Issues of Advocacy and Social Justice

"CASE 14

Antisocial Personality Disorder

Checklist

Antisocial Personality Disorder

1.

Persons repeatedly disregard and violate the rights of other people in 3 or more of the following ways:

(a) Little or no adherence to social and legal norms.

(b) Deceitfulness.

(c) Impulsivity or poor planning.

(d) Irritability and hostility marked by repeated fights.

(e) Careless disregard for safety of self or others.

(f) Failure to behave responsibly in the spheres of work or finances.

(g) No regret for hurting or mistreating others.

2.

Persons are at least 18 years old, but showed signs of conduct disorder before they were 15 years old.

(Based on APA, 2013.)

Jack was a 22-year-old single man, admitted to a state psychiatric hospital in a large midwestern city with complaints of depression and thoughts of suicide. He was admitted to the hospital after arriving there one evening appearing completely distraught. He told the psychiatrist on call that he could not bear life any longer and was thinking of ending it all. Jack said he had spent the past hour standing on the overpass of a nearby highway, staring down at the traffic and trying to gather enough courage to jump. He eventually decided he could not do it and, realizing he was near a hospital, pulled himself together enough to “get some help instead of running away from my problems.”

Most of the individuals with antisocial personality disorder are not interested in receiving treatment. Those individuals who receive treatment typically have been forced to participate by an employer, their school, or the law (McRae, 2013).

In relating these events, Jack seemed deeply upset. Occasionally he would stop speaking and bury his face in his hands. When the psychiatrist asked what sort of difficulty he was experiencing, Jack replied, “You name it, I’ve got it.” He said that he had recently lost both his job and his girlfriend, and now his mother was gravely ill, among other things. He feared that unless he got some help, he was going to “go off the deep end.”

Jack Disturbed or Disturbing?

The psychiatrist was concerned that Jack would consider suicide again, so decided to admit Jack to the psychiatric ward and place him on suicide precautions. An orderly escorted the young man to the admitting desk, where the clerk took down pertinent information. After that, Jack surrendered his valuables—a wallet with no identification, $3 in cash, and an earring—and was escorted to a locked ward.

When they arrived at the door to the ward, the orderly took out an enormous skeleton key, opened the large metal door, and escorted Jack inside.

The orderly brought him to the nurses’ station, a large semicircular area enclosed in safety glass, where a half-dozen staff members were busily typing patients’ notes into the computers. Upon seeing Jack, a nurse exited the station, introduced herself, and took him to his room, one of 15 down a long, bare corridor reserved for male patients (female patients occupied an identical corridor on the other side of the floor). At the room, the nurse gave Jack some pajamas and a hospital-issue daytime outfit; she informed him that a relative could bring another set of his own clothes tomorrow, if he preferred. She also told Jack that she would have to take his shoelaces, since the admitting physician had ordered suicide precautions, and she gave him a pair of slippers to use as footwear.

After the nurse left, Jack flopped down on his bed and buried his face in his pillow. An hour later, a house physician came by to give Jack a routine physical examination, which seemed to perk him up a little. Jack greeted the physician with a friendly, “Hi, Doc,” and the doctor examined the young man’s heart, lungs, blood pressure, and other vital signs. To make conversation, he remarked on an “interesting” tattoo that Jack had on his chest, a crude picture of a nude woman striking a pose that left nothing to the imagination. With obvious pride, the patient explained, “Yeah, I got it in honor of my girlfriend.” After the physician left, Jack donned his hospital pajamas, got into bed, and slept soundly through the night.

The next morning, he joined the other patients in the day area, where breakfast was being served. As he took his place at the table, he announced that he was “hungry as a horse,” and began chowing down with abandon. After he finished his own food, he glanced over at a patient across the table and noticed that the man, a patient with schizophrenia, had only nibbled at his eggs and toast. “Hey, old- timer,” Jack called out, “you don’t mind if I take some of your grub, do you?” The man just stared, glassy-eyed, while Jack, without waiting for a response, took his plate and started scraping its contents onto his own dish.

The terms sociopathy and psychopathy denote a psychological pattern similar to antisocial personality disorder, although some distinctions have been drawn

between these disorders. Typically, psychopathy is seen as a more severe form of antisocial personality disorder (Coid & Ullrich, 2010).

