Antisocial Personality Disorder

Antisocial Personality Disorder is a personality disorder marked by a pattern of antisocial behavior which begins in childhood or early adolescence and is characterized by aggressiveness, fighting, hyperactivity, poor peer relationships, irresponsibility, lying, theft, and inappropriate sexual activity, as well as drug and alcohol abuse.

As adults, assaultiveness, self-defeating impulsivity, hedonism, promiscuity, unreliability, and continued drug and alcohol abuse may be present. Criminality may be involved.

Individuals with antisocial personality disorder fail at work, change jobs frequently, tend to receive dishonorable discharges from the military, are abusing parents and neglectful spouses, have difficulty maintaining intimate relationships, and may be convicted and spend time in prison.

Antisocial Personality Disordered persons are frequently anxious and depressed and show both conversion symptoms and factitious symptoms. Antisocial behavior often peaks in the late adolescence and early twenties and lessens in the late thirties. This is primarily a diagnosis of males, the prevalence rate being approximately 4:1 males to females.

Clinical Presentation

The Antisocial Personality Disorder is recognizable by the following behavior and interpersonal style, cognitive style, and emotional style.

The behavioral style of antisocial personalities is characterized by poor job performance, repeated substance abuse, irresponsible parenting, persistent lying, delinquency, truancy, and violations of others’ rights.

Antisocial Personality Disordered individuals are also noted for their impulsive anger, hostility, and cunning. They are forceful individuals who regularly engage in risk-seekign and thrill-seeking behavior.

Their interpersonal style is characterized as antagonistic and belligerent. They tend to be highly competitive and distrustful of others and thus poor losers. Their relationships may at times appear to be “slick” as well as calculating.

The flavor of this DSM-5 diagnosis still retains some of the “criminal” diagnostic category. Yet, these criteria can also characterize the behavior of successful businessmen, politicians, and other professionals , who could be described as ambitious, hard driving, and successful.

The cognitive style of the antisocial personality is described as impulsive and cognitively inflexible as well as externally oriented. Because they are contemptuous of authority, rules, and social expectations, they easily rationalize their own behavior.
Their feelings or emotional style are characterized by shallow, superficial relationships that involve no lasting emotional ties or commitments. They avoid “softer” emotions such as warmth and intimacy because they regard these as signs of weakness.

GuiltOpens in new window is seldom if ever experienced. They are unable to tolerate boredom, depression, or frustration and subsequently are sensation-seekers. They are callous toward the pain and suffering of others and show little guilt or shame over their own deviant actions.

DSM-5 Characterization

Individuals with this personality disorder are characterized by an unremitting pattern of disregarding and violating the rights of others. They disrespect and disregard laws and social norms, and regularly engage in acts that are grounds for arrest.

These individuals lie, are deceitful, and will take advantage of others for pleasure or for personal profit. They are impulsive and fail to plan ahead. They are also irritable and aggressive, which results in physical fights or assaults.

It is not surprising that these individuals disregard the safety of others as well as of themselves. Their irresponsibility is demonstrated by their failure to engage in consistent work behavior and failure to meet financial obligations. Furthermore, their lack of remorse is shown by their indifference in having hurt, mistreated, or stolen from others (American Psychiatric Association, 2013).

Case Example: Mr. A.
Mr. A. is a 24-year-old Hispanic male who presented late in the evening to the emergency room at a community hospital, complaining of a headache. His description of the pain was vague and contradictory. At one point he said the pain had been present for three days, while at another point it was “many years.” He indicated that the pain led to violent behavior and described how, during a headache episode, he had brutally assaulted a medic while he was in the Air Force. He gave a long history of arrests for assault, burglary, and drug dealing. Neurological and mental status examinations were within normal limits except for some mild agitation. He insisted that only Darvon—a narcotic—would relieve his headache pain. The patient resisted a plan for further diagnostic tests or a follow-up clinic appointment, saying unless he was treated immediately “something really bad could happen.”

Case Example: Mr. A.

Mr. A. is a 24-year-old Hispanic male who presented late in the evening to the emergency room at a community hospital, complaining of a headache. His description of the pain was vague and contradictory. At one point he said the pain had been present for three days, while at another point it was “many years.”

He indicated that the pain led to violent behavior and described how, during a headache episode, he had brutally assaulted a medic while he was in the Air Force. He gave a long history of arrests for assault, burglary, and drug dealing.

