Which behavior is a characteristic of a patient diagnosed with antisocial personality disorder?

Abstract

Antisocial personality disorder (ASPD) remains a major challenge, not only in forensic mental health care: the diagnosis itself is controversial; evidence for treatment is rare; and, in contrast to other personality disorders, patients with ASPD reject rather than seek treatment. Past research on the aetiology of ASPD suggests that complex gene-environment interactions are risk factors for the development of antisocial behaviour and the disorder itself. An important aspect of forensic treatment planning is to understand the function of offending and other antisocial behaviour. Different models and treatment approaches for ASPD have emerged from established psychological therapies for personality disorders and have been adapted for forensic psychotherapy. Case formulation is a useful tool that helps us to understand behavioural patterns of offending and that can be used not only for treatment but also for risk assessment of individuals with ASPD.

7.3.3 Antisocial Personality Disorder

The concept of ASPD refers to behavior in adults (and sometimes adolescents) that is similar to CCDs in children. Among the main symptoms of ASPD are extreme insensitivity to the feelings of others, lack of conscience, manipulativeness, impulsivity, recklessness, untrustworthiness, and deceptiveness. ASPD also encompasses the concept of psychopathy (although some make fine-grained distinctions). Basically, psychopaths are individuals who exhibit a grandiose sense of self-worth and a parasitic lifestyle (Hare 1980; Cleckley 1982:204; Forth et al. 1996). ASPD focuses more on behavior and lifestyle, while psychopathy focuses more on psychological traits.

ASPD and CCD (discussed above) are closely related concepts. In fact, in some diagnostic regimens, a key criterion for being diagnosed ASPD is having been diagnosed with CCD diagnosis prior to age 15 (Rueter et al. 2000; Dargis et al. 2015:820).

Of course, CCD and ASPD are clinical disorders, not legal categories. Nevertheless, both of these disorders have been found to be unusually common among persistent criminal offenders (Moffitt 1993; Raine 2002). Put another way, it is not illegal to have been diagnosed with CCD or ASPD, but those who have been so diagnosed have an unusually high probability of having been arrested and imprisoned for violating criminal laws by the time they are full adults. It is also worth noting that both CCD and ASPD are much more prevalent in males than in females (Ellis et al. 2008:393–395).

The findings from the three studies of the relationship between ASPD and social status are shown in Table 7.3.3. The table indicates that this condition is significantly more prevalent in the lower social strata than in the upper strata.

Table 7.3.3. Relationship Between Social Status and Antisocial Personality/Psychopathy

Course

ASPD–psychopathy is essentially a lifelong condition that is evident within childhood, albeit as yet not fully developed, and remains largely present throughout adulthood, consistent with all personality disorders (APA, 2013). Many clinicians and researchers though have been uncomfortable in diagnosing personality disorders within childhood, given the implication that they would be labeling a child with a largely lifelong condition. However, ASPD is the personality disorder for which there is a clear childhood variant: conduct disorder. Conduct disorder, an externalizing disorder of childhood, includes aggression to people and/or animals (e.g., bullying, fights), destruction of property, deceitfulness (lying or stealing), and serious rule violations. Conduct disorder is clearly a childhood variant of ASPD. In fact, one is required to document evidence for features of conduct disorder when diagnosing ASPD (APA, 2013). Approximately 40% of children who meet criteria for conduct disorder (particularly if there is an early age of onset) grow up to meet criteria for ASPD. In addition, DSM-5 now includes a specifier for conduct disorder for the presence of limited prosocial emotions; more specifically, lack of remorse or guilt, callous lack of empathy, unconcern about performance, and/or shallow or deficient affect (APA, 2013). These additional traits are clearly extending the concept of adult psychopathy to children with a particularly severe form of conduct disorder (Barry et al., 2000; Frick, Ray, Thornton, & Kahn, 2014), a proposal presaged by Lynam (1996) years ago.