Another patient sitting at the table reprimanded Jack for having taken the older patient’s food. “We’re not supposed to share food. It’s against regulations. Besides, that fellow is pretty sick. He’s been throwing up for days. You wouldn’t want to eat anything he’s touched.”

Jack was unimpressed by the patient’s disapproval. “Who appointed you hall monitor?” he asked. “I guess you want all the food for yourself. Well, sorry, pal, I beat you to it.”

Antisocial personality disorder is as much as three times more common among men than women. Women with antisocial personality disorder have been found to have more frequent parent-related adverse events in childhood, such as emotional and/or sexual abuse, and more adverse events as an adult (Alegria et al., 2013).

Jack in Treatment Using Therapy to His Advantage

Later that morning, Dr. Selina Harris, a staff psychiatrist, arrived to conduct an evaluation of Jack. Dr. Harris found the young man standing at a pool table in the day area, playing a game of eight-ball with another patient. As soon as the psychiatrist approached, Jack looked up and smiled. He had an appealing, cheerful quality, and at first Dr. Harris wasn’t sure she had the right patient. She was expecting someone deeply depressed, as specified in the admitting note. This patient, however, was extending the warmest, happiest greeting.

“Hey, Doc. Good to meet ya,” he said. “I’m just shooting a little game of pool here.”

Dr. Harris explained that she would be Jack’s doctor while he was hospitalized, and had him accompany her to her office on the unit floor. Once inside, she asked Jack to take a seat and told him that she wanted to know all about the troubles he had been having and why he had been contemplating suicide. Jack confirmed that he was “real depressed” and didn’t know if life was worth living. When the psychiatrist asked what he was depressed about, the patient replied, “Everything and anything.” He went on to explain that it was mainly his girlfriend but,

basically, he “just felt like giving up.” He said, “Frankly, Doc, it’s too painful to talk about.” Jack didn’t look particularly pained, however.

Dr. Harris told him that they would have to discuss these matters eventually, if he was to get any help. At this, Jack said he didn’t think that talking would do any good. “Don’t they have meds for depression?” he asked. “What’s there to talk about when all you got to do is take a pill? How about giving me some Prozac?”

“Did you ever take Prozac?” Dr. Hams asked.

“Me? Oh, no.”

“Did you ever take any psychiatric drugs?” she asked.

“No,” Jack insisted, “This is my first time in the loony bin, or even talking to a shrink.”

“How about street drugs? Did you ever try those?” the psychiatrist asked.

People with antisocial personality disorder have higher rates of alcoholism and substance-related disorders than do the rest of the population (Brooner et al., 2010; Reese et al., 2010).

‘’To be perfectly honest with you, I have tried marijuana—but who hasn’t? I stay away from the harder stuff, though.”

Since Jack would not discuss his depression, Dr. Harris tried a different tack, asking the young man about his living situation, his work, and his family. Jack replied simply that he had been living with his girlfriend, but “she’s real sore at me now.” He explained that he had recently lost his job at a loading dock after another employee had stolen some goods and then blamed the theft on Jack. Dr. Harris tried to inquire more about that matter, but Jack said he was getting tired and wanted to go lie down.

Before he departed, the psychiatrist asked him whether he was still having thoughts of suicide. Jack replied that he was feeling more secure now that he was in the hospital, and he was hopeful that Dr. Harris could help him. The psychiatrist explained that, in order for her to help him, he would have to talk more about his feelings. The patient promised that, in time, he would. He just had to develop “a little rapport” with Dr. Harris first.

Jack got up and opened the door to leave, but then paused in the doorway as if having second thoughts. He said he really appreciated the time that the psychiatrist had given him, and hoped that they could talk more. As the young man spoke, Dr. Harris observed his hand slip down the edge of the door, and push the button that unlocked the door handle, allowing entry from the outside. For a moment, she considered confronting Jack with what she had just seen, but decided to let the matter ride.

Jack said goodbye, and after he had rounded the corner, Dr. Harris pushed the button to lock the door once again. As it was getting late, she packed up her briefcase and left for the day.

