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Many of the psychological/psychiatric disorders are related to types of normal behaviors or feelings that many individuals typically possess; however, the disordered part of the behavior occurs when these behaviors or feelings are pervasive, extremely intense, last for lengthy periods, and result in some type of distress or impairment in a person’s ability to function within relatively normal limits.`
Personality disorders are no exception to this understanding of what many clinicians refer to as abnormal behavior.
Personality disorders are expressed in the behaviors, attitudes, beliefs, and thinking patterns of individuals, and they go against societal and cultural expectations. These patterns of behavior, emotions, and thinking are pervasive (meaning that they affect nearly every aspect of the individual’s functioning), longstanding (meaning that they were observable at a relatively early age in the individual), rigid (meaning that they are resistant to change even if they are irrational and dysfunctional), and lead to distress or issues with functioning in the individual. Many individuals with personality disorders suffer severe ramifications as a result of their behaviors, and their behaviors often severely affect others. Perhaps there is no better example of how a personality disorder results in dysfunctional behavior that affects both the person and others than antisocial personality disorder.
People with antisocial personality disorder have an overall disregard for the rights of others and engage in behaviors that violate the rights of others to such a degree that their behavior often produces significant distress and even leads to physical and emotional damage to others. The use of manipulating others and deceit is pervasive in these individuals, and it drives their entire being. Other people are often simply viewed as pawns to assist these people in achieving their own goals. These individuals will typically demonstrate conduct issues before the age of 15 in areas of aggression toward animals or people, property destruction, theft, or serious violation of rules, such as truancy or behavioral problems in school.
Everyone uses someone else to obtain a goal at one time or another; however, the majority of people who occasionally do this have feelings for others and can empathize with them. Individuals with antisocial personality disorder lack the ability to empathize with others and view them as targets and means to an end.
Antisocial personality disorder belongs to the Cluster B group of personality disorders, according to the American Psychiatric Association (APA), indicating that the primary issues have to do with behavior that is erratic, dramatic, and/or emotional.
APA lists seven formal diagnostic criteria for antisocial personality disorder. An individual must have demonstrated at least three of these since they were 15 years old. The formal diagnostic criteria will not be presented here; however, the general picture of antisocial personality disorder is one of:
An individual must demonstrate some of these types of behaviors before the age of 15; however, they cannot be diagnosed with antisocial personality disorder unless they are 18 or older. Individuals displaying these types of behaviors under the age of 18 are most often diagnosed with some form of conduct disorder. As with all personality disorders, the behaviors that are observed in the individual cannot be better explained by another mental health disorder (e.g., bipolar disorder), the use of drugs or alcohol (although these individuals often use drugs or alcohol), and the presence of some medical condition, such as a head injury.
The thinking patterns and approach of individuals with antisocial personality disorder reflect a tendency toward:
As might be expected, many of these individuals are often pegged as career criminals; however, in some circles, many of the traits these individuals display actually can be applied in a functional manner. The stereotypical businessman who habitually ruins others in business in attempts to further their own agenda is consistent with many of the types of behaviors associated with antisocial personality disorder. While certainly a proportion of individuals with criminal backgrounds will express the traits of antisocial personality disorder, it should be understood that not all individuals with antisocial personality disorder are career criminals, and certainly, not all individuals convicted of one or more different legal infractions are individuals with antisocial personality disorder. This disorder is diagnosed according to its diagnostic criteria and presents as longstanding, persistent, and rigid patterns of behavior.
It appears that the highest prevalence of antisocial personality disorder occurs in men with severe alcohol use disorders (greater than 70 percent). The prevalence of antisocial personality disorder also appears higher in people who come from lower socioeconomic backgrounds, especially individuals living in poverty. The disorder is chronic, but longitudinal studies indicate that the symptoms may be somewhat less evident in individuals after they turn 40 years old regarding their potential to commit overt criminal behaviors; however, the tendency for these individuals to engage in substance abuse does not remit significantly with age.
There are no known causes of antisocial personality disorder, but there is a very strong genetic component. It is believed that genetic and other biological factors interact with certain environmental factors in the expression of this disorder.
Treating individuals with antisocial personality disorder is very challenging. Individuals who have antisocial personality disorder externalize their issues, meaning that they blame them on others or on things like bad luck or environmental factors. They do not typically view themselves as the cause of much of their discomfort and will place the blame for any distress they experience on external factors.
Thus, it should be quite obvious that these individuals do not typically come to mental health clinicians asking to be treated for their personality disorder. Most often, they are forced into treatment due to issues with the legal system or with other external organizations, or via other individuals who refer them. Their complaints are most often complaints of depression or even issues resulting from substance abuse.
There are no formal medications that can treat antisocial personality disorder. A variety of medications can be prescribed depending on the individual case, including such drugs as antidepressants, anxiolytic drugs, antiepileptic drugs, stimulant drugs, and even other central nervous system depressants. These are typically prescribed for specific symptoms in individuals, indicating that formal medical treatment is aimed at symptom management and not necessarily at treating the entire syndrome. In general, legal sanctions, including imprisonment, fines, and parole or probation, are often used to address behaviors associated with individuals who have antisocial personality disorder; however, these are not always effective.
Psychotherapy can be useful in treating these individuals; however, as one might expect, there is a high rate of attrition in individuals who are in treatment. Often, these individuals need very concrete rules and require limit setting, such as the threat of incarceration or heavy fines if they do not participate in some structured treatment program. And even then, these individuals will often manipulate the system. Therapy should be structured around changing individual patterns of thinking and relating to others. Certain types of Cognitive Behavioral Therapy are considered to be useful in this context. One particular form of cognitive therapy known as schema therapy may be particularly useful.
Schemas are mental models that individuals create of the world, and they are typically very longstanding and resistant to change. Individuals act in accordance with their schemas without even thinking about their actions. Identifying and addressing the schemas of individuals with antisocial personality disorders can be an effective way to change many of their dysfunctional behaviors. Individuals who have co-occurring substance use disorders will require attention to both disorders. Substance use disorder treatment for these individuals is typically performed in the traditional manner; however, the emphasis should be maintained on setting limits and specifying concrete consequences for individuals who attempt to stretch or break the rules of treatment.
Getting individuals involved in group therapy and/or support groups with other individuals who have been in treatment and benefitted from it can be extremely useful in the treatment of antisocial personality disorder. These individuals can learn to relate to one another and develop goals that are productive by modeling the behaviors of other individuals who are similar to them. Often, in such treatment groups, the senior members set limits for and expectations of newer members, which lead to productive and positive changes for all members of the group.