Consistent with all personality disorders, there are also compelling data to indicate that ASPD is a relatively chronic disorder which persists throughout adulthood, although research does suggest that as the person reaches middle to older age, the frequency of criminal acts decreases. Nevertheless, the core personality traits may remain largely stable (Hare et al., 2012).

Psychopaths are typically quite comfortable in their skin, even though the psychopathic traits cause considerable trouble for them. As noted earlier, the life of a psychopath is at times glamorized and can be very appealing at a young age. Henry Hill was a member of the New York City Mafia; more specifically, the Lucchese crime family. His life story was portrayed in the highly successful Martin Scorsese movie, Goodfellas. As an adolescent, Hill famously stated, “At the age of twelve my ambition was to be a gangster” (Pileggi, 1985, p. 13). However, the exciting psychopathic lifestyle can come with a heavy cost. Although psychopaths are clearly dangerous to others, they are also actually dangerous to themselves. The prognosis for their future is not good. Psychopathic persons have a very difficult time maintaining employment; their relationships are unstable; they are at risk of serious injury and even death; and many spend a considerable amount of time imprisoned (Hare et al., 2012).

Indeed, the outcome for the three psychopaths identified earlier within this chapter illustrates well the not uncommon, unhappy ending. The movie Goodfellas ends with Henry Hill entering a witness protection program, avoiding a very long imprisonment by informing on most everyone else within his crime family. Subsequently, Hill was divorced by his wife, disavowed by his two children (Hill & Hill, 2004), and arrested again numerous times (often for drug-related crimes), contributing to a removal from the witness protection program. The life course for Ted Bundy ended even worse, with an execution by electric chair. As indicated earlier, Clyde Barrow died as a young adult, ambushed in a hail of gunfire (Traherne, 2000).

Sociopathy, Antisocial Personality Disorder, & Psychopathy

Sociopathy & Antisocial Personality Disorder. In 1909, Birnbaum proposed the term “sociopathy” to describe an individual characterized by antisocial behavior, impulsivity, and marked deficits in empathy and emotional processing. Birnbaum’s take on this construct differed from previous conceptualizations of psychopathy, as he focused on the socio-environmental factors of antisocial behaviors (also Lykken, 1957) rather than biological ones (i.e., hard-wired; psychopathy). Sociopathy was the precursor to antisocial personality disorder. “Sociopathy” appeared as a diagnostic category in the first Diagnostic and Statistical Manual of Mental Disorders (DSM; APA, 1952). The category included two subcategories, “dissocial reaction” and “antisocial reaction.” The “antisocial reaction” was most like the traditional conceptualizations of psychopathy (Jenkins, 1960) and was described as

always in trouble, profiting neither from experience or punishment and maintaining no loyalties to any person, group or code. They are frequently callous and hedonistic, showing marked emotional immaturity with lack of sense of responsibility, lack of judgment, and an ability to rationalize their behavior so that it appears warranted, reasonable, and justified (p. 38).

In the second DSM (II, APA, 1968), Antisocial Personality Disorder (ASPD) replaced sociopathy as a diagnostic category. ASPD was distinguished from other personality disorders by a focus on incorrigible antisocial traits and behaviors that occurred within a pattern of higher order personality traits, such as egocentrism, callousness, impulsivity, guiltlessness, and recalcitrance to remediation efforts or punishment (APA, 1968). Incapable of significant loyalty to individuals, groups, or social values, the ASPD individual was described as selfish, callous, irresponsible, and impulsive, as well as unable to feel guilt or to learn from experience or punishment. Additional characteristics included low frustration tolerance, a tendency to blame others, and the proffering of rationalizations for problematic personal behavior (APA, 1968).

Since the personality traits described in the DSM-II were difficult to assess reliably, the DSM-III ASPD criteria shifted toward easily identified behaviors. This shift, influenced by the social deviancy model and the work of Lee Robins (1966), increased reliability. The resultant group of ASPD individuals were very heterogeneous, decreasing the usefulness of the diagnosis, particularly within incarcerated populations (Gacono & Meloy, 1994).a As noted by Millon and Davis (1996):

The DSM formulation of ASPD … fails to recognize that the same fundamental personality structure, with its characteristic pattern of ruthless and vindictive behavior, is often displayed in ways that are not socially disreputable, irresponsible, or illegal (p. 443).