The next morning she sought Jack for another interview. This time she found him seated in the television viewing area. He apparently was enjoying himself immensely, laughing loudly at a situation comedy, while the other patients stared glumly at the same set. As Dr. Harris approached, the young man looked up and greeted her with a cheery, “Hey, Doc! I’ll be ready in a minute, as soon as this show is over.” The psychiatrist waited for Jack in her office.

A few minutes later he ambled in, closed the door, and sat down. Then he began telling Dr. Harris that she had upset him, that she had hurt his feelings by locking her door after he had unlocked it; it showed she didn’t trust him. Going even further, he told her that it was underhanded and dishonest of her. The psychiatrist was momentarily dumbstruck. Jack was accusing her of dishonesty for relocking her own door!

Twelve-month prevalence rates of antisocial personality disorder range from 0.2 percent to 3.3 percent. The prevalence is highest (up to 70 percent) among individuals with substance abuse and criminal histories (APA, 2013).

“What were you trying to do by unlocking my door?” she asked.

Jack replied that he just didn’t like locked doors. “Speaking of which,” he added, “I can’t take being cooped up in here all day and night. I know I was suicidal before, but I think I’m coming out of it. Can’t I have grounds privileges?” Then he went on, “Look, I’m sorry about the lock thing. It was a stupid prank I pulled. I’ve just been upset about having to be in a hospital—even though I know I need to be here,” he quickly added.

Dr. Harris explained that in order for anything to change in Jack’s hospital status— the lifting of suicide precautions, conferring grounds privileges, or whatever—he would have to discuss his situation more openly.

Jack’s attitude then changed, and he said he was ready to speak frankly. First, he apologized profusely for any trouble he had caused. He said that if he was sometimes crude, it was a front he had developed out of fear that others might take advantage of him if he didn’t act like he could take care of himself. He admitted to Dr. Harris that he had spent 6 months in prison for a “stupid petty theft”; while in prison, he was bullied constantly because of his small stature. That experience had hardened him, he said, and now he sometimes “acted like a jerk,” even among people who had his best interests at heart.

Jack went on to admit that he hadn’t really considered suicide; he had simply claimed that to gain admission to the hospital. In his opinion, however, it was no exaggeration to say that he was at the end of his rope. He said that since being paroled, he had had tremendous difficulty finding and keeping a job. He had tried everything, from mechanic to electrician to drill press operator, at various auto plants, but in each case he was laid off within a few weeks because of his low seniority in the union.

In one study, clinical psychologists viewed videos of statements made by individuals and evaluated their truth or falsehood. The clinicians were able to identify 62 percent of the lies, a performance similar to that of federal judges (Ekman et al., 1999). Interestingly, a more recent study discovered that men, but not women, with high levels of psychopathy also performed better than chance in terms of detecting real-life emotional lies (Lyons, Healy, & Bruno, 2013).

In addition, he explained, his mother’s heart condition had worsened considerably, forcing her to be hospitalized. Because neither one of them was now working, they lost their apartment. And his girlfriend, with whom he sometimes lived, had gotten fed up with his losing jobs and his inability to contribute to the rent, and had demanded that he leave. After being kicked out, he had gone to a homeless shelter before being hounded out of there by “ruthless thugs” who stole whatever money he had left. Feeling that he was losing this daily struggle for survival, he had come to the hospital.

Jack said he was sorry if he had offended anyone with his charade for getting admitted, but he felt he was suffering as much as any patient, and his false claim of suicidal thoughts showed just how desperate he was. He said he felt he was experiencing a “crisis of confidence” and he needed some intensive therapy to help him through this period. “Look,” he concluded, “I could tell you that I still want to commit suicide, but I’m trying to be honest with you now in the hope that I’ll get the right kind of help.”

Dr. Harris listened to Jack’s story with an open mind. Although skeptical about his claims, she decided against recommending immediate discharge. Instead, she decided to proceed with a complete pretreatment evaluation, which included a mental status exam, an electroencephalogram, psychometric testing, and an occupational evaluation. His case conference would be held in 5 days, at which point the treatment team would decide whether to discharge him or proceed with treatment. In the meantime, the psychiatrist removed Jack’s suicide precautions, but reminded him that he would still be restricted to the locked unit for at least the next several days.

