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ANTISOCIAL
PERSONALITY
DISORDER
SPEAKER: AMIT CHOUGULE
dramitkumarchougule@gmail.com
OVERVIEW
 Introduction
 Historical Aspects And Evolution Of The Concept
 Epidemiology
 Different Perspectives
 Comorbidity
 Course And Prognosis
 Assessment
 Management
 Ethical Issues
A MODEL OF PSYCHIATRIC DISORDERS
1. Disorders of brain chemistry/brain functioning:
 Schizophrenia Bipolar disorders
 Anxiety disorders Major depressions
2. Disorders of self in relation to others:
Personality disorders
Addictions
Disorders related to trauma
3. Disorders of self in relation to community and society:
Dissocial personality disorders
Conduct disorder
INTRODUCTION
 Dissocial personality disorder:
 Personality disorder usually coming to attention because
of a gross disparity between behaviour and the prevailing
social norms
 Anti-social Personality Disorder:
 A pervasive pattern of disregard for and violation of the
rights of others
PSYCHOPATH SOCIOPATH
1% of general population 4% of general population
Highly heritable
Minnesota twin study showed 60%
heritability
They are simply “ That way”
Origin lies in environment and
upbringing
Defective parenting style
Highly educated and have good
career
Uneducated and unable to have a
steady job
Controlled behaviour Erratic
Manipulative Impulsive
Unable to form an personal
attachment
Can form an attachment to a
particular group
Take calculated risks, minimize
evidence
Spontaneous crimes, tend to leave
evidence

PSYCHOPATHY VS SOCIOPATHY VS
ASPD
 The terms “sociopath” and “antisocial personality” refer to
behavior and its consequences
 “Psychopath” to inner experience
 Most sociologists, criminologists believe that ASPD is caused
by social conflicts and thus prefer the term Sociopathy
 Those who believe that a combination of psychological,
biological, genetic and environmental factors all contribute to
the ASPD are more likely to use the term psychopathy
1.Gross disparity between behaviour and the prevailing
social norms
2.Flagrantly and pervasively violate the rights of others
Dissocial
personality
disorder
Psychopathy/
Sociopathy
Antisocial
personality
disorder
FROM NORMALITY TO ABNORMALITY
Adventurers
Self-sufficiency
Ambition
Competitiveness
Individuality
self-determination
Dissenting
Personality
Unconventional
Push boundaries
Independent
Autonomous
Impulsive
Irresponsible
DISSOCIAL
PERSONALITY
DISORDER
STYLE VS DISORDER
PERSONALITY STYLE PERSONALITY DISORDER
Own value system above that of the
group
Consistently violates social norms
through illegal activities
Spin objective events to its advantage
without engaging in outright deception
Deceive to achieve its own ends
Style is naturally spontaneous and self-
indulgent
Too impulsive to consider the
consequences of its actions
Assertive in creating a felt physical
presence
Irritable and aggressive to the
point of repeated fights or
assaults
Remain free of external constraints
spend on the joys of the present rather
than save prudently for the future
Consistently irresponsible as to
work and financial obligations
Aggressively or impulsively self-serving,
but within moral, social, and legal
boundaries
Lacks a conscience and
rationalizes exploitation of others
Antisocial personality disorder
HISTORICAL ASPECTS AND EVOLUTION
OF CONCEPT
 Psychopathy was described by Theophrastus a student of
Aristotle
 1800:Philosophical debate between free will and
determinism
 Philippe Pinel (1801,1806):
1. Form of madness known as “la folie raisonnante”
2. manie sans delire (insanity without delirium)
3. Unimpaired intelligence and full awareness of actions
4. Intended to be descriptive, not value-laden
HISTORICAL ASPECTS AND EVOLUTION OF
CONCEPT
 Prichard (1835): Moral Insanity
Despite understanding the choices before them, their
conduct was swayed by overwhelming compulsions
“Can these individuals understand the consequences or
individuals are defective in character and therefore, worthy
of moral condemnation”
HISTORICAL ASPECTS AND EVOLUTION OF
CONCEPT
 Specific cerebral center controlled morality (Maudsley,1874)
 Koch (1891): Psychopathic inferiority
 Syndrome as an “congenital or acquired inferiority of brain
constitution”
 Kraepelin (1905) classified ‘Personality disorder’
 Schneider(1923):
 Individuals with ‘psychopathic personalities’ as those who ‘suffer
through their abnormalities or through whom society suffers’
HISTORICAL ASPECTS AND EVOLUTION OF
CONCEPT
 Psychopathy:
Literally meaning “Psychological Pathology”
First three decades of the twentieth century
Hervey Cleckley’s The Mask of Sanity (1941)
Hare developed the Psychopathy Checklist Revised (PCL-R)
which was influenced by the previous work of Cleckley
HISTORICAL ASPECTS AND EVOLUTION
OF CONCEPT
 DSM-I in 1952 included the diagnosis of Sociopathic Personality
Disturbance
1. Antisocial sociopaths referred to common offenders
2. Dissocial sociopaths included white collar criminals
 The diagnosis evolved to reflect the changing attitudes of the era
 Criminality was due to environmental factors in particular a lack
of socialization
 In 1980 with the publication of the DSMIII only the term ASPD
was used
EVOLUTION OF DSPD
Free
will
Madness
Moral
Problem
Anatomical
abnormality/
Biological
abnormality
Psychological
abnormality/
Environmental