The DSM-III-R (APA, 1987) ASPD added a criterion, “lacks remorse (feels justified in having hurt, mistreated, or stolen from another)”, while continuing the emphasis on violent criminal acts, a trend that would continue in DSM-IV. These latter versions of the DSM (III, III-R, IV, IV-TR, 5) required evidence of conduct disorder with onset before age 15 and excluded the diagnosis of ASPD in instances where antisocial behavior occurred exclusively during Schizophrenia or manic episodes. The ASPD in DSM-III, III-R, IV, and IV-TR (1980, 1987, 1994, 2000) no longer resembled psychopathy (see Table 3.1).

Table 3.1. Cleckley’s (1976) 16 psychopathy criteria, both DSM-5 ASPD criteria, and ICD-10 Dissocial PD criteria.

There were no changes to ASPD in DSM-5 (APA, 2013). An additional dimensional trait based (rather than purely behavioral) list of criteria for coding ASPD was added in the “Alternative DSM-5 Model for Personality Disorders” section. In this section, seven personality traits must be considered to diagnose Antisocial Personality: manipulativeness, callousness, deceitfulness, hostility, risk-taking, impulsivity, and irresponsibility.b Additionally, impairment in at least two of the following areas: identity, self-direction, empathy, and intimacy must be present for this diagnosis. The specifier “with psychopathic features” was also included. However, unlike the PCL-R, which provides a reliable method for coding items, it is suggested clinicians use a self-report measure to assess these criteria (Personality Inventory for DSM-5 (PID-5; APA, 2013). The ICD-10’s (World Health Organization, 2010) most recent corollary of ASPD is the Dissocial Personality Disorder (see Table 3.1).

Psychopathy. From the beginning of recorded history, there have been descriptions of “psychopaths.” In the early 19th century, Philippe Pinel (1801/1962) observed a condition containing manie sans delire (insanity without delirium) and la folie raisonnante (impulsive & antisocial acts without impairment in intellectual or reasoning abilities). Rush (1812) would describe this syndrome as an abnormal moral depravity characterized by lifelong character traits of irresponsibility and lack of empathy. Similarly, Prichard (1835) coined the term moral insanity to include persons with a flawed character and a lack of empathy, as well as a variety of disorders such as Schizophrenia and Mental Retardation.

In 1891, Koch added psychopathic inferiority to the growing list of terms, while Kraepelin (1903–1904) introduced the concept of psychopathic personalities. Both Koch and Kraepelin described a complex disorder containing a variety of traits and behaviors. Koch, additionally, believed that there was a physical basis for psychopathy. In 1941, Cleckley’s seminal work The Mask of Sanity brought needed clarity to what had been a never-ending array of descriptions and terms. His thorough clinical study resulted in a list of 16 criteria that were accepted as a working model for psychopathy (Johns & Quay, 1962).

Robert Lindner (1943) began a thorough examination of psychopathy with the Rorschach and used a 30 item-checklist to identify psychopaths. Later, Martinez (1972) used a checklist based on Cleckley’s criteria as an independent measure for psychopathy (prior to the PCL-R). She compared three groups: psychopathic (N = 15), mixed (N = 15), and non-psychopathic (N = 15) females on several demographic and testing variables. Martinez (1972) found psychopathic females (P) differed from non-psychopathic females (NP) on age of first offense and criminal versatility. Martinez (1972) hypothesized physiological gender differences, but similar behaviors for male and female psychopaths.