A mental status exam is a structured interview in which the clinician asks about specific symptoms, such as anxiety or hallucinations; observes other symptoms, such as emotional expression or motor activity; and tests certain cognitive capacities, such as memory or abstract reasoning.

Jack thanked her profusely for “understanding” and said he would cooperate with the evaluation procedures and make less of a pest of himself. During the next several days, the patient seemed true to his word. He was well-behaved and cooperated fully with all the evaluation procedures. But then, the day before his case conference, he disappeared. The building was searched, but there was no sign of Jack. A few hours later, Dr. Harris received a call from the state police saying they had picked up a patient—obviously Jack—for possession of a stolen vehicle, hers. Jack had also been charged with driving without a license, driving while intoxicated, speeding, and failure to heed a stop signal. The police said they were calling to investigate Jack’s claim that the psychiatrist had lent him the car. Dr. Harris explained that she certainly had not done this, but was nevertheless willing to drop any charges. The police replied that they already had enough

outstanding warrants on Jack to hold him “from here to doomsday,” and he was arraigned on the other charges.

With Jack unable to return to the hospital, his next of kin—his mother—was contacted to pick up his personal articles. His mother was in perfect health, in spite of Jack’s dramatic story of her grave heart condition and recent hospitalization. After picking up her son’s belongings, she spoke with Dr. Harris and supplied some details about his background.

A Parent’s Tale Watching Antisocial Behavior Unfold

“In most of us, by the age of thirty, the character has set like plaster, and will never soften again.”—William James (1890)

Jack’s mother, Marlene, told Dr. Harris that everyone who encountered Jack as a toddler immediately fell in love with him. “He was such a sweet child, and he had a smile that could win over anyone.” However, “as soon as he was old enough to go to school, the trouble started.”

At about the time that Jack entered first grade, he seemed to develop a “thing” for jewelry or, more accurately, for stealing it. For example, he would take items from Marlene’s jewelry case and sell them one by one to classmates or to older boys in the neighborhood, often for no more than pocket change, which he would spend on candy or trading cards. Marlene and her husband learned what Jack was doing after he tried to sell a pair of genuine pearl earrings to his second-grade teacher for $5.00. At first, his parents just scolded him. When the behavior continued, the scoldings turned into beatings. Eventually, they decided that the only way to deal with the situation was to keep their valuables—bills, coins, jewelry—under lock and key.

Jack’s parents provided him with a generous allowance in an effort to reduce his desire for spending money. However, this desire could never be satisfied. By the age of 8, the boy began breaking into neighbors’ houses to steal items to sell. In many ways, he became quite ingenious in these break-ins. He learned to pick locks, disable alarms, and slip into small openings. At the same time, however, the way in which he would dispose of the stolen items often seemed remarkably stupid, according to his mother. His most spectacular bungle occurred when he

tried to sell jewelry to members of the very same household from which it was stolen.

This triggered his first arrest, at age 10, but he was remanded to the custody of his parents, who told the judge that they would figure out a way to control him. They did indeed try to control his antisocial ways by keeping a more careful eye on him. When Jack went to school, for example, they would actually escort him into the building to make sure that he was attending classes. But the boy was not beyond slipping out in the middle of the day, inevitably to get into some kind of trouble.

Jack’s stealing soon took a more serious turn. He joined up with a group of teenagers who made a profession of shoplifting. They saw in Jack an opportunity to acquire stolen goods with a reduced risk of detection, since Jack was much younger and less likely to be suspected. Typically, one of the teenagers would case a store, locate items of interest, and then send Jack inside to remove the items according to their instructions. The gang would then sell the items to a regular fence who paid them in cash, drugs, and alcohol.

Associating with these older boys led Jack to develop more varied and sophisticated interests and a precocious sexual awareness. The turning point in his antisocial career came when, at age 12, he lured a 10-year-old neighborhood girl into some woods behind her house, undressed her, and tried to perform sex acts with her. When she started screaming, her mother came running and was confronted with the horrifying scene. Jack at first claimed that the girl had lured him into the woods. When that didn’t work, he offered the girl’s mother $5.00 “to keep her mouth shut.” As it became apparent that the woman was not warming to the negotiations, 12-year-old Jack finally tried threats, telling the mother she had better take the money or she would get the same treatment.

