Consult-Liaison Education Medicine

Personality Disorders (V): The Definition of Antisocial.

In casual parlance, the term “antisocial” can mean “shy” or “introverted”, as in, “No, I’m not going to that party… I’m feeling antisocial.”

The word “antisocial” in clinical settings, however, is an abbreviation for the condition of Antisocial Personality Disorder, which has nothing to do with shyness or introversion.

Here is how DSM-4 defines Antisocial Personality Disorder:

A. There is a pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years, as indicated by three (or more) of the following:

Think of “antisocial” as referring specifically to “antisociety”. (This is why people opine that Hannibal Lecter and Volde—uh, He-Who-Must-Not-Be-Named—have antisocial personality disorder. Do also note that the terms “psychopaths” and “sociopaths” refer to an extreme form of antisocial personality disorder, but not all individuals with this condition are violent serial killers. People who work in mental health often quip that there are some people with antisocial personality disorder who do quite well for themselves in government and CEO positions.)

We’ll talk more about the “occurring since age 15 years” part in criterion C below.

(1) failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest

This criterion, when taken alone, is problematic. By definition, Galileo Galilei and Mahatma Gandhi would have been on their way to a diagnosis of antisocial personality disorder.

I repeat this often here, perhaps more so to remind myself: (1) Context matters, and (2) This is how psychiatry can become an agent of social control.

(2) deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure

This, paired with criterion A7 (“lack of remorse”), is often cited for this diagnosis.

(3) impulsivity or failure to plan ahead

This is a matter of degree. (We all, occasionally, are impulsive and don’t plan ahead.) The outcomes of the impulsivity and failure to plan ahead also matters. Generally, this criterion can result in the behaviors described in the rest of the diagnosis.

(4) irritability and aggressiveness, as indicated by repeated physical fights or assaults

The modifier of “repeated physical fights or assaults” strongly suggests that this is not primarily an emotional condition; it is a behavioral condition. That “failure to conform to social norms with respect to lawful behaviors” refers to this.

(5) reckless disregard for safety of self or others

Individuals with this condition can be dangerous. They often die by violent means (such as suicide and homicide).

(6) consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations

Our culture values consistent work behavior and financial responsibility. This is why such behavior is considered “antisociety”.

(7) lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another

This is arguably the most compelling (and most often cited) criterion for antisocial personality disorder. Most people, regardless of which culture they belong to, feel some regret, shame, or guilt upon breaking a social contract. These individuals do not.

B. The individual is at least age 18 years.

A person must be a legal adult.

C. There is evidence of Conduct Disorder with onset before age 15 years.

By definition, Conduct Disorder is the predecessor of Antisocial Personality Disorder. DSM-4 defines Conduct Disorder as “a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated. The specific behaviors characteristic of Conduct Disorder fall into one of four categories: aggression to people and animals, destruction of property, deceitfulness or theft, or serious violation of rules.” The authors are arguing that Antisocial Personality Disorder doesn’t just come out of the blue. A pattern was already in motion.

D. The occurrence of antisocial behavior is not exclusively during the course of Schizophrenia or a Manic Episode.

This is a corollary to the previous criterion. Schizophrenia and a Manic Episode are considered “episodic” (yes, even schizophrenia). As you may recall, personality disorders are considered “chronic“.

You can now see why it can be challenging to work with people with antisocial personality disorder. To help us avoid automatic reactions of disdain for these individuals, we’ll next learn why people might develop this condition.