitize one to engaging in less extreme deviant behaviors, making them easier. Repetitive deviant behaviors such as cruelty negatively influence the conscience in how the act is perceived. The more an individual performs a behavior; it generally becomes easier to perform again, regardless if the behavior is acceptable. In addition, if individuals are also guided by moral thinking, and when morals are underdeveloped it influences the clarity of right and wrong. Moral thinking is developed and strengthened through personal decisions to take moral actions, but is hindered by being coerced into moral action. (Myers, D., 1996, p.139)
The qualifying criteria of individuals with antisocial personality disorder are as followed. The individual repeatedly fails to adhere to the social norms that carry consequences of arrest, regardless if the individual has been previously held accountable for his or her actions. To achieve goals of personal profit and pleasure, the individual will lie, con, deceive, or use aliases to manipulate others. These people show an inability to foresee consequences of their actions, are impulsive, or fail to plan ahead. The personal safety of the individual and others are held with reckless disregard.
Individuals show increased signs of irritability and aggression through the frequency of physically violent behaviors towards others. These people show patterns of being irresponsible through the inability to manage their financial affairs and maintaining consistent employment. After violating the rights of another, through theft, physical harm, cruelty, or etc the individual presents a lack of remorse or justifies his or her behavior. To further meet, the criteria the individual must be at least eighteen years of age, and met the criteria for conduct disorder after the age of fifteen.
Most individuals with antisocial personality disorder present common associated features that conflict with the social norm. The failure to demonstrate concern for the emotional state of others is a highlighted component of antisocial personality disorder. However, not directly life threatening, it allows the individual to participate in actions that often hurt others. These individuals rarely show signs of empathy, especially when they are the source of the other person’s hardship. A blatant disregard for their own action and the consequences to a victim’s physical or mental condition coincides with their inability to connect with others on an emotional level.
The separation from society becomes a source of advantage when violating another’s rights. People within the normal population, governed by social rules and norms, are often viewed merely as sheep that are beneath the sanctimonious self-perception of those with antisocial personality disorder. The lack of conformity to the social norms is the weakness they are diagnosed for, while viewed as a personal strength that allows them to elevate his or herself above the masses. With this being the underlying social belief system, it becomes logical as to why so few seek treatment, or why successful treatment statistics are rare. The ideology is that they are not the ones who are sick, we are; we are the ones who are weak, and therefore, we deserve what happens to us. The consequences of social conformity are pain, suffering, and personal loss as we are neither not smart enough, nor strong enough to think for ourselves and behave as they do.
Failures to succeed in normal society, educationally and occupationally, are undermined by a sense of arrogance that puts such activities beneath them. A self-appraisal that asserts, if he or she were to actually perform a specific job or take part in a class, he or she would exceed the efforts of all others. However, more often than not such tasks are rarely carried out for very long, as the initial goal in their being there may be misrepresented. A failure to carry out long term goals are lost or forgotten in the work that is required to achieve those goals. This maybe derived from a reality that it is not in the goal to succeed, but the goal that he or she could actually prove, they could be there if they wanted.
If proof of attendance is used to replace the failure of reaching a goal, it becomes a reinforcer of being better than those who have to be there. Moving in and out of society by way of mediocre jobs helps to reinforce their arrogance as it gives further opportunities to use faulty self-talk to justify social incompetence. This arrogance increases the high value of their own opinions over others as well as speaking to others, as though they are inferior. It is not uncommon for those with antisocial personality disorder to manipulate conversations to make his or herself seem of greater intelligence. This is often accomplished by using words or technical dialogue that will hopefully impress the user by affirming a sense of inferiority in them. These individuals master verbal manipulation and in such skills can often even intimidate or bait professionals. (Comer, R., 2001, p. 518-519)
It should not be surprising that because people with antisocial personality disorder have such profoundly underdeveloped interpersonal skills that intimate relationships are often unhealthy. These individuals often view sex and love as two very separate aspects of life. This point allows for the high potential of these individuals having histories that include many sexual partners. In addition, intimate relationships with those they do have emotional attachments, in many cases are not monogamous. These individuals can be found exploiting and deceiving others with the intent to meet their own sexual needs with no regard for the other persons needs.
With having such irresponsible sexual behaviors these individuals often, parent children for which they are incapable of providing adequate care. Even in cases of planned pregnancies, the children often suffer from negligence or abuse. Poor hygiene and inadequate nourishment often lead to illnesses in these children. It is not uncommon for these children to rely on people outside of the home to provide for their basic needs. When children are not living with the parent who has been diagnosed with antisocial personality disorder, it is uncommon that they receive financial support from this parent.
