39. Antisocial Personality Disorder

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39. ANTISOCIAL PERSONALITY DISORDER

Elissa M. Bail, M.D. , and Rob in 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 one’s 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 fre-

quent 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. Examplesof such characters in literature and film include Fagin i n Dickens’ Oliver Twist he Benefactor in

Dickens’ David Copperfield, and the title characters in Bonnie and Clyde. The specific criteria for

the DSM IV1diagnosis are presented below:

A. There is a pervasive pattern of disregard for and violation of the rights of others occurring since

1 failure to conform to social norms with respect to lawful behaviors as indicated by repeat-

2. deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal

3. impulsivityor failure to plan ahead.4. irritability and aggressiveness, as indicated by repeated physical fights r assaults.

5 . reckless disregard for safety of self or others.

6. consistent irresponsibility,as indicated by repeated failure to sustain consistent work behav-

7. lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated,

aye 15,as indicated by 3 or more of the following:

edly performing acts that are grounds for arrest.

profit or pleasure.

ior or honor financial obligations.

or stolen from another.

B. The individual is at least 18 years.

C. There is evidence of conduct disorder with onset before age 5 years.

D. Occurrence of antisocial behavior is not exclusively during the course of schizophrenia or a manic

From American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders,

Antisocial personality disorder, as currently conceptualized in DSM IV, is a quantitative (behav-

iorally anchored) rather than qualitative (trait- or predisposition-based) diagnosis. However, it is im-

portant 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 spousehad 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 differ-

entiation between antisocial personality disorder and normative legal and social violations is largely

quantitative. Individuals with antisocial personality disorder, beginning in childhood, consistently

I98

episode.

Fourth Edition. Washington, DC, American Psychiatric Association, 1994, with permission.



An isocial Personality Disorder I99

and inflexibly commit a higher frequency of antisocial behaviors resulting in maladaptive social oroccupational functioning.

The credo of the individual with antisocial personality disorder can be summarized as “I be-

lieve; therefore, it is so.” Such individuals are 100 certain of the veracity of their viewpoint, 100

certain that beca use they want som ething, they shou ld receive it. They are 100 certain that be-cause 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 just i f ied i n 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 indi-

viduals d o not think abou t how others perceive them an d are not concerned about the effect of their

behavior on others. Qualities such as empathy, remorse, reliability, and sincerity depend on under-

stand ing events fro m the vantage of others. The antisocial individual’s low m otivation to under-

stand another’s point of view may account f or his or her limited ability to dem onstr ate 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 includ e physical, historical, and interpe rsonal characteristics of the patient and the

practitioner’s response to the patient. Physical characteristicsof the patient include 1 multiple

tattoos, espec ially “jail-house’’ tattoos, which generally are of poor quality and completed by non-

professional 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 occup ation or in-

volvement in sports and (2) unstable lifestyle. Interpersonal characteristics nclude an ingratiating

interaction style, (2) entitled attitude with frequen t demands, (3) superficial charm with overall func-

tioning and level of success well below the level anticipated on the basis of perceived level of intelli-

gence, (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 “I’m telling you the truth, doc ” and

(6) statements suggesting a pattern of projecting blame onto others. Examples of such statements in-

clude, ‘Yeah, doc, those doctors in the p en, they’re not like you, they don’t know what they’re doing.

They never told me I shouldn’t drink . smoke . ” or “yeah, they really screwed up” or “yea h,

those fast food restaurants, they really ought to be sued by somebody . . . t is theirfault we all got

this cholesterol problem.”The practitioner’s responsesoften include:

1. A perception that the patient’s complaints or requests are manipulative, including an uncom-fortable feeling that the patient is seeking drugs. Suggestive evidence includes an u nusual d egree of

knowledge about pain m edication, a request for spe ifi addictive medication, vague responses to

questions about prior treatment providers, or subjective com plaints justifying addictive m edication

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 patient’s report, vague answ ers to m any questions, o r an irritable,

defensive response to detailed questioning.