problem
Personality
disorder
EPIDEMIOLOGY
 Condition is much more prevalent among men
 The lifetime prevalence in two North American studies was
4.5% among men and 0.8% among women
(Robins et al.,1991)
 Two European studies found a prevalence of:
1. 1.3% in men and 0% in women (Torgensen et al., 2001)
2. 1% in men and 0.2% in women (Coid et al., 2006)
 Women have:
1. Greater severity of problems
2. More complex comorbidities for both Axis I and Axis II
disorders
3. Poor outcomes
PRISON SETTING
 Worldwide- Prevalence of 47% for
men and 21% for women
 In the UK- Prevalence is:
1. 63% for male remand prisoners
2. 49% male sentenced prisoners
3. 31% female prisoners
 The prevalence of Psychopathy in
UK prisoners is:
1. 4.5% using a PCL-R score of 30
2. 13% using a score of 25
(Fazel & Danesh, 2002, Hare et al., 2000,Singleton et al., 1998)
BIOLOGICAL PERSPECTIVES
 Inborn temperaments-Aggression, Fearless, Impulsive
 Cleckley (1950):
1. Semantic aphasia
2. Inborn inability to understand and express the meaning of
emotional experience
3. Struggle to learn the emotional mechanics of interpersonal
communication
 Siever, klar, and coccaro (1985) suggest that:
1. Less cortically aroused but more motorically
disinhibited
2. Tend to act before they can take time to reflect
 Low serotonin and high cortisol and testosterone
PSYCHODYNAMIC FACTORS
 The ego develops, but the superego does not
 Total personality remains dominated by the infantile id and its
pleasure principle (friedlander,1945)
 Characteristics of “id”
Completely centered on its own immediate needs
Dominated by sex and aggression
Demands immediate gratification
No tolerance for frustration
 Lack of conscience is the most important characteristic
INTERPERSONAL PERSPECTIVE
 According to Kiesler (1996), the antisocial personality
represents almost pure interpersonal hostility
 People with ASPD are oppositional, irritable, and rude
 They are quick to argue, ignore the feelings of others, resist
cooperation, and readily provoke disputes
 Defiant and ruthlessly attack, torment, and abuse others who
thwart their intentions
 Antisocials also seek to control others, while vigorously
resisting any and all attempts by others to control them
How does the antisocial personality develop
from the interpersonal perspective?
 Children exposed to neglect, indifference, hostility, and
physical abuse are likely to learn that the world is a cold,
unforgiving place
 Such infants lack normal models of empathic tenderness
 Future people with ASPD never learn to control aggression
adequately
 They learn that physical intimidation and violence can be
used instrumentally with peers and siblings to coerce their
behavior
What shifts the child down a specifically
antisocial pathway?
 Neglect and abuse are rather
nonspecific factors, implicated in the
early childhood of many personality
disorders
 Benjamin- “context of parenting”
 Parents of future people with ASPD
are neglectful and stern
disciplinarians
COGNITIVE PERSPECTIVE
 Beck et al. (1990) hold that the core beliefs of antisocials are
organized around a need to see themselves as strong and
independent
 World is seen as an intrinsically hostile place
 Survival demands survival-oriented core beliefs
“I must look out for myself”
“If I am not the aggressor, then I will be the victim”
“It’s okay to take advantage of someone who allows it”
CONTRAST WITH OTHER PERSONALITIES
Antisocial Borderline Histrionic
Manipulative Need to dominate,
seize power
Attempt to evoke
support and
nurture
Attempt to occupy and
hold the center of
attention
Impulsivity shortsighted
fixation on
immediate
gratification
impulsive in
reaction to anxious
feelings of
emptiness or
depersonalization
Impulsivity is part of
emotional
dramatization
Acting out intense verbal
threat or violence
acting-out often
takes the form of
suicidal gestures
ASPD VS NPD
 Share a tendency to be tough-minded, glib, superficial,
exploitative and lack empathy
 Narcissistic personality disorder(NPD) does not include
characteristics of impulsivity, aggression, and deceit
 Individuals with ASPD are not needy of the admiration and
envy of others
 Persons with NPD usually lack the history of conduct
disorder in childhood or criminal behavior in adulthood
ASPD AND COMORBIDITY
 Swanson and colleagues (1994) community study showed:
Increased prevalence of nearly every other psychiatric
disorder:
1. 90.4% having at least one other psychiatric disorder
2. Substance misuse is the most important Comorbidity
 Epidemiological Catchment Area (ECA) study:
1. Five times more likely to misuse alcohol and illicit drugs
2. Half have co-occurring anxiety disorders
3. Quarter have a depressive disorder
COURSE AND PROGNOSIS
 Antisocial behaviours have their onset before age 8 years
 Nearly 80% of people with ASPD developed their first
symptom by age 11 years
 Boys develop symptoms earlier than girls
 Robins observed that a child who makes it to age 15 without
exhibiting antisocial behaviours are less likely to develop
ASPD
 An estimated 25% of girls and 40% of boys with CD will later
meet criteria for ASPD
 Subset of antisocial adults have no history of childhood CD
COURSE AND PROGNOSIS
 ASPD is more common in men and more likely to persist when compared
with women