Other associated features that are common among those with antisocial personality disorder involve living condition. Because of difficulties in the work force, they are unable to be self-supporting, which increases the need for them to engage in criminal behavior. With out a sufficient means of financial support the individuals often live in conditions of poverty and at some point have been or will become homeless. Those individuals who have served in the armed forces may have been dishonorably discharged. Those with antisocial personality disorder may spend a considerable amount of their lives incarcerated, on parole, or probation and have had multiple convictions for various crimes. Furthermore, because of the high-risk life styles of these individuals, life spans are cut short by way of suicide, accidents, and homicide.
People with antisocial personality disorder may share experience negative psychological states more so than those in the average population. A constant state of dysphoria may encompass much of their psychological well-being. When considering the stresses of finance, employment, etc complaints of tension frequently arise. However, tension may also be caused be the result of a physiological abnormality attributed with this disorder. These individuals find it difficult to deal with boredom, and lack the skills to find constructive solutions to it. A depressed mood may also be frequently experienced.
Several physiological elements have been associated with antisocial personality disorder. “Research reveals that people with this disorder often experience less anxiety than other people, and so may lack a key ingredient for learning.” (Comer, R., 2001, p.521) This can account for learning derived from negative experiences as well as perceiving emotional cue or anxiety in others. Individuals may develop a coping response to aversive stimuli, such as child abuse, where normal emotional responses diminishes and new emotional based learning occurs or is reinforced. The new emotional based learning to violent stimuli may rewire neural circuitry that associates empathy or sympathy of others in violent situations. (Carlson, N., 2001, p. 343)
For the diagnosis of antisocial personality disorder to be given, the individual must have met the diagnosis qualification for conduct disorder. Conduct disorder similarly reflects the behaviors presented in antisocial personality disorder tailored to accommodate age based criteria, as it is a childhood disorder. The DSM-IV-TR states conduct disorder is, “A repetitive and persistent pattern of behavior in which the basic rights of others or major age appropriate societal norms or rules are violated, as manifested by the presence of three (or more) of the following criteria in the past 12 months, with at least one criterion present in the last six months.” (p. 98). Because this disorder may not have been diagnosed in childhood, the time frame is inapplicable as long as a notable pattern in criteria was presented. The following includes the criteria as well as possible causation, as conduct disorder is a prerequisite of antisocial personality disorder.
The first category addresses the forms of aggression towards people and animals. This may include bullying, threatening, and intimidating the child’s peers. The child may often provoke or initiate physical fights or has with intent been physically cruel to people or animals on numerous occasions. The child may use weapons that result in serious or life threatening harm to another individual. The child has initiated or been apart of a theft, while confronting the victim such as in a mugging or armed robbery. The child may also have forced a peer into sexual activity.
The second category involves the child’s participation in the destruction of property. This requires the child’s deliberate acts of setting a fire to cause serious damage, or destroying someone’s property by other means. The third category encompasses deceitfulness or theft. The child may have broken into a house, car, or building, or con another for goods, favors, or to avoid obligation by lying. The child may also have a history of theft while not confronting the victim, as seen in shoplifting.
The fourth category demonstrates the child’s serious violation of rules. Before the child is thirteen years, he or she disregards the parents imposed curfews by not coming home on time. The child on multiple occasions has run away from home, being away all night, or on one occasion left for an extended time. The child has a history of truancy from school prior to thirteen years. Furthermore, a child with conduct disorder has clinically significant deficits in social, academic, or occupational functioning.
The similarities between the diagnostic criteria of antisocial personality disorder and conduct disorder should not come as surprise. As the individual matures in age, so too, will his or her behaviors evolve. Because antisocial personality disorder does present in a pervasive pattern, the underlying psychological and sociological causes must begin during childhood. “The family is the child’s introduction to society and has, therefore, borne the major responsibility for socializing the child.” (Berns, R., 1993, p.49) With socializing the child as being the task, the tools the parent has and uses to accomplish the task will then predict the outcome.
With the family prevalence associated with antisocial personality disorder there is an increased likelihood that the parents may have the same or a related disorder. If the parent has not been diagnosed, in most cases, the parent will present some of the genetic characteristics of the disorder. In addition to the biological components, low socioeconomic and urban ecological based systems make up the fundamental tools and availability of acquiring new tools, to socialize the child. The parenting style and skills used to raise a child are also considered tools but those are likely to be influenced by the three fundamental factors the carious behaviors presented in conduct disorder are often attributed to how parents utilizes these four tools.