With this incident, Jack entered the world of serious legal trouble and was sentenced to a year in reform school. There, he learned more advanced methods of taking advantage of others. As soon as he was released, he embarked on a career of auto theft. He could now hot-wire a car in 30 seconds, and would do so whenever he needed cash or transportation. Why take the bus, he reasoned, when there were cars all around? Jack’s mother estimated that he hot-wired 50

cars before finally getting caught in the act, leading to another term in reform school, this time for 2 years.

Antisocial personality disorder was called “moral insanity” during the nineteenth century.

When he was released, at almost 15 years old, his parents tried to persuade him to return to school and pay enough attention to his studies to get a high school diploma. The teenager agreed to attend a trade school to learn how to repair electrical systems and electronic components. His mother now realized that her son had probably favored this route because he had hoped to become more skilled at disabling alarm systems; also, with electronics training, he thought he might get jobs that would bring him into contact with equipment worth stealing.

Jack actually stayed with his electrical studies, and after receiving his certificate at age 17 found employment at an auto plant, assisting in the installation of electrical systems. He seemed to work hard for several months, and Marlene marveled at his capacity to apply himself. But it all came to an end when he was later caught stealing electrical supplies on a massive scale. Somehow, he had gained access to the plant’s supply depot where he had been removing switches, wiring, batteries, and other electrical supplies for sales to competing auto plants. He eventually got caught when, in a manner reminiscent of his childhood error, he tried selling some of these supplies back to his own plant.

Thus, at age 18, Jack was sentenced to 3 years in a state penitentiary. Not being the violent sort, he was paroled after 18 months for good behavior. Upon his release, he stunned his former colleagues by applying for employment at the very same auto plant where he had been caught stealing. He expressed outrage and hurt, seemingly sincere, when they refused to take him back. For the next several months, Jack hitchhiked around the country, bouncing from one job to the next.

People with antisocial personality disorder tend to respond to warnings or expectations of stress with low brain and bodily arousal, such as slow autonomic nervous system arousal and slow electroencephalogram waves (Gaynor & Baird, 2007; Perdeci et al., 2010). This may help explain the inability of many such individuals to experience constructive levels of fear or to learn from negative experiences.

As for his love life, Jack’s mother reported that he had been married at least twice, although she doubted he had ever been divorced. He met his first wife at age 21, while hitchhiking around the country after his release from prison. Marlene had never met the woman, but learned from Jack that she was a 45- year-old divorcée who had picked the young man up as he was hitchhiking through her town. Jack later told his mother that this woman completely repulsed him: she was dull and unattractive, according to his description. Nevertheless, he felt a sexual stirring while riding in the car with her and proposed sexual intercourse. The woman replied, half teasingly, that he would have to marry her first. Jack immediately agreed, and they drove nonstop to a western state where they found a justice of the peace to perform the ceremony. Then they paid for a motel room where Jack got what he’d asked for hours before.

The next morning, the couple drove back to the bride’s hometown, and Jack moved into her house. He resided there for a few weeks, until she started nagging him about finding work. At this, he decided he had hung around long enough, and he departed for home, hitchhiking and hot-wiring his way there.

Once back in his home state, Jack acquired several girlfriends, one of whom he married under similar circumstances. In each such involvement, Jack showed no concern about the age, appearance, or character of the woman. Rather, his interest in women seemed largely a matter of housing and, to a lesser extent, sex. No sense of love or attachment was ever involved.

At the time that Jack had sought admission to the psychiatric hospital, he was, according to his mother, in truly desperate straits. She and Jack’s father—fed up with having to hide their valuables constantly—had refused to allow him entry into their home and his latest girlfriend had locked him out. Marlene suspected that in seeking hospital admission, her son was simply looking for a place to stay, although he may also have considered the prospect of obtaining psychiatric drugs, either to use or sell, as an added bonus. Typically, Jack would become bored with his schemes when they could not be executed immediately; this was probably why he ran off with Dr. Harris’s car rather than continue his stay at the hospital. Marlene, an old hand at Jack’s behaviors, encouraged the psychiatrist not to take the car theft personally, explaining that he probably chose her vehicle only because her name on the reserved space had caught his eye.