 Guze (1976) found that male felons were still antisocial by interview at
follow-up (87% at 3 years, 72% at 9 years)
 Martin and colleagues (1982) found that among women:
1. 33% were engaging in criminal behaviour at 3 years
2. 18% at 6 years
 Black and colleagues (1995) longitudinal follow up study in Men showed
that”:
1. Reduced impulsive behaviour and criminality with time
2. Continued to have significant interpersonal problems throughout their
lives
PREVENTIVE MEASURES
 Secondary prevention with principles of primary prevention
 Applied to people who are markedly at risk or who show its very early
signs
 Interventions tend to focus on the reduction of risk and strengthening of
resilience
 Risk factors:
Poverty, unemployment, inadequate transportation, sub-standard
housing, parental mental health problems and marital conflict
 Elmira Project:
Early intensive nurse home visitation intervention worked well to
prevent child maltreatment in the early years and delinquency at 15
years’ follow-up
PRESENTATION IN HEALTHCARE
 Rarely present in healthcare settings requiring help to deal
directly with problems arising from their personality disorder
 ‘Treatment rejecting’ rather than ‘treatment seeking’
 People antisocial personality disorder present for treatment:
1. Comorbid condition and/or they have been coerced into
treatment
2. By a relative or some external authority in a crisis
RISK ASSESSMENT
 Psychopathy Checklist Revised (PCL-R; Hare, 1991)
1. It is a measure of psychopathy
2. Shown to correlate highly with violence risk
3. Widely used in violence risk assessment
4. Measure of severity for antisocial personality disorder
 Screening version (PCL-SV) - 12 items providing a score
from 0 to 24 (Hart et al., 1999)
 Violence Risk Assessment Guide (VRAG)
 Offender Group Reconviction Scale (OGRS)
TREATMENT AND MANAGEMENT
Pharmacological treatments
 The research evidence justifying the use of these interventions
is limited
 DSM diagnosis has limited uses for treatment planning
 (Livesley, 2007), Soloff (1998) recommended a symptom-
orientated approach:
1. Impulse–behavioural
2. Affective
3. Cognitive-perceptual
 SSRIs and antimanic drugs for impulsive dyscontrol
 SSRIs and other antidepressants for emotional dysregulation
 Low dose antipsychotics for cognitive-perceptual abnormalities
THERAPEUTIC TRAPS
 For Antisocials therapy is just another annoying encounter with
the constraining forces of society
 Antisocials are basically interested in shrugging off external
constraints
 Therapy goals are:
1. To develop a sense of conscience
2. Express guilt
3. Express a sincere desire to reform and make amends
 They should change slowly and mostly in response to the
searching and confrontive questions of the therapist
THERAPEUTIC TRAPS
 Duping of therapist by Antisocials by:
1. Seemingly sincere expressions of regret
2. Guilt about the destruction of life and property
3. Existential despair about the wasting own life
 Naive therapists get trapped:
1. Those who “need” to cure their subjects
2. Those who might compete against fellow therapists by
displaying their psychopath as one who grew a
conscience
THERAPEUTIC TRAPS
 Therapists often:
1. Exhibit a variety of intense countertransference
reactions
2. Become suspicious, angry, and resentful
3. They may miss opportunities to catalyze real change
with a genuine therapeutic alliance
DEALING WITH THERAPEUTIC TRAP
 Beck et al. (1990) suggest:
1. Self-assurance
2. Reliable but not infallible objectivity
3. Relaxed and non-defensive interpersonal style
4. Clear sense of personal limits
5. Strong sense of humor
 Frances (1985) suggests that the therapist openly
acknowledge the vulnerability of the therapy setting to the
possibility of manipulation, as many subjects appreciate such
frank disclosure
STRATEGIES AND TECHNIQUES
 The ultimate goal of therapy is developing a sense of nurturing
attachment (Benjamin, 1996)
 The primary objectives of therapy are:
1. To find some way of bonding with the antisocial person
2. To develop a therapeutic alliance
 Address the underlying sense of hostility as they are coerced into
therapy
INTERPERSONAL THERAPY
 Interpersonally Benjamin (1996) suggests that antisocial
subjects lack constructive socializing experiences
 Strategies that can be used to help antisocials internalize
values:
1. Sports figures to model warm and benevolent attitudes
2. Put antisocial in a potentially nurturing position
3. Giving a pet or allowed to instruct children in some
supervised context such as a skill or a sport
COGNITIVE THERAPY
 Beck et al. (1990) and D. Davis describes the use of
cognitive therapy
 Move the subject from a primitive to a more abstract level of
moral reasoning
 Make subjects recognize that their actions affect others and
have reciprocal consequences for themselves
 Delay of gratification and teaching skills necessary to make
enlightened self-interest
PSYCHOSOCIAL INTERVENTIONS
 Therapeutic community
 The therapeutic community movement had a significant
impact on mental healthcare in the mid to late 20th century
(Lees et al., 2003)
 Prison service (Grendon Underwood; Snell, 1962) and drug
service
 High costs
 Absence of convincing evidence for efficacy
ETHICAL CONSIDERATIONS IN ANTISOCIAL
PERSONALITY DISORDER
 Whether ASPD/Psychopathy/Sociopathy is a disorder at all?