None of these clues are pathognom onic fo r the diagnosis of antisocial personality disorder. They

are sufficiently suggestive to warrant particular notice and consideration of more detailed question-

ing, 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 C atchm ent Area (EC A) study, and the National Com orbidity Survey

(NCS). The prevalence of antisocial personality disorder in these studies was 2.4 and 3.5 , re-

spectively. In the National Comorbidity Study, 5.8 of men and 1.2% of women met criteria for an-

tisocial 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 syn ony-

mously. This is un fortunate as it fosters poor communication and poor d iagnostic reliability. Historically,

the terms psychopath and sociopath referred to persons who not only exhibited bad behavior, but suf-fered from a disorder characterized by deficits in empathy and an inability to m anage interpersonal rela-

tionships. Factor-analytic studies suggest two separate elements in psychopathy: criminality and

pathologic inteipersonallaffective behavior. Hare’s Psychopathy Check list measures both elements.

When both elements are considered, only 10-25 of crim inals meet d iagnostic criteria for psychopathy.

In comparison, between tw o-thirds and th ree-quarters of m ale prison populations meet the definition ofantisocial personality disorder w hen DSM IV criteria are used. In other words, psychopaths are probably

a more pathologic subset of the b roader category of those with an tisocial 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, impul-

siveness, egocentricity, shallow affect, and a failure to learn f rom experience. Criteria based on traits

are generally less diagnostically reliable. A trait approach requires the diagnostician to determine ab-

solutely the presence or absen ce 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 Ch ecklist-R evised 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 diag-

nostic reliability. Though it may be difficult to reach agreement on whether a given patient is irre-

sponsible, it is relatively easy t o determine whether a person has o r has not failed to honor financial

obligations o r provide child suppo rt. Althoug h clinicians can diagn ose reliably the presen ce or ab-

sence of a personality disorder, they are not able to distinguish reliably between the different person-

ality disorders. B ecause of its beh avioral anch ors, however, the diagnosis of antisocial personalitydisorder has the highest diagnostic reliability of all personality disorders.

5 Discuss the differential diagnosis of antisocial personality disorder

Antisocial p ersonality disord er mu st be differentiated fro m antisocial behavior. Antisocial be-

havior may be comm itted intermittently by m any people without m ental disorders or m ay be a symp-

tom of another disorder. To differen tiate between antisoc ial beha vior an d antisocial personality

disorder it is necessary to consid er whe ther the patient m eets criteria for a personality disorder.

Patients must dem onstrate a pervasive, enduring, and inflexible antisocial pattern of perceiving, re-

lating to, and thinking about themselves, others, and their environment.

Although antisocial personality disorder, not unexpectedly, is represented disproportionately inprison populations, a p attern of criminal behavior (beginning before or after age 15) is insufficient to

make the diagno sis. Studies of prison pop ulations have reported prevalence rates of antisocial per-

sonality disord er as low as 40 and as high as 75 . Prisoners without antisocial personality disor-

der may include “professional criminals,” those involved in organized crime, and one-time

offenders. Many such persons clearly disregard th e rights of others and may h ave no remorse for

their harmful effects. However, if they are neither aggressive nor impulsive, they probably do notmeet 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 depend ence are statistically significant. The presen ce of one of the three diagnoses in-creases the probability of the presence of the others. Despite this association, the diagnosis of antiso-

cial personality disorder should not be given if crim inal behavior and other antisocial behavior occur

only in the context of add iction.

Specific symptoms of antisocial personality disorder are associated with many psychiatric disor-

ders. Patients with schizophren ia, mania, sexual perversions, mental retardation, organic brain syn-

dromes, and other personality disorders (including narcissistic personality disorder) may demonstratesome but not all features of antisocial personality disorder. For example, patients with schizophrenia,



Antisocial Personality Disorder 20

mental retardation, a nd organic brain syndromes are likely to dem onstrate impaired occupational

and parental functioning. All of these disorders are sometimes associated with impulsive acts, in-

cluding 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 o r in fact is desired by the victim. At times,

only the absence of sym ptoms of a conduct d isorder 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, in-

cluding individual vulnerabilities, particular developmental learning histories, and environmentalstressors. Individual vulnerabilities includ e gen etic factors. Twin studies have de mo nstrated that

there is significant heritability involved in criminal behavior. EEG studies have found a high fre-

quency of abnormalities in sociopaths. There are studies which suggest those wh o develop antisocial

