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Antisocial personality disorder

Antisocial personality disorder. The most salient diagnostic feature of antisocial personality disorder is a repeated violation of the rights of other people and the normal society. You may also put it in more formal terms, sociopaths is used to describe these people and psychopath is also used at times. People with this disorder are not usually patients. They are more often found in courts and prisons and welfare offices, sometimes in government. Usually if people do come to mental health facilities they come because they are unwilling, they are dragged there unwillingly by police or other authority figures, or they come there because they are wanting to avoid the consequences of some act of theirs. By definition, people with antisocial personalities sort of begin the disorder.

In childhood they typically lie, steal, fight. They have pervasive difficulties with authority. In adolescence their sexual behavior may be unusually aggressive. It is usually excessive drinking and drug use. By the time they reach adulthood they are usually unable to hold a job or maintain stable family ties. Alcoholism, vagrancy and social isolation are quite common among these people. A substantial number of people with antisocial personality disorder commit suicide, contrary to the popular image of these people as oblivious to what goes on in the outside world.

People with antisocial personality disorder can be quite charming. They are often very good and manipulating and conning other people, so that in fact they can present to you the psychiatrist in a strikingly normal fashion. In fact, when I was in training one teacher said to me, "When you see someone in consultation who appears to have no disorder at all, think first about the possibility that someone might not have a disorder, which we usually donít think about, and think secondly about the possibility that this is psychopath, this is someone with antisocial personality disorder." The major defense that these people use is acting out. That they really give expression through action to feelings that they are largely unaware of.

Diagnostic criteria. You have to look at conduct disorder before the age of 15 and then a pattern of irresponsible antisocial behavior after the age.

In terms of the etiology, both environmental and genetic factors are clearly implicated in the genesis of antisocial personality disorder. The main environmental factor appears to be sustained deprivation in childhood of any consistent stable relationship. The classic example of this kind of deprivation is parents who are inconsistently available to the child and parents who are impulsive and erratic in their behavior. Parents who are beset with substance abuse, mental problems of their own, including a personality disorder. So itís no surprise that antisocial personality disorder is frequently found in the parents of people.

In terms of genetic factors, studies have shown that having a sociopathic or alcoholic father is a powerful predictor of developing antisocial personality, even in children who were adopted away and raised by foster parents or adoptive parents who did not have antisocial personality disorder and are not substance abusers. Studies also suggest genetic factors and the concordance among identical twins of antisocial personality disorder is far higher than in fraternal twins. The antisocial personality disorder is not correlated with living in a high crime area, it is not correlated with keeping bad company. Itís not correlated with being a member of a deviant sub-group within our society.

In terms of the prevalence of this disorder, itís estimated to be 3% for males and less than 1% for females. This disorder is more commonly found among the lower socioeconomic groups. Probably because most people with antisocial personality disorder have very poor work records and therefore impaired earning capacity. Also the fathers of people with this disorder often had antisocial personality disorder, so many of these people grew up impoverished. But antisocial personality disorder is found in all 

In terms of the course and prognosis; two changes seem to occur. As they enter their 30ís and 40ís the symptoms of this disorder seem to remit. Roughly 2% of antisocial people stop their antisocial behavior each year after the age of 21 and many of those that stop their antisocial behavior in adult years become hypochondriacal, depressed and become chronic substance abusers. So some people seem to improve, some people seem to burn out and sink into more internalized forms of psychopathology. Itís important to distinguish antisocial personality disorder from criminality. Because antisocial personality disorder impairs all aspects of a personís life and particularly this disorder is characterized by a lack of loyalty. So that antisocial people canít maintain loyalty to family, to friends, even to the mob if they are part of the mob. There are other people who engage in criminal behavior who can be quite loyal to other people, including their families. Borderline personality disorder is often confused with antisocial personality disorder because borderlines can act out in antisocial ways. But borderline individuals are usually more overtly self-destructive. They have more chaotic, overtly chaotic relationships. Itís important to distinguish antisocial personality disorder from mania because, as you know, mania can involve quite a bit of antisocial behavior. But as you also know, mania is clearly episodic in almost all cases, rather than chronic. And antisocial behavior is chronic, and goes way back. It is also important to distinguish substance abuse from antisocial personality disorder, as you know the two often go hand in hand. But one of the important things about substance abuse research that has taught us is that many people look antisocial, look like they have other personality disorders while they are under the influence of substance abuse. When you remove the substances from their lives, when they are substance free, they may take up to a year, many people no longer exhibit features that would give them the diagnosis of antisocial personality disorder or other personality disorders. So it is very possible that substance abuse is primary for some people and that the manifestations that seem to be a personality disorder are secondary. Unfortunately most of the time we simply have to try to deal with both at once.

Antisocial people look unreachable and untreatable, and as I said, when their behavior is rigidly contained many of them will respond to interpersonal therapies but they are extremely sensitive to criticism and rejection. Peer support is often very effective in helping antisocial people understand more about their denial of their own destructive behavior. One of the things that we are all tempted to do is to rescue charming sociopaths from the consequences of their behavior and this is absolutely contraindicated. So one of the things that is an absolute condition of any treatment in any evaluation, even in the emergency room, is that the antisocial individual is responsible for whatever they have done and that your job is not to help to mitigate the consequences. That has

Borderline personality disorder individuals are very adept at blackmailing other people to do their bidding and many of you are quite familiar with this; the patient who is about to leave at the end of a Friday afternoon session and puts a hand on the doorknob and says, "Oh, by the way. I have a stash of pills and I think Iíll probably kill myself so I wonít see you next week." Many borderline individuals are overwhelmed by anger and frustration. They have low frustration tolerance. And often it is the overflow affect that prompts impulsive activity. Repeated self-destructive acts are the other most discriminating feature of the borderline disorder. So intense unstable relationships and repeated self-destructive acts are really the most discriminating diagnostic features. The self-destructive acts include wrist slashing, overdosing, car crashes, drug use, sexual promiscuity, abrupt changes in jobs. Often these are people who look quite good on interviews for jobs but