A number of structural brain abnormalities have been found among individuals with antisocial personality disorder and psychopathy (for example, deficits in the frontal gray matter, amygdala, uncinate fascisculus, and hippocampus, and increased size of the corpus callosum). Although consistent differences have been difficult to find, researchers are now able to identify structural brain differences between “successful” and “unsuccessful” psychopaths (that is, the ones who don’t get caught and the ones who do) (Pemment, 2013).

Jack’s mother then signed for her son’s belongings—the wallet, the $3, and the earring—and departed.

Jack No Success with Therapy

Marlene’s departure marked the end of Dr. Harris’s involvement with Jack. The young man had left the psychiatrist’s professional life as suddenly as he had entered it. And the therapist was certain she had made little or no impact on him. This failure of treatment did not surprise her, although it did cause her disappointment. During her short time working with him, she had come to suspect that Jack manifested antisocial personality disorder, a pattern that is notoriously unresponsive to treatment. Based on her talks with Jack and with his mother, Dr. Harris felt that he clearly met the DSM-5 criteria for a diagnosis of this disorder. That is, he failed to conform to social norms; also, he was deceitful, impulsive, reckless, irresponsible, and remorseless. And, as the DSM-5 criteria stipulate, he would have met the criteria for conduct disorder well before the age of 15.

The DMS-5 requires that there be evidence of conduct disorder prior to the age of 15 in order to meet the diagnostic criteria for antisocial personality disorder.

Although many people with this personality disorder exhibit criminal behavior, their brand of criminality is often marked by idiosyncratic qualities. For one, their criminal acts often seem to be inadequately motivated. The individual may, for example, commit a major crime for very small stakes. In this regard, Dr. Harris recalled that Jack tried to sell his mother’s pearl earrings for $5. Also, the criminal acts of these individuals often seem to be committed without much sense of self- preservation. They may fail, for example, to take obvious precautions against detection when carrying out their crimes. Here, again, Dr. Harris recalled Jack’s attempts to sell items to the very source from which they were stolen.

In short, Jack showed the disorder’s classic overall pattern of long-standing antisocial behavior, dating from childhood, aimed at nothing higher than the immediate gratification of transient desires. His behavior did not seem to be deterred by any sense of shame, remorse, or even plain self-interest.

Clinicians have generally despaired of devising an effective treatment for antisocial personality disorder. Perhaps the main reason for this is that people with the disorder, by definition, have no recognition that their behavior pattern is problematic. They usually reject the need for or value of psychological treatment, and so they are unlikely to initiate it or adhere to it for very long. Still other factors may also be at work, but the sad reality remains that the mental health field is currently unable to help most people with this personality disorder.

Finding an effective treatment for antisocial personality disorder has been challenging. Some short-term studies have suggested that cognitive-behavioral therapy and contingency management can help decrease substance abuse in those with antisocial personality (Messina, Wish, & Nemes, 1999). However, attempts to find value in cognitive-behavioral therapy or other forms of therapy for the treatment of antisocial personality disorder have been unsuccessful (Davidson et al., 2009).

Unfortunately, the single greatest hope for improvement may lie with the simple passage of time. It appears that adults with this pattern, who often begin a criminal career as teenagers, significantly reduce their level of criminal activity after age 40. That is, they experience fewer convictions and serve less time in prison as they grow older. The reason for this shift remains unclear, but, for now, it is the one optimistic note in an otherwise bleak affair.

Assessment Questions

1. What is one of the most common reasons individuals with antisocial personality disorder end up in therapeutic treatment?

2. What inconsistencies did you notice as you read about Jack’s complaints prior to being hospitalized and his behavior after he was admitted?

3. What other psychiatric disorders appear with patients who have antisocial personality disorder?

4. What are the statistics regarding the gender of people with this diagnosis?

5. What behaviors did Jack finally manifest that fit a diagnosis of antisocial personality disorder?

6. Give 3 examples from Jack’s mother’s story that suggested Jack was a candidate for a personality disorder as an adult?

7. What are some possible biological explanations for antisocial personality disorder?

8. Why is treatment usually ineffective for this personality disorder?

9. List 4 criteria that Jack exhibited that convinced Dr. Harris that Jack’s diagnosis should be antisocial personality disorder.

10. What eventually happens to many individuals who have this personality disorder?"