personality are born with an “uninhibited temperam ent,” lack of norm al fearfulness, and a constitu-

tionally based failure to leam from n egative 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 w hich is eni-

pirically anchored. This theory has generated interventions, primarily prevention, with demonstrated

success. Patterson proposes the following learning history: First, parents teach their children antiso-

cial 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 paren t neg-

atively reinforces the child. For exam ple, a mother ask s her son to clean his room. Like m ost children,

he does not com ply imm ediately, so the mother asks again. The child throws a tantrum. The m otherexperiences the tantrum as aversive and stops asking him to clean his room. Thu s the child is nega-

tively reinforced for his tantrum; in o ther 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 u se aversive behavior to avoid responsibility.

The second step in the developm ent of antisocial behavior occurs w hen the child begins school.

The child’s aversive behavior leads to a p redictable social outcom e: 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 d o well academically and thus may fail to learn to read or com pute math. Such

failures have dire consequ ences for occupational an d social future. Ste p three of the inexorab le se-

quence occurs when after being rejected, the child gravitates toward deviant peer groups. Such peersare likely to provide positive feedback for antisocial behaviors and punishm ent for prosocial behaviors.

Epidem iologic studies have identified clear environm ental and social factors which correlate with

antisocial personality disorder. Social structures affect the prevalence of personality disorders by low -

ering or raising the threshold at which other risks influence their development.6Though there are nodifferences in prevalence of antisocial personality disorder among U.S. racial groups, there are impor-

tant cross-cultural differences in its prevalence. In east Asian cultures with low como rbid alcoh olism,

antisocial personality disorder has an unexpe ctedly 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 supp orted by the fact that the prevalence of antisocial personality disorder is

increasing dramatically in North Am erica. Both the EC A and NCS studies found that the lifetimeprevalence of antisocial personality disorder nearly doubled am ong youn g people in 15 years. Such

rapid increases in such a short time period can be accou nted for by chan ges in the social environm ent.

7. What is the prognosis for the patient with antisocial personality disorder?

Impairment is the rule, although it may range from mild to severe. No t uncomm only, profes-sionals or laypersons refer to various prominent persons, such as politicians, as “sociopaths.”

Sociopathic qualities such as disregard for the truth and lack of remo rse are perhaps present in m any




individuals drawn to positions of national recognition or power. However, economic or political suc-

cess 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.

Impairm ent due to the disorde r is frequently severe. Typically, such individuals fail to becom eindependent, 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 sui-

cide, homicide, or com plications of drug or alcohol abuse.

Although people who meet criteria for antisocial personality disorder are at risk of early dea th, the

prognosis for those who live to middle-age is som ewhat 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 per-

sonality disorder 29 years after initial hospitalization. The vast majority has ongoing impairm ents, par-

ticularly in interpersonal relationships. Th e mo st 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 per

sonality disorder?

Health care professionals frequently experience the following problems with patients diagnosedwith antisocial personality disorder: (1 ) difficulty in collecting reliable history, (2) difficulty in man-

aging 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 d ishonesty of patients with antisocial personality disorder m akes it difficult to collect reli-

able history. Inconsistency or vagueness is a clue that the patient may be lying. Nonverbal cues in-

clude stam mering, short an swers, hesitations, excessive blinking, dilated pupils, and excessive

touching of clothing. The patient is likely to blame the clinician who questions inconsistencies (e.g.,

“aren’t you listening?” “you heard that wrong,” “I didn’t say that,” or “use your head, d oc”). In such

situations, straightforward delineation of the co sts and benefits of presenting an accurate history is

useful. Patients with antisocial personality disorder respond best to an approach based on self-inter-

est. Fortunately, they typically have the capacity a nd m otivation 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 patient’s responsibility to deal with the consequences of antisocial behav ior.

2. The clinician m ust set clear expectations regarding acceptable behavior.

3. Th e clinician must take a nonjudgmental stance and objectively help the patient to considerthe 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 (probab le reduction in care). Given the patient’s difficulty

appreciating any point of view other than his or her ow n, i t is more effective to emphasize the effects

on self than on others.