 For Philosophers:
Psychopathy is a medical entity to explore issues of moral
reasoning and responsibility
 For Psychologists and Psychiatrists:
Whether people with antisocial personality disorder are subject of
medical discourse at all
Implications for criminal responsibility
 Much of the current research is used to address this debate
 If biological basis- then it is a disorder which needs treatment or at
least intervention
ETHICAL CONSIDERATIONS
 Conceptual slippage:
‘Antisocial behaviour’ is not the same as criminality or
violence or antisocial personality disorder or psychopathy
 Brain research cannot explain why people in general choose
to behave antisocially
 All human behaviours are complex
 It seems very probable that genetic vulnerability interacts
with environment to produce a neural matrix that contributes
causally to socially significant rule breaking
 Only a contribution and not a total explanation
ETHICAL CONSIDERATIONS
 Researchers and healthcare policy makers need to understand
that:
Problems posed by these people are social ones
There has to be a social/political dimension to the work that is
undertaken
 This seems alien to many healthcare professionals and
scientists who see biosciences as politically and morally neutral
 Biological model for anti social behaviour is unlikely to change
public attitudes
ETHICAL ISSUES- TREATABILITY
 The notion of ‘treatment’ raises a number of ethical issues
The assumption that it is a disorder that is amenable to
intervention
 A key issue is test of therapeutic outcome
 Most ethical arguments about healthcare resources are utilitarian
in nature:
 “What will bring about the most good for the greatest
number?”
ETHICAL ISSUES OF COERCION IN
RELATION TO ASPD
 The only people with capacity who cannot refuse treatment, and
can have treatment forced upon them, are those with mental
disorders who pose a risk to themselves or others
 Most libertarian philosophical arguments (Saks, 2003):
Forced medical treatment is only justified to improve a person’s
own health and safety
Insult to dignity is outweighed by the prevention of serious
harm
 What is the extent to which societies should coerce people into
treatment that is not of benefit to them directly?
ETHICAL ISSUES OF COERCION IN
RELATION TO ASPD
 Mental health professionals often argue that they are not
being unethical in two ways:
1. Patients are benefiting even if indirectly
At least they are benefiting from not being allowed to
harm others
Discriminatory—generally competent citizens are
allowed to choose whether they do harm or not, and take
the consequences
2. People who are a risk to others have lost some of their
claims to full exercise of autonomy
ETHICAL ISSUES OF COERCION IN RELATION
TO ASPD
 Need for distinction to be made between legal coercion and
therapeutic persuasion
 Unlikely that all antisocial patients can be coerced into pro-
social thinking or behaviour
 Balance between:
The rights of individuals to have liberty
VS
Rights of a community to be protected from potential harm
THE ETHICS OF PUBLIC PROTECTION
 The extent to which a range of healthcare professionals should be
involved in public protection
Act on knowledge to assist in public protection from a small
number of risky individuals with mental disorders
VS
Make the care of the patient their first concern
 A possible ethical and legal solution to the tension is:
Informed consent for both risk assessments and medico-legal
interviews
Clearly advise patients/defendants of the purpose of the interview
The use to which the material will be put
Who will be informed of the outcome
ETHICAL ISSUES AND CHILDREN
 The prevention of antisocial personality disorder
 Justified in terms of beneficial consequences in the future:
1. No (or reduced) antisocial personality disorder
2. Prevention of harm to others and costs to society
 Outcomes look very attractive
 The question is:
At what cost to human dignity and justice will these benefits
come?
Will the ends justify the harms done in the process?
Most importantly in ethical decision making: who gets to
decide?
REFERENCES
1. Book. Theodore. M. Personality disorders in modern life.
Second edition. Florida. Coral gables.
2. Book. Antisocial personality disorder: treatment,
management and prevention. National collaborating centre
for mental health. National institute for health & clinical
excellence. The british psychological society and the royal
college of psychiatrists. 2010
3. Book. Tasman. A. Psychiatry. Fourth edition. John wiley &
sons, ltd.2015
They are angry
They make you angry
They need help
You can help them
“ Will you ?”