While well intentioned, these checklists lacked the empirical development evident in the work of Robert Hare’s Psychopathy Checklists. Hare (1980) began his work utilizing a 7-point rating scale, representative of personality and behaviors consistent with Cleckley’s (1941) 16 criteria (see Table 3.1; Hare, 2003). These items, however, were difficult to score and required a substantial amount of subjective interpretation. The 7-point scale was replaced with a more user friendly 22 item Psychopathy Checklist (PCL; Hare, 1985). Two items, drug or alcohol abuse and a previous diagnosis of “psychopathy” were eliminated from the PCL in the 20 item Hare Psychopathy Checklist-Revised (Hare, 1991, 2003). The Psychopathy Checklists (PCL-R; Hare, 2003; PCL: SV; Hart, Cox, & Hare, 1995; PCL: YV; Forth, Kosson & Hare, 2003) were developed, normed, and validated exclusively on males. There has been less research with the PCL-R with women compared to men (Blanchette & Brown, 2006; Cunliffe, Gacono, Meloy, & Taylor, 2013; Cunliffe et al., 2016; Logan & Weizmann-Henelius, 2012; Nicholls, Odgers, & Cooke, 2007; Verona & Vitale, 2006, 2018).

The PCL-R’s two-factor structure (Factor 1; selfish, callous, and remorseless use of others; Factor 2; chronically unstable and antisocial lifestyle) contains a combination of traits and behaviors (see Table 3.2). Recently, the factors have been renamed (Factor 1, Interpersonal/Affective; Factor 2, Social Deviance) with the addition of four subcomponents or facets (facet 1 [Interpersonal]; facet 2 [Affective]; facet 3 [Lifestyle]; and facet 4 [Antisocial]; Hare, 2003). This differs from the one Factor behavioral structure of the DSM-5 ASPD diagnosis.

Table 3.2. PCL-R Items (Hare, 2003).

While many of the PCL-R items may be accurate for use with females (Bolt, Hare, Vitale, & Newman, 2004), some of the item descriptions do not sufficiently capture the syndrome in women (Cunliffe & Gacono, 2005; Cunliffe et al., 2013, 2016; Grann, 2000; Strand & Belfrage, 2005; Vablais, 2007; Appendices A & B). Differential Item Functioning analyses comparing female and male offenders revealed that females had higher scores on Item 5 (Conning/Manipulative), and lower scores on items 12 (Early Behavioral Problems), 18 (Juvenile Delinquency), and 20 (Criminal Versatility; Bolt et al., 2004). The PCL-R may require revisions to adequately capture these distinctions (Cunliffe et al., 2013, 2016; see Chapter 4 & Appendices A & B).

In forensic populations, base rates for ASPD are 50%–80%, compared to only 15%–25% for psychopathy (Hare, 2003) depending on security level. For females in secure settings, prevalence rates of psychopathy (PCL-R ≥ 30) have ranged from 1.05% to 31% with 9%–31% in prisons (Beryl, Chou, & Völlm, 2014; Dolan & Völlm, 2009, 37% in our female sample).

ASPD and Psychopathy Dynamic Formulations. Kernberg (1975) utilized levels of personality organization as a way of discriminating among neurotic, borderline, and psychotic patients (Acklin, 1997). It was a supplement to descriptive approaches to diagnosis and it aids in differential diagnosis (Kernberg, 1984).

Kernberg’s three levels of personality constitute a personality structure while psychiatric diagnoses (i.e., paranoid, narcissistic) would constitute a personality style (Acklin, 1997). Three levels were identified (neurotic, borderline, and psychotic), such that neurotic would be higher functioning, borderline would be intermediate, and psychotic would be the lower functioning. The neurotic level was contrasted from the borderline and psychotic levels due to an integrated identity and use of higher-level defenses such as repression (anxiety-related thoughts and memories are kept in the unconscious). The borderline and psychotic levels are contrasted based on reality testing (difficulty objectively differentiating from the internal and external world). Specifically, the borderline’s reality testing improves, and the psychotic’s reality testing deteriorates (Acklin, 1997). Borderline personality organization was characterized by four criteria: nonspecific manifestations of ego weakness, a shift toward primary process thinking, specific defensive operations, and pathological internalized object relations (Kernberg, 1975). Within the borderline level, poor impulse control, and poor anxiety tolerance is usually observed (Acklin, 1997). The individual organized at the borderline level uses primitive defenses of which splitting is the central mechanism (see Kosson, Gacono, & Bodholdt, 2000; Kosson, Gacono, Klipfel, & Bodholdt, 2016; see Table 3.3 for the definitions for defenses).