Children, particularly those with a predisposition to developing antisocial personality disorder, are predominately set on course, to develop the disorder based on parental reading. “Psychopathology derives in large part from problems and conflicts that arise in early mother-child relationships but is made worse by other stresses.” (Corsini, R., 2000, p. 111) Children first learn about social relationships and social behaviors in the home. This behavioral understanding is then what the child perceives as the social norm when entering public institutions such as school. If the child’s peers present the same or similar behaviors the child’s will be positively reinforced, if negative feed back is received the child is only able to assess this with what he or she knows.
Though there may be other causes for the symptoms of conduct disorder, those of child abuse, maltreatment, and discipline will be identified here. “The family circumstances of maltreated children impair the development of emotion, self-regulation, empathy and sympathy, self-concept, and social skills.” (Berk, L., 2000, p. 592) These developmental impairments are the same for the qualifying criteria in assessing a diagnosis of antisocial personality disorder. Maltreated children prove to be disciplinary problems in organized social settings because of their inability to conform to social norms, lack of motivation, and cognitive maturity level. This dramatically influences educational success that will have an impact in adulthood. Furthermore, this may be the source that conceives the spiritual, consciences, and moral difficulties attributed to substance-related disorder and antisocial personality disorder.
Ethnicity also contributes to the cause of antisocial personality disorder. Families immigrating to new countries also suffer from psychopathology and affective disorders that create hardships for the communities. The post immigration factors, which include loss of support system, language barriers, stress, and anxiety of leaving ones homeland, can precipitate psychological disorders. Conflicting societal norms increases the difficulty of acculturation often creating conflict between parents and children. This parent/child conflict and the parents own life stresses affects parenting practices that result in the child developing behavioral problems.
The child’s home life difficulties and socialization difficulties have the potential of resulting in conduct disorder. If left uncorrected the child risks the potential of acquiring antisocial personality disorders in adulthood. The treatment for such problems becomes more complex in such situations as ethnical factors also contribute symptoms of the disorder. The average person with a personality disorder rarely seeks treatment, as they do not see themselves as having a problem. This characteristic couple with a cultural belief that deems discussing private family problems with a stranger increases the chances that this individual will not seek help, and if forced by courts to seek therapy, he or she will not participate.
Children who are physically punished or abuse become more aggressive themselves, and incidentally learn fewer problem-solving skills that are nonviolent. Punishment often reflects the child’s own aggressive behavior so the child receives fewer alternatives to his or her own behavior. Physical punishment is often perceived as retaliation for a transgression from the parent, which will likely result in retaliation attacks toward the child’s peers for their transgressions. This fosters a belief a pattern of justification for their violent behavior, removing the burden of remorse because of, “He had it coming!” sentiments. “Kids become accustomed to physical pain that such pain is no longer important to them, therefore a useless deterrent to future violence.” (Kostelnik, M., 1993, p.248)
A child’s aggressive behavior increases the chances of the child not being accepted into peer groups. This increases social isolation and decreases opportunities to develop social norms. Often aggressive behavior can be linked to the child dropping out of school or engaging in criminal activity. The regard for social norms is never fully developed, as a sense of belonging to society was not fostered. This develops in a circular fashion and is continuously reinforced as antisocial behavior results in social isolation, which induces further antisocial behavior. (Berger, k., 1995)
Antisocial personality disorder has proven to be extremely difficult to treat due to the wide range of problems it encompasses. It seems treatment of antisocial personality disorder carries a general consensus show in the following statements. “Antisocial personality disorders are rarely treated with success.” (Coon, D., 1997, p. 530) “Generally, however most of today’s treatment approaches have little or no impact on people with antisocial personality disorder.” (Comer, R., 2001, p. 523) Since the scope of the disorder is so wide, for treatment to be successful it must be flexible enough to utilize a variety of approaches.
Treatment requires time, motivation, commitment, and a desire to change, all of which are qualities that tend to be underdeveloped in those with antisocial personality disorders. Treatment of antisocial personality disorder may include social skills training, problem-solving skills training, and parent management training. Individuals can benefit from operant conditioning techniques to replace aggressive behavior with pro-social behavior. Family therapy that addresses family systems and individuals should also be included in the treatment scope. Programs utilized to transition adults and children into becoming members of society have proven to be helpful.
Treatment is most successful in outpatient care, when emotion is the foundation. Because of the difficult in applying appropriate feelings to behaviors, one of the most helpful skills the therapist can teach an individual with antisocial personality disorder, is how to do this. This lesson in feeling can be done so in such a way that the client learns how to deal will feelings that are frightening. In addition, for the client to want to continue therapy, the client needs to be able to come to terms with therapy as being a good choice for him or her and worthwhile enough to continue. When therapy is successful, the client will likely indicate this by developing signs of depression, which needs to be actively addressed with the client.
