In this paper, my aim was to give a general overview of antisocial personality disorder so that I could broaden my understanding of this mental illness. I used textbook material, information from the DSM-5, and several outside sources to try to create a complete picture of the main points of the disorder, such as the causes development, symptoms, prognosis, prevalence, and treatment options for this disorder. I also looked into possible sociocultural influences on the development of the disorder, and consider whether or not it is a legitimate disorder that should be acknowledged by the mental health community. I conclude this work with a personal critique of what I have taken away from my research.
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Antisocial Personality Disorder: An Overview
In order to be successful in any society, it is important to be able to abide by the rules that the society puts forth. While there are a lot of cultural differences about what is normal and what is not, one could venture to pick out some universal moral guidelines—harming someone, stealing, conning, and lying are generally rejected. Breaking the law and disregarding the safety of oneself or others would also fall on the societal “don’t” list. While most people find it fairly easy to live within the bounds that society sets (or at least feel guilty when they don’t), people with an antisocial personality disorder find it significantly more difficult. This disorder, also commonly known as psychopathy or sociopathy, is rather difficult to deal with—and rather fascinating to study. In my experience, there is a serious social stigma attached to antisocial personality disorder. When I think of this disorder, or of the term “psychopath,” there is a learned connection that immediately goes to danger and fear. In the media and Hollywood, people with this disorder are connected with many of the most heinous crimes—serial murders, rape, highly successful scam operations. Although the traits associated with antisocial personality disorder make sense with these types of crimes, it is not nearly as common as television and movies make it seem.
This general misconception is one reason that I was interested in studying this disorder. The second reason that I was so interested in studying this disorder was a thought that I had one day while discussing the high levels of criminal behavior within the population of people with antisocial personality disorder. Although they often participate in criminal activity, there is something wrong with their mind that does not allow them to process their actions the same way I am able to process my actions. The thought struck me that if I could lie to get ahead and I did not feel an ounce of guilt (because I had no capacity for guilt), even though I knew it was wrong, would I do it? I know that there is a still a choice—but I think that the disorder these people have necessitates a shift in our perspective of their actions. It was this thought that really led me to want to have a much more full understanding of this disorder.
Historical and Diagnostic Features
The causes of antisocial personality disorder, like many other personality disorders, are difficult to pinpoint. One reason for this is because many people with these disorders do not seek help until they have had the problem for years, and they still may not recognize that anything is wrong—often, it is the distress of other people in their lives that eventually causes them to seek help. Because of this delay in treatment, it is not easy to study people with personality disorders from the onset of their problem (Durand & Barlow, 2013). However, there is definitely some sort of biological connection. The American Psychiatric Press Review of Psychology: Volume 11 states, “There is little doubt that there exists a genetic predisposition to antisocial personality disorder, as indicated by a variety of adoption, family history, and twin studies.” (Tasman, 1992, p. 67). There are also significant ties to sociocultural factors, which was researched in the Cambridge Study of Delinquent Development. This study showed several factors such as a convicted parent, large family size, low intelligence, a young mother, and a disrupted family which correlated with later antisocial personalities. (Farrington, 2000).
Although it is hard to pinpoint a cause of this disorder, we are fairly sure that it originates in childhood and follows a chronic course through adulthood. Despite the fact that it probably originates in childhood, antisocial personality disorder cannot be diagnosed until a person is 18. For children who tend to violate societal norms, there is the diagnosis of conduct disorder; many adults who are diagnosed with antisocial personality disorder were diagnosed with conduct disorder as a child (Durand & Barlow, 2013). Although antisocial personality disorder is chronic, it does seem to wane as a person gets older, especially around the age of forty. While this remission is most evident in the lessening of criminal behavior, it is also likely that the full spectrum of antisocial behaviors as well as substance abuse will go down. (American Psychiatric Association [APA], 2013). The DSM-5 outlines the main symptoms that are prevalent in antisocial personality disorder and says, “The essential feature of antisocial personality disorder is pervasive pattern of disregard for, and violation of, the rights of others that begins in childhood or early adolescence and continues into adulthood” (APA, 2013). Symptoms of this disorder include frequent breaching of law, deceitfulness (lying to and conning others for personal gain), impulsiveness, irritability, aggressiveness, recklessness, and irresponsibility. Furthermore, there is an apparent lack of remorse for having caused harm to another person (APA, 2013). This set of symptoms found within someone who is at least 18 years of age and shown signs of conduct disorder from the age of 15 merits a diagnosis of antisocial personality disorder.
However, a mental health professional should always exhaust all of their options when diagnosing. In the case of antisocial personality disorder, it is also possible that the involved symptoms only show up within the course of schizophrenia or bipolar disorder; if this is the case it should not be diagnosed as a personality disorder. Substance abuse can also be associated with these symptoms. If this is the case, a clinician should examine whether or not antisocial behavior was exhibited in childhood and have continued into adulthood. If not, it is more likely a substance abuse disorder. If so, and the substance abuse also began in childhood, there may be a double diagnosis necessitated. When diagnosing any personality disorder, it is important to look closely at the distinguishing features, because several personality disorders can share very similar traits. If all the features are met for two or more disorders, all can be diagnosed as comorbid disorders. Finally, because antisocial personality is closely correlated to criminal activity, it is necessary to see that antisocial personality features accompany the criminal act—otherwise, it is simply criminal behavior (APA, 2013).