The health care provider also m ay expe rience conflict between responsibility to the patient andresponsibility to the patient’s dependents or society. Informing the patient of the limits of confiden-

tiality at the onset of treatment helps to am eliorate such problems. F or exam ple, the patient shouldbe 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 informedthat 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 n ot only provides info rmation but also enables the clinician to wearone rather than multiple hats. For example, in the case of mandated reporting of child abuse, by con-

sulting 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 than50 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 patient’s responsibility to deal with the conseq uences of his or her behavior, the provider m ust

deal appropriately with her o r his own feelings. The clinician’s perusal of police reports may result

in anger, fear, or horror. So m e clinicians avoid reading police reports fo r fear that such feelings m ayprevent them from providing adequate care. As a result of the marked tendency of patients with anti-

social personality disorder to project blame and responsibility, the clinician may experien ce gu ilt,

impotence, and hopelessness. It is important, particularly for the introspective health care provider,

to study the patient’s behavior, not his or her own. Finally, it is important to recogn ize that feelings

of apathy or boredo m may shield more intense feelings. Signs that clinicians m ay be acting out their

feelings inappropriately include forgetting appointments and other commitments, collud ing with

staff in denigrating the patient, colluding with the patient in denigrating staff, giving the patient spe-

cial 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) ex-

presses concern about personal safety, whether based on clearcut logic o r “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 comp le-

tion 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 comp lete fabrica-

tion of symptoms fo r secondary gain). For example, the patient may wish to avoid work, m ilitary con-scription, or prison time or to obtain financial gain, disability payments, or drugs. Clinicians should

ask them selves, “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 addic-

tive medications when possible. When such medications are prescribed, the clinician must be ex-plicit and write ou t exactly how much is to be dispensed-e.g., “dispense 4 (four).” Th e 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 amo unts should be prescribed from visit to v isit. The patient should

be notified that the clinician will not provide ex tra prescriptions if they are “lost,” “stolen,” or “acci-

dentally flushed down the toilet.”

CONTROVERSY

10. Is antisocial personality disorder a treatable condition?Against:

1. Prior com prehensive, costly programs in which offen ders were diverted to secure treatment

facilities rather than prison demonstrated no sufficient improvement or decrease in recidivism to

warrant the co st to society. In fact, in one study (Rice, et al.) a psychopathic subset actually demon-

strated increased violent recidivism after receiving treatment, in contrast to the non-psych opathic an-

tisocial 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 ou tcome studies of patients with antisocial personality d isorder involve

significant method ologic problems: 1 ) Few outcome studies identified subjects by DSM I11 or




DSM-111-R criteria; (2) no stu dies in which diag nos tic criteria were well-defined em ployed no n-

treated 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 pa-

tients with antisocial personality disorder treated with other modalities for an extended time in a

forensic setting. Schizophrenia do es not respond to psychody namic psychotherapy but is generallyagreed to be a treatable condition. Depression does not generally im prove with psycho analysis but

often responds to cognitive therapy, antidepressant medication, or a combination o f 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 pre-

vented. Parent-manage ment training, cognitive therapy, and court-diversion appear to be promising

approaches. In summary, conclusions about the treatability of antisocial personality disorder are pre-

mature; it is as scientifically valid to say that su ch patients are treatable as it is to say that they are not.

2. Patients w ith antisocial personality disorder have a significant risk of early death but also a

good chan ce of spontaneous remission (or at least substantial improvement) if they live till age 30 or

35. At a minim um, this observation supports crisis intervention strategies aimed a t decreasing the risk

of early death and minim izing negative effects of antisocial behavio rs on both the patient and others.

3. For unclear reasons, the standard for psychiatric medical con ditions ap pears to equate “treat-

ment” 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 treata-

bility of antisocial personality diso rder requires clea r definition of the target symptoms to be reduced

or relieved. Target symp toms may include prevention o r treatment of violent death, aggression, sub-

stance abuse, impulsivity, or concomitant major mental disorders. Individuals with antisocial per-

sonality disorder have a 5-50-fold increased risk of exp eriencing concurrent mania, schizophrenia,

and alcohol or drug abuse. Prognosis is improved by treatment of con current anxiety and depression.

Treatment of such disorders may prolong life and decrease personal and societal dam age while

awaiting possible spontaneous remission.

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39. Antisocial Personality Disorder