Treatment for those with antisocial personality disorder for those individuals confined to an institution, such as a jail would most benefit from an educational based approach to therapy. This therapy should offer multiple opportunities to learn new coping skills, especially those with a history of aggression and violence. Basic social skills that focus on personal relationships within the family, friends, and members of community with focuses in areas like communication and respect may prove to have mild benefits. The therapist may consider addressing goals for the individual after he or she is released. The problem with this in large is the failure to preplan and follow through, good intentions are often left at the gate upon release.
Dr. Philip Long has indicated that clients with antisocial personality disorder cannot be cured through a one on one therapeutic approach. These individuals need multiple social interactions to begin developing the social skills needed to supplement parent/child relationships in which they were deprived. "Membership in altruistic but revolutionary movements, such as the Black Panthers or Guardian Angels; self-help groups, such as AA; and even marriage to a person as needy as the patient - all seem to be more useful to the antisocial personality than one-to-one therapy." (Long, P., 1990) After one on one treatment appears to be going well, it would further the therapeutic progress to refer the client to a group therapy program with an experienced leader. Therapists should not offer group programs until the client is comfortable with addressing, accepting, and dealing with the emotions that may arise.
Alcoholics Anonymous. (2005). The Big Book Online (chap. 5). Retrieved July 15, 2005, from http://www.aa.org/bigbookonline/en_BigBook_chapt5.pdf
American Psychiatric Association. (2003). DSM-IV-TR: Vol. . Diagnostic and Statistical Manual of Mental Disorders (4th ed.). Washington, DC: Author. (Original work published 2000)
Berger, K. S., & Thompson, R. A. (1995). The Developing Person: Vol. . Through Childhood and Adolescence (4th ed.). New York: Worth Publishers Inc. (Original work published 1980)
Berk, L. E. (2000). Child Development (5th ed.). Massachusetts: Allyn and Bacon. (Original work published 1989)
Berns, R. M. (1993). Child, Family, Community: Vol. . Socialization and Support (3rd ed.). Florida: Harcourt Brace Jovanovich Publishers. (Original work published 1985)
Carlson, N. R. (2001). Physiology of Behavior (7th ed.). Massachusetts: Allyn and Bacon. (Original work published 1977)
Comer, R. J. (2001). Abnormal Psychology (4th ed.). New York: Worth Publishers. (Original work published 1992)
Coon, D. (1997). Essentials of Psychology: Vol. . Exploration and Application (7th ed.). California: Brooks/Cole Publishing Company.
Corsini, R. J., & Wedding, D. (2000). Current Psychotherapies (6th ed.). California: Wadsworth/Thomas Learning.
Craighead, L. W., Craighead, W. E., Kazdin, A. E., & Mahoney, M. J. (1994). Cognitive and Behavioral Interventions: Vol. . An Empiracle Approach to Mental Health Problems. Massachusetts: Allyn and Bacon.
Doweiko, H. E. (2002). Concepts of Chemical Dependency (5th ed.). California: Brooks/Cole.
Grohol, J., Dr. (1998). Antisocial Personality Disorder Treatment. Psych Central. Abstract retrieved July 13, 2005, from http://psychcentral.com/disorders/sx7t.htm
Kostelnik, M. J., Ph.D., Stein, L. C., M.S., Whiren, A. P., Ph.D., & Soderman, A. K., Ph.D. (1993). Guiding CHildren's Social Development (2nd ed.). New York: Delmar Publishers Inc.
Long, P. W.. Antisocial Personality Disorder Treatment. Mental Health. Abstract retrieved July 15, 2005, from http://www.mentalhealth.com/rx/p23-pe04.html
McGoldrick, M., Giordano, J., & Pearce, J. K. (1996). Ethnicity & Family Therapy (2nd ed.). New York: The Guilford Press.
Medical Encyclopedia. (2004). Treatment. Antisocial Personality DIsorder. Abstract retrieved July 15, 2005, from http://www.nlm.nih.gov/medlineplus/ency/article/000921.htm#Expectations%20(prognosis)
Mental Help Net. (2001).
Treatment - Antisocial
Personality Disorder. Personality
Myers, D. G. (1996). Social Psychology (5th ed.). New York: McGraw-Hill. (Original work published 1983)
Oltmanns, T. F., & Emery, R. E. (1998). Abnormal Psychology (2nd ed.). New Jersey: Prentice-Hall Inc.
Papalia, D. E., & Olds, S. W. (1988). Psychology (2nd ed.). New York: McGraw-Hill. (Original work published 1985)
Shea, S. C., M.D. (1998).
Vol. . The Art of Understanding (2nd ed.). Philadelphia: Saunders.
work published 1988)