Thank you

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Antisocial personality disorder

  • 2. OVERVIEW  Introduction  Historical Aspects And Evolution Of The Concept  Epidemiology  Different Perspectives  Comorbidity  Course And Prognosis  Assessment  Management  Ethical Issues
  • 3. A MODEL OF PSYCHIATRIC DISORDERS 1. Disorders of brain chemistry/brain functioning:  Schizophrenia Bipolar disorders  Anxiety disorders Major depressions 2. Disorders of self in relation to others: Personality disorders Addictions Disorders related to trauma 3. Disorders of self in relation to community and society: Dissocial personality disorders Conduct disorder
  • 4. INTRODUCTION  Dissocial personality disorder:  Personality disorder usually coming to attention because of a gross disparity between behaviour and the prevailing social norms  Anti-social Personality Disorder:  A pervasive pattern of disregard for and violation of the rights of others
  • 5. PSYCHOPATH SOCIOPATH 1% of general population 4% of general population Highly heritable Minnesota twin study showed 60% heritability They are simply “ That way” Origin lies in environment and upbringing Defective parenting style Highly educated and have good career Uneducated and unable to have a steady job Controlled behaviour Erratic Manipulative Impulsive Unable to form an personal attachment Can form an attachment to a particular group Take calculated risks, minimize evidence Spontaneous crimes, tend to leave evidence 
  • 6. PSYCHOPATHY VS SOCIOPATHY VS ASPD  The terms “sociopath” and “antisocial personality” refer to behavior and its consequences  “Psychopath” to inner experience  Most sociologists, criminologists believe that ASPD is caused by social conflicts and thus prefer the term Sociopathy  Those who believe that a combination of psychological, biological, genetic and environmental factors all contribute to the ASPD are more likely to use the term psychopathy
  • 7. 1.Gross disparity between behaviour and the prevailing social norms 2.Flagrantly and pervasively violate the rights of others Dissocial personality disorder Psychopathy/ Sociopathy Antisocial personality disorder
  • 8. FROM NORMALITY TO ABNORMALITY Adventurers Self-sufficiency Ambition Competitiveness Individuality self-determination Dissenting Personality Unconventional Push boundaries Independent Autonomous Impulsive Irresponsible DISSOCIAL PERSONALITY DISORDER
  • 9. STYLE VS DISORDER PERSONALITY STYLE PERSONALITY DISORDER Own value system above that of the group Consistently violates social norms through illegal activities Spin objective events to its advantage without engaging in outright deception Deceive to achieve its own ends Style is naturally spontaneous and self- indulgent Too impulsive to consider the consequences of its actions Assertive in creating a felt physical presence Irritable and aggressive to the point of repeated fights or assaults Remain free of external constraints spend on the joys of the present rather than save prudently for the future Consistently irresponsible as to work and financial obligations Aggressively or impulsively self-serving, but within moral, social, and legal boundaries Lacks a conscience and rationalizes exploitation of others
  • 11. HISTORICAL ASPECTS AND EVOLUTION OF CONCEPT  Psychopathy was described by Theophrastus a student of Aristotle  1800:Philosophical debate between free will and determinism  Philippe Pinel (1801,1806): 1. Form of madness known as “la folie raisonnante” 2. manie sans delire (insanity without delirium) 3. Unimpaired intelligence and full awareness of actions 4. Intended to be descriptive, not value-laden
  • 12. HISTORICAL ASPECTS AND EVOLUTION OF CONCEPT  Prichard (1835): Moral Insanity Despite understanding the choices before them, their conduct was swayed by overwhelming compulsions “Can these individuals understand the consequences or individuals are defective in character and therefore, worthy of moral condemnation”
  • 13. HISTORICAL ASPECTS AND EVOLUTION OF CONCEPT  Specific cerebral center controlled morality (Maudsley,1874)  Koch (1891): Psychopathic inferiority  Syndrome as an “congenital or acquired inferiority of brain constitution”  Kraepelin (1905) classified ‘Personality disorder’  Schneider(1923):  Individuals with ‘psychopathic personalities’ as those who ‘suffer through their abnormalities or through whom society suffers’
  • 14. HISTORICAL ASPECTS AND EVOLUTION OF CONCEPT  Psychopathy: Literally meaning “Psychological Pathology” First three decades of the twentieth century Hervey Cleckley’s The Mask of Sanity (1941) Hare developed the Psychopathy Checklist Revised (PCL-R) which was influenced by the previous work of Cleckley
  • 15. HISTORICAL ASPECTS AND EVOLUTION OF CONCEPT  DSM-I in 1952 included the diagnosis of Sociopathic Personality Disturbance 1. Antisocial sociopaths referred to common offenders 2. Dissocial sociopaths included white collar criminals  The diagnosis evolved to reflect the changing attitudes of the era  Criminality was due to environmental factors in particular a lack of socialization  In 1980 with the publication of the DSMIII only the term ASPD was used