Table 3.3. Kernberg’s (1975) Personality Organization Defenses (also see Cooper et al., 1988).

Kernberg’s (1975) use of the term antisocial personality described a condition more akin to psychopathy than the DSM’s ASPD. In his discussions, he noted that both Borderline Personality Disorder (BPD) and ASPD would be organized at the borderline level, relying on primitive defenses such splitting, idealization, and devaluation rather than repression and other higher-level defenses (neurotic). The presence of borderline personality organization has been empirically measured and confirmed for both male and female ASPD individuals and psychopaths (Gacono, 1988, 1990; Gacono & Meloy, 1992; Gacono, Meloy, & Berg, 1992; see latter part of this chapter; Chapters 4 and 5Chapter 4Chapter 5). Gacono, Nieberding, Owen, Rubel, and Bodholdt (2001) and Bodholdt, Richards, and Gacono (2000) described psychopathy as a combination of behavioral and affective features including borderline, narcissistic, histrionic, and paranoid personality disorders.

Antisocial personality disorder

Individuals with antisocial personality disorder (ASPD) experience social difficulties, including violating social norms, aggression, impulsiveness, deceitfulness and manipulation, and poor problem solving (APA, 2013). Research is limited in regards to effective treatment approaches; however, CBT, including problem solving and interpersonal skills training, has been examined with mixed results. In particular, studies have shown CBT to reduce reoffending, have no result, or to incite iatrogenic effects (e.g., clients learned skills to better manipulate others; see Hare & Hart, 1993).

Enhanced thinking skills (ETS), a variant of CBT, is gaining support. ETS teaches impulse control, flexible thinking, general and moral reasoning, and interpersonal problem-solving skills in 20 2-h group sessions over a period of 5 weeks. ETS has been shown to be successful among male prisoners with ASPD in reducing recidivism rates and improving functioning related to avoidance, aggressiveness, impulsivity, resentment, and paranoia (Doyle et al., 2013), as well as improved social problem-solving skills (McDougall, Perry, Clarbour, Bowles, & Worthy, 2009).

Dimensional mentalizing profile characteristic of BPD and ASPD

Individuals with BPD and ASPD easily find themselves switching to persistent automatic mentalizing. Stress and arousal, especially in an attachment context, bring automatic mentalizing to the fore and disengage the neural systems that are associated with controlled mentalizing. Under these conditions, interactions become nonquestioning precisely when they need to be more controlled and contextualized. Thinking becomes impulsive; the individual makes assumptions about others’ thoughts and feelings that are not reflected upon or tested. Logic is intuitive, unreasoned, and nonverbal. As a consequence, patients may be overly distrustful (paranoid) or, in BPD, sometimes overly trustful (naive).

Patients with BPD may show excessive concern about their own internal state; that is, they hypermentalize in relation to the self without having an awareness of how others perceive them. In contrast, patients with ASPD tend to avoid self-scrutiny and hypermentalize about others. Failure to balance self-perception with sincere curiosity about how one is perceived by others (people with ASPD do not care how others perceive them) can lead to exaggeration of the self-image in either a positive (more common in ASPD) or a negative (more common in BPD) direction. A balanced, adaptive form of self-mentalizing conditioned by the social context is absent.

Patients with BPD and ASPD pay more attention to external indicators of mental states, and their initial ideas, arising from automatic mentalizing, go unchecked by controlled, reflective mentalizing. For example, if the clinician looks out of the window, to the patient this means that the clinician is not taking the patient seriously. A focus on external features, in the absence of reflective mentalizing, renders an individual highly vulnerable in social contexts, as it generates interpersonal hypersensitivity and hypervigilance.