Neurological and mental status examinations were within normal limits except for some mild agitation. He insisted that only Darvon—a narcotic—would relieve his headache pain. The patient resisted a plan for further diagnostic tests or a follow-up clinic appointment, saying unless he was treated immediately “something really bad could happen.”

Psychopathy, Sociopathy, and Antisocial Personality Disorder

Psychopaths, sociopaths, and antisocial personalities can engage in criminal behavior. For this reason, some clinicians use the terms psychopath and sociopath interchangeably.

Because research indicates some notable differences in behavior and in etiology, others prefer to differentiate psychopathy and sociopathy (Hare, 1993; Walsh & Wu, 2008).

For example, Hare (1993) identifies specific deficits in psychopaths that distinguish them from sociopaths. These include interpersonal deficits, i.e., grandiosity, arrogance, and deceitfulness, as well as affective deficits, i.e., lack of guilt and empathy.

Specifically, psychopaths are characterized by a global empathic deficit. In contrast, sociopaths can emotionally attach to others, and may feel badly when they hurt those individuals to whom they are attached. Yet, sociopaths can lack empathy and attachment toward society, and are not likely to feel guilt in harming a stranger or breaking laws.

So while both psychopaths and sociopaths are capable of committing heinous crimes, the psychopath would commit crimes against family members or “friends” (as well as strangers) and feel little to no remorse.

In terms of etiology, research suggests that psychopathy is more of an innate and genetic phenomenon, whereas sociopathy is more the result of environmental factors such as poverty, exposure to violence, and overly permissive or neglectful parenting (Stout, 2005).

Currently, Antisocial Personality Disorder is both a legal designation and DSM diagnosis that can be applied to both psychopaths and sociopaths (Walsh & Wu, 2008).

Biopsychosocial – Adlerian Conceptualization

The following biopsychosocial formulation may be helpful in understanding how the antisocial personality is likely to have developed.

Biologically, antisocial personalities manifested “difficult child” temperaments (Thomas & Chess, 1977). As such, their patterns were unpredictable, they tended to withdraw from situations, showed high intensity, and had a fairly low, discontented mood.

This ill-tempered infantile pattern has been described by Millon (2011) as resulting in part from a low threshold for limbic stimulation and a decrease in inhibitory centers of the central nervous system. Their body types tend to be endomorphic (lean) and mesomorphic (muscular) (Millon, 2011).

Psychologically, these individuals have a unique view of themselves, others, and the world.

They tend to view themselves with some variant of the theme: “I am cunning and entitled to get whatever I want.” In other words, they see themselves as strong, competitive, energetic, and tough.
Their view of life and the world is a variant of the theme: “Life is devious and hostile, and rules keep me from fulfilling my needs.”

Not surprisingly their life’s goal has a variant of the theme: “Therefore, I’ll bend or break these rules because my needs come first, and I’ll defend against efforts to be controlled or degraded by others.”

Acting out and rationalization are common defense mechanisms used by the antisocial personality disoredered individual.

Socially, predictable parenting styles and environmental factors can be be noted for the Antisocial Personality Disorder. Typically, the parenting style is characterized by hostility and deficient parental modeling. Or, the parents might have provided such good modeling that the child could not or refused to live up to high parental standards.

The parental injunction is that, “The end justifies the means.” Thus, vindictive behavior is modeled and reinforced. The family structure tends to be disorganized and disengaged.

The antisocial pattern is confirmed, reinforced, and perpetuated by the following individual and systems factors: The need to be powerful and the fear of being abused and humiliated leads to a denial of “softer” emotions plus uncooperativeness. This, along with the tendency to provoke others, leads to further reinforcement of antisocial beliefs and behaviors.

Treatment Considerations

In terms of treatment goals, these individuals are usually not interested in presenting for treatment or are resistant to treatment if they are forced by the courts, employers, or other agencies.

Individual therapy, in and of itself, has proved to be remarkably ineffective with these individuals. However, special residential treatment programs have shown some promise (Reid, 1989). There appears to be at least one exception to receptivity to psychotherapeutic treatment. When the antisocial personality disordeded individual experiences a moderate degree of depression, he or she may be willing to engage in psychotherapy in order to reduce depressive symptoms.

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