  • 17. EPIDEMIOLOGY  Condition is much more prevalent among men  The lifetime prevalence in two North American studies was 4.5% among men and 0.8% among women (Robins et al.,1991)  Two European studies found a prevalence of: 1. 1.3% in men and 0% in women (Torgensen et al., 2001) 2. 1% in men and 0.2% in women (Coid et al., 2006)  Women have: 1. Greater severity of problems 2. More complex comorbidities for both Axis I and Axis II disorders 3. Poor outcomes
  • 18. PRISON SETTING  Worldwide- Prevalence of 47% for men and 21% for women  In the UK- Prevalence is: 1. 63% for male remand prisoners 2. 49% male sentenced prisoners 3. 31% female prisoners  The prevalence of Psychopathy in UK prisoners is: 1. 4.5% using a PCL-R score of 30 2. 13% using a score of 25 (Fazel & Danesh, 2002, Hare et al., 2000,Singleton et al., 1998)
  • 19. BIOLOGICAL PERSPECTIVES  Inborn temperaments-Aggression, Fearless, Impulsive  Cleckley (1950): 1. Semantic aphasia 2. Inborn inability to understand and express the meaning of emotional experience 3. Struggle to learn the emotional mechanics of interpersonal communication  Siever, klar, and coccaro (1985) suggest that: 1. Less cortically aroused but more motorically disinhibited 2. Tend to act before they can take time to reflect  Low serotonin and high cortisol and testosterone
  • 20. PSYCHODYNAMIC FACTORS  The ego develops, but the superego does not  Total personality remains dominated by the infantile id and its pleasure principle (friedlander,1945)  Characteristics of “id” Completely centered on its own immediate needs Dominated by sex and aggression Demands immediate gratification No tolerance for frustration  Lack of conscience is the most important characteristic
  • 21. INTERPERSONAL PERSPECTIVE  According to Kiesler (1996), the antisocial personality represents almost pure interpersonal hostility  People with ASPD are oppositional, irritable, and rude  They are quick to argue, ignore the feelings of others, resist cooperation, and readily provoke disputes  Defiant and ruthlessly attack, torment, and abuse others who thwart their intentions  Antisocials also seek to control others, while vigorously resisting any and all attempts by others to control them
  • 22. How does the antisocial personality develop from the interpersonal perspective?  Children exposed to neglect, indifference, hostility, and physical abuse are likely to learn that the world is a cold, unforgiving place  Such infants lack normal models of empathic tenderness  Future people with ASPD never learn to control aggression adequately  They learn that physical intimidation and violence can be used instrumentally with peers and siblings to coerce their behavior
  • 23. What shifts the child down a specifically antisocial pathway?  Neglect and abuse are rather nonspecific factors, implicated in the early childhood of many personality disorders  Benjamin- “context of parenting”  Parents of future people with ASPD are neglectful and stern disciplinarians
  • 24. COGNITIVE PERSPECTIVE  Beck et al. (1990) hold that the core beliefs of antisocials are organized around a need to see themselves as strong and independent  World is seen as an intrinsically hostile place  Survival demands survival-oriented core beliefs “I must look out for myself” “If I am not the aggressor, then I will be the victim” “It’s okay to take advantage of someone who allows it”
  • 25. CONTRAST WITH OTHER PERSONALITIES Antisocial Borderline Histrionic Manipulative Need to dominate, seize power Attempt to evoke support and nurture Attempt to occupy and hold the center of attention Impulsivity shortsighted fixation on immediate gratification impulsive in reaction to anxious feelings of emptiness or depersonalization Impulsivity is part of emotional dramatization Acting out intense verbal threat or violence acting-out often takes the form of suicidal gestures
  • 26. ASPD VS NPD  Share a tendency to be tough-minded, glib, superficial, exploitative and lack empathy  Narcissistic personality disorder(NPD) does not include characteristics of impulsivity, aggression, and deceit  Individuals with ASPD are not needy of the admiration and envy of others  Persons with NPD usually lack the history of conduct disorder in childhood or criminal behavior in adulthood
  • 27. ASPD AND COMORBIDITY  Swanson and colleagues (1994) community study showed: Increased prevalence of nearly every other psychiatric disorder: 1. 90.4% having at least one other psychiatric disorder 2. Substance misuse is the most important Comorbidity  Epidemiological Catchment Area (ECA) study: 1. Five times more likely to misuse alcohol and illicit drugs 2. Half have co-occurring anxiety disorders 3. Quarter have a depressive disorder
  • 28. COURSE AND PROGNOSIS  Antisocial behaviours have their onset before age 8 years  Nearly 80% of people with ASPD developed their first symptom by age 11 years  Boys develop symptoms earlier than girls  Robins observed that a child who makes it to age 15 without exhibiting antisocial behaviours are less likely to develop ASPD  An estimated 25% of girls and 40% of boys with CD will later meet criteria for ASPD  Subset of antisocial adults have no history of childhood CD
  • 29. COURSE AND PROGNOSIS  ASPD is more common in men and more likely to persist when compared with women  Guze (1976) found that male felons were still antisocial by interview at follow-up (87% at 3 years, 72% at 9 years)  Martin and colleagues (1982) found that among women: 1. 33% were engaging in criminal behaviour at 3 years 2. 18% at 6 years  Black and colleagues (1995) longitudinal follow up study in Men showed that”: 1. Reduced impulsive behaviour and criminality with time 2. Continued to have significant interpersonal problems throughout their lives
