June 2013 – Page 2 – Maria Yang, MD

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.

The education steering committee (a formal title they don’t actually have) called me on Friday to offer specific suggestions for my presentation on personality disorders. It is always a blessing when members of your audience tell you what they want to learn. Don’t let that information go to waste.

The committee opined that the personality disorders staff encounter most often include:

borderline personality disorder
antisocial personality disorder
dependent personality disorder

(The first two did not surprise me, but the third did.)

They also commented that staff often do not view personality disorders as psychiatric conditions; they merely comment that “they’re just personality disorders”. Even worse, when some staff hear that someone has a personality disorder, they automatically think, “Oh, so that person is an @$$hole.”

(There’s that heuristic again of reducing conditions down to a single word. To be clear, “@$$hole” is not a clinical entity.)

Upon listening to the committee’s suggestions, it appears that they would like the audience to learn the following three things[1. When giving talks or presentations, “start with the end in mind”: What are the main points you want the audience to take away? Realize that you can’t cover anything. What ideas can you plant that will make people want to learn more?]:

The etiology of personality disorders. Though personality disorders may be egosyntonic, the vast majority of people do not actively choose to experience the thoughts, emotions, and behaviors they have. There is a fair amount of research on borderline and antisocial personality disorders[2. Individuals with antisocial personality disorders are often a captive audience… because they are incarcerated. More commentary on that later.], which indicate that genetics and childhood experiences influence the development of these conditions.

One of the tragic childhood experiences that seems to foster development of both borderline and antisocial personality disorders is chronic sexual abuse. It is not difficult to imagine how someone who was sexually abused as a child may have problems regulating his own thoughts, behaviors, and emotions as an adult.

Empathy training. Learning the etiology of personality disorders will hopefully lend itself to “empathy training”. It’s not easy to “put yourself in someone else’s shoes”, though, at some point, we have all felt like our emotions were out of control, had thoughts that disturbed us, and did things that we don’t like. All of those things have negatively affected our relationships with other people. (Remember that individuals with personality disorders are often unable to adopt more flexible ways of coping with stress, not because they don’t want to, but because they just can’t in that particular moment. That doesn’t mean that they can’t learn new coping skills in the future.) Reminding people of their own experiences with unpleasant past experiences (i.e. when they were pissed off and did things they now regret) and how it affected their relationships will hopefully help them change their perspective and increase their patience and empathy.

Brief, effective interventions when working with individuals with personality disorders. Oh, how we all want the quick fix.

One of the main points I will address I already touched upon in a previous post. To be effective with other people, particularly when their emotions (regardless of what those emotions are) are running high, you must have some awareness of what your own emotions are. (Psychodynamic types call this “countertransference”.) People naturally tend to blame others for how they are feeling and, yes, it is true that our emotions are affected by what other people do. However, your resulting thoughts and behaviors from your emotions can have a significant impact on what happens next.

Acknowledging that you are feeling an emotion and then recognizing what that emotion is are vital first steps to managing difficult situations with skill. (Acknowledging and recognizing the emotions of the other person are vital next steps. Behavioral types call this “validation”.)

I cannot control how the audience will use the information I present, but I fear that any suggestions I offer will be applied as an algorithm. Flowcharts and recipes can be useful, but flexibility and creativity are important tools when working in situations that are not logical (and, really, emotions and the thoughts and behaviors we have in response to emotions are often illogical). Learning how to really pay attention in the moment seems like a “touchy feely” concept instead of a technical skill. It’s also a skill that is often difficult to execute.

Time to do more reading and think about delivery. More to follow.