It is often this criminal behavior aspect of this disorder that brings it into the public eye. Jack Pemment (2012) speaking about psychopaths in our culture wrote, “Despite inflicting terror into our hearts with the idea of a remorseless killer who is ‘programmed’ to kill, they are also heralded as intrinsically fascinating” (p. 1). While these people may be fascinating, it is important to remember that antisocial personalities often are associated with low economic status and urban settings. Those who exhibit antisocial behavior are often coming from a rough environment, and it is important that clinicians consider the social and economic background when assessing these individuals and making decisions about their diagnosis (APA, 2013). Based on criteria from former DSM manuals, the prevalence of antisocial personality disorder is between 0.2% and 3.3%. This prevalence is higher in samples of people who come from hard socioeconomic or challenging sociocultural background. The prevalence among populations such as males who abuse alcohol, patients at substance abuse clinics, and prisons is disproportionately high, sometimes greater than 70% (APA, 2013).
For those who have this disorder, prognosis is not particularly positive. This is a chronic disorder, and to date there are no cures like we have for other psychological disorders, and there have been very few success stories treating antisocial adults with behavioral therapy (Durand & Barlow, 2013). However, the level of dysfunction involved seems to go down significantly after a long period of time—Robins and Regier (1991) found in their study that on average, from first to last symptom, the disorder lasts 19 years. This general pattern of remission over time is the most positive prognostic factor for this disorder. Part of the reason that prognosis is so low is that treatment for adults with antisocial personality disorder is particularly difficult. Firstly, people with disorder almost never identify themselves as in need of treatment, and therefore they do not ever go; Meloy (n.d.) states that only one in seven will ever discuss their disorder with a doctor.
For those who do go to treatment, it is still difficult to achieve results. Beyond that, seemingly positive results seen may even be faulty—a characteristic of people with this disorder is lying and exhibiting manipulative behavior, so it is hard to tell whether or not therapy is working. In fact, one study has shown that those who were showing the most
signs of success in therapy were the ones who were actually relapsing in undesirable behavior the most—they had just learned what they needed to say to the therapist to get good remarks, and they were able to simulate it well (Bennett, 2011). While there has been no “miracle drug” for the treatment of antisocial personality disorder, there has been some slight pharmacological treatment success. The successes in this realm have been primarily with the symptoms of aggression and impulsiveness. Lithium (a medication often used for bipolar disorder) has been shown to reduce aggressive impulsive episodes.
A drug called Divalproex has seen some success in measurements of irritability, verbal assault, and assault against objects. While these may help, it is still not a treatment that leads to significant recovery and long-term success in treating this disorder (Bennett, 2011). Nothing has been a tried and true treatment for this disorder, but it has been shown that early intervention can help prevent full-blown symptoms later on. Early intervention seems to be the key in the success of these treatment plans—it seems as though once a person is an adult, it is hard to treat the symptoms of their personality disorder (Durand & Barlow, 2013). Psychological interventions like family and cognitive behavioral therapy have seen significant success. Family therapy gives participants skills to cope with their family and other issues, and helps to improve parenting,skills, often by encouraging support of the child and reducing stress within the home. Cognitive behavioral interventions are aimed at teaching problem-solving and social skills which helps affected individuals maintain a more normal level of function later on (Bennett, 2011).
In doing this research, I learned that this disorder is similar to, but not nearly as drastic as, the idea that I had of it before. I had always thought that this was an extremely rare disorder (still not incredibly common, but more so than I thought), and that those that did have it were bound to exhibit some sort of cold, calculated, criminal behavior. Although many are caught up in criminal activity and do things that hurt those around them (for example, lying to and stealing from people that love them), they are not often doing things like committing serial murders. I also learned from one article I read that there are definite, biological differences in the brains of people with antisocial personalities and the brains of normal, healthy people. I think this is very interesting because in my opinion this further validates the disorder. If people have legitimate differences in the structure of their brain, they are truly suffering from an illness that there may be nothing that they can do about. It may also explain why treatment that works on many other psychological disorders does not work as well for people with this disorder.
The biggest challenge that mental health experts have with diagnosing this disorder is that people who have it do not believe that they have anything wrong with them, and therefore they do not come in for treatment. It is impossible to diagnose if the mental health expert doesn’t get the chance. Second to this, the biggest challenge would be that the disorder itself is characterized by manipulation and lying, so a client may not be honest with a therapist about what is going on psychologically, and they may be very good at the front that they put up. Antisocial personality disorder is most definitely a justifiable disorder. I think that there have been enough cases (particularly the few drastic ones) in which this disorder has clearly represented itself. Although this disorder may not cause percieved distress to the individual, it still limits them from having a healthy human experience, and it often causes significant distress in the lives of those who love the individual with the disorder.
Finally, as I said before, I think that the brain research that has been conducted solidifies the existence of the disorder, and it most definitely should be included in the DSM-5 as well as future versions. It saddens me that there are not currently any viable treatment options for this disorder. As someone wanting to pursue a career in mental health, I would hate to have a client that I was absolutely unable to help. I hope that in the near future we will either find a form of therapy that will work for those already affected, or that we will be able to more successfully catch and curb these behaviors at a young age so that these individuals have a chance to lead successful, healthy lives.
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