  • 30. PREVENTIVE MEASURES  Secondary prevention with principles of primary prevention  Applied to people who are markedly at risk or who show its very early signs  Interventions tend to focus on the reduction of risk and strengthening of resilience  Risk factors: Poverty, unemployment, inadequate transportation, sub-standard housing, parental mental health problems and marital conflict  Elmira Project: Early intensive nurse home visitation intervention worked well to prevent child maltreatment in the early years and delinquency at 15 years’ follow-up
  • 31. PRESENTATION IN HEALTHCARE  Rarely present in healthcare settings requiring help to deal directly with problems arising from their personality disorder  ‘Treatment rejecting’ rather than ‘treatment seeking’  People antisocial personality disorder present for treatment: 1. Comorbid condition and/or they have been coerced into treatment 2. By a relative or some external authority in a crisis
  • 32. RISK ASSESSMENT  Psychopathy Checklist Revised (PCL-R; Hare, 1991) 1. It is a measure of psychopathy 2. Shown to correlate highly with violence risk 3. Widely used in violence risk assessment 4. Measure of severity for antisocial personality disorder  Screening version (PCL-SV) - 12 items providing a score from 0 to 24 (Hart et al., 1999)  Violence Risk Assessment Guide (VRAG)  Offender Group Reconviction Scale (OGRS)
  • 33. TREATMENT AND MANAGEMENT Pharmacological treatments  The research evidence justifying the use of these interventions is limited  DSM diagnosis has limited uses for treatment planning  (Livesley, 2007), Soloff (1998) recommended a symptom- orientated approach: 1. Impulse–behavioural 2. Affective 3. Cognitive-perceptual  SSRIs and antimanic drugs for impulsive dyscontrol  SSRIs and other antidepressants for emotional dysregulation  Low dose antipsychotics for cognitive-perceptual abnormalities
  • 34. THERAPEUTIC TRAPS  For Antisocials therapy is just another annoying encounter with the constraining forces of society  Antisocials are basically interested in shrugging off external constraints  Therapy goals are: 1. To develop a sense of conscience 2. Express guilt 3. Express a sincere desire to reform and make amends  They should change slowly and mostly in response to the searching and confrontive questions of the therapist
  • 35. THERAPEUTIC TRAPS  Duping of therapist by Antisocials by: 1. Seemingly sincere expressions of regret 2. Guilt about the destruction of life and property 3. Existential despair about the wasting own life  Naive therapists get trapped: 1. Those who “need” to cure their subjects 2. Those who might compete against fellow therapists by displaying their psychopath as one who grew a conscience
  • 36. THERAPEUTIC TRAPS  Therapists often: 1. Exhibit a variety of intense countertransference reactions 2. Become suspicious, angry, and resentful 3. They may miss opportunities to catalyze real change with a genuine therapeutic alliance
  • 37. DEALING WITH THERAPEUTIC TRAP  Beck et al. (1990) suggest: 1. Self-assurance 2. Reliable but not infallible objectivity 3. Relaxed and non-defensive interpersonal style 4. Clear sense of personal limits 5. Strong sense of humor  Frances (1985) suggests that the therapist openly acknowledge the vulnerability of the therapy setting to the possibility of manipulation, as many subjects appreciate such frank disclosure
  • 38. STRATEGIES AND TECHNIQUES  The ultimate goal of therapy is developing a sense of nurturing attachment (Benjamin, 1996)  The primary objectives of therapy are: 1. To find some way of bonding with the antisocial person 2. To develop a therapeutic alliance  Address the underlying sense of hostility as they are coerced into therapy
  • 39. INTERPERSONAL THERAPY  Interpersonally Benjamin (1996) suggests that antisocial subjects lack constructive socializing experiences  Strategies that can be used to help antisocials internalize values: 1. Sports figures to model warm and benevolent attitudes 2. Put antisocial in a potentially nurturing position 3. Giving a pet or allowed to instruct children in some supervised context such as a skill or a sport
  • 40. COGNITIVE THERAPY  Beck et al. (1990) and D. Davis describes the use of cognitive therapy  Move the subject from a primitive to a more abstract level of moral reasoning  Make subjects recognize that their actions affect others and have reciprocal consequences for themselves  Delay of gratification and teaching skills necessary to make enlightened self-interest
  • 41. PSYCHOSOCIAL INTERVENTIONS  Therapeutic community  The therapeutic community movement had a significant impact on mental healthcare in the mid to late 20th century (Lees et al., 2003)  Prison service (Grendon Underwood; Snell, 1962) and drug service  High costs  Absence of convincing evidence for efficacy
  • 42. ETHICAL CONSIDERATIONS IN ANTISOCIAL PERSONALITY DISORDER  Whether ASPD/Psychopathy/Sociopathy is a disorder at all?  For Philosophers: Psychopathy is a medical entity to explore issues of moral reasoning and responsibility  For Psychologists and Psychiatrists: Whether people with antisocial personality disorder are subject of medical discourse at all Implications for criminal responsibility  Much of the current research is used to address this debate  If biological basis- then it is a disorder which needs treatment or at least intervention