8.2.4 Antisocial

The hallmark of the antisocial personality disorder is a tendency to disregard and to violate the rights of others (American Psychiatric Association, 2013). Antisocial individuals are very deceitful, repeatedly lying to others and “conning” them for personal gain, and feel no remorse for the harm their actions have caused to others.1 The antisocial person tends to be aggressive (e.g., committing assaults and getting into fights), to be irresponsible (e.g., failing to hold a job or to pay debts), and to be impulsive and reckless (e.g., doing dangerous activities that put others at risk).

Perpetrators’ Personality Characteristics

Incarcerated rapists are commonly diagnosed with antisocial personality disorders, and studies of nonincarcerated samples also have found that perpetrators have a tendency to disregard social norms. Among college students, sexual assault perpetrators score lower on measures of socialization and responsibility and higher on measures of narcissism than do nonperpetrators. A lack of empathy has also been found to characterize both incarcerated and nonincarcerated perpetrators. Commonly, sexual assault perpetrators have been found to possess impulsive and aggressive personality traits. Consistent with the antisocial traits they commonly possess, perpetrators often have a history of delinquent behavior. This combination of aggressiveness, impulsiveness, antisocial tendencies, and lack of empathy may make it easy for some men to feel comfortable using force to obtain sex.

Antisocial personality

Violence manifested by persons with the antisocial personality disorder is just one of many antisocial behaviors. These patients repeatedly get into physical fights and violence involving their spouses, children, and individuals outside of the family. A number of other antisocial behaviors include destroying property, harassing others, stealing, engaging in illegal occupations, driving in a reckless or intoxicated manner, and being involved in promiscuous relationships. The patient often lies, does not honor financial obligations, and is unable to sustain consistent employment. Alcohol and substance abuse are often problems. The violence toward others and other aspects of antisocial behavior are not accompanied by remorse or guilt. Violence is often accompanied by little display of emotion and seems cold-blooded. Issues of self-esteem and/or revenge frequently underlie the violence.

Prevalence and overview of societal costs

Many of those with early-onset CD develop antisocial personality disorder (ASPD) in adulthood (see Beauchaine et al., 2017; Robins, 1966). In fact, retrospective emergence of CD before age 15 is required to diagnose ASPD (American Psychiatric Association, 2013). Thus, continuity of externalizing behavior should be considered in any discussion of antisociality, as elaborated below (Beauchaine et al., 2017). Although prevalence rates of CD and ASPD are only 3%–6% among males and 1% among females (American Psychiatric Association, 2013; Kessler et al., 1994), about half of all property offenses and violent crimes are committed by affected individuals (e.g., Farrington, Ohlin, & Wilson, 1986). As a result, roughly half of incarcerated adult males in the United States meet criteria for ASPD (see Beauchaine, Klein, Crowell, Derbidge, & Gatzke-Kopp, 2009). Collectively, they account for over $70 billion in annual and federal corrections costs (Schmitt, Warner, & Gupta, 2010; Teplin, 1994)—a figure that omits the financial burden of crimes that led to incarceration.

Although often unacknowledged, about 1 in 20 males who suffer from ASPD eventually commits suicide. This rate is roughly 300 times that observed in the general population (Dyck, Bland, Newman, & Orn, 1988). Thus, CD and its developmental sequelae are major public health concerns for which improved understanding of etiology and formulation of more effective prevention and intervention programs are desperately needed. Unfortunately, research on prevention and treatment of CD does not receive levels of state and federal funding that many other psychiatric disorders garner (see, e.g., Insel, 2017). Likely reasons for this are complex and beyond the scope of this chapter. As we discuss below, however, prevention programs are most effective when delivered in childhood, before adolescents become embedded in multiple reinforcement systems that maintain antisocial behavior (e.g., deviant peer affiliations, the criminal justice system), and before problems with substance use emerge (see, e.g., Webster-Stratton & Taylor, 2001). In fact, effective prevention programs for 5-year olds who are on early-onset CD trajectories cost only 6%–12% of the cumulative 25-year economic burden of not intervening (Bonin, Stevens, Beecham, Byford, & Parsonage, 2011).