  • 43. ETHICAL CONSIDERATIONS  Conceptual slippage: ‘Antisocial behaviour’ is not the same as criminality or violence or antisocial personality disorder or psychopathy  Brain research cannot explain why people in general choose to behave antisocially  All human behaviours are complex  It seems very probable that genetic vulnerability interacts with environment to produce a neural matrix that contributes causally to socially significant rule breaking  Only a contribution and not a total explanation
  • 44. ETHICAL CONSIDERATIONS  Researchers and healthcare policy makers need to understand that: Problems posed by these people are social ones There has to be a social/political dimension to the work that is undertaken  This seems alien to many healthcare professionals and scientists who see biosciences as politically and morally neutral  Biological model for anti social behaviour is unlikely to change public attitudes
  • 45. ETHICAL ISSUES- TREATABILITY  The notion of ‘treatment’ raises a number of ethical issues The assumption that it is a disorder that is amenable to intervention  A key issue is test of therapeutic outcome  Most ethical arguments about healthcare resources are utilitarian in nature:  “What will bring about the most good for the greatest number?”
  • 46. ETHICAL ISSUES OF COERCION IN RELATION TO ASPD  The only people with capacity who cannot refuse treatment, and can have treatment forced upon them, are those with mental disorders who pose a risk to themselves or others  Most libertarian philosophical arguments (Saks, 2003): Forced medical treatment is only justified to improve a person’s own health and safety Insult to dignity is outweighed by the prevention of serious harm  What is the extent to which societies should coerce people into treatment that is not of benefit to them directly?
  • 47. ETHICAL ISSUES OF COERCION IN RELATION TO ASPD  Mental health professionals often argue that they are not being unethical in two ways: 1. Patients are benefiting even if indirectly At least they are benefiting from not being allowed to harm others Discriminatory—generally competent citizens are allowed to choose whether they do harm or not, and take the consequences 2. People who are a risk to others have lost some of their claims to full exercise of autonomy
  • 48. ETHICAL ISSUES OF COERCION IN RELATION TO ASPD  Need for distinction to be made between legal coercion and therapeutic persuasion  Unlikely that all antisocial patients can be coerced into pro- social thinking or behaviour  Balance between: The rights of individuals to have liberty VS Rights of a community to be protected from potential harm
  • 49. THE ETHICS OF PUBLIC PROTECTION  The extent to which a range of healthcare professionals should be involved in public protection Act on knowledge to assist in public protection from a small number of risky individuals with mental disorders VS Make the care of the patient their first concern  A possible ethical and legal solution to the tension is: Informed consent for both risk assessments and medico-legal interviews Clearly advise patients/defendants of the purpose of the interview The use to which the material will be put Who will be informed of the outcome
  • 50. ETHICAL ISSUES AND CHILDREN  The prevention of antisocial personality disorder  Justified in terms of beneficial consequences in the future: 1. No (or reduced) antisocial personality disorder 2. Prevention of harm to others and costs to society  Outcomes look very attractive  The question is: At what cost to human dignity and justice will these benefits come? Will the ends justify the harms done in the process? Most importantly in ethical decision making: who gets to decide?
  • 51. REFERENCES 1. Book. Theodore. M. Personality disorders in modern life. Second edition. Florida. Coral gables. 2. Book. Antisocial personality disorder: treatment, management and prevention. National collaborating centre for mental health. National institute for health & clinical excellence. The british psychological society and the royal college of psychiatrists. 2010 3. Book. Tasman. A. Psychiatry. Fourth edition. John wiley & sons, ltd.2015
  • 52. They are angry They make you angry They need help You can help them “ Will you ?” Thank you

Editor's Notes

  1. First personality disorder to be recognized in psychiatry
  2. Semantic refers to meaning, and aphasia is broadly considered a class of disorders related to the understanding or production of language
  3. Therapist may wish to suggest that because external forces have mandated a course of therapy, the time might as well be used constructively, even though the therapist has no personal investment in the outcome
  4. and involve higher level thinking about motives, beliefs, attributions
  5. It is a general principle of bioethics that respect for the autonomy of patients is paramount and a general principle of law that everyone has control over his/her own body and any treatment interventions that are offered. Under the new Mental Capacity Act (HMSO, 2005), any person with capacity can refuse treatment, even if this is to his/her own detriment