Antisocial Personality Disorder (ASPD)

Antisocial Personality Disorder (ASPD)

Antisocial Personality Disorder (ASPD)

Those with antisocial PD (ASPD) chronically disregard and violate the rights of other people; they cannot or will not conform to the norms of society. This said, there are a number of ways in which people can exhibit ASPD. Some are engaging con artists; others are, frankly, graceless thugs. Women (and some men) with the disorder may be involved in prostitution. In still other individuals, the more traditional antisocial aspects may be obscured by the heavy use (and often purveyance) of illicit drugs.

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Although some of these people seem superficially charming, many are aggressive and irritable. Their irresponsible behavior affects nearly every life area. Besides substance use, there may be fighting, lying, and criminal behavior of every conceivable sort: theft, violence, confidence schemes, and child and spouse abuse. They may claim to have guilt feelings, but they don’t appear to feel genuine remorse for their behavior. Although they may complain of multiple somatic problems and will occasionally make suicide attempts, their manipulative interactions with others make it difficult to determine whether their complaints are genuine.

DSM-5 criteria for ASPD specify that, beginning before age 15, the patient must have a history that would support a diagnosis of conduct disorder; as an adult, this behavior must have continued and been extended, with at least four ASPD symptoms.

As many as 3% of men, but only about 1% of women, have this disorder; it is found in about three-quarters of penitentiary prisoners. It is more common among lower-socioeconomic-status populations and runs in families; it probably has both a genetic and an environmental basis. Male relatives have ASPD and substance-related disorders; female relatives have somatic symptom disorder and substance-related disorders. Childhood attention-deficit/hyperactivity disorder is a common precursor, and childhood conduct disorder is a requirement (see above).

Although treatment seems to make little difference to patients with ASPD, there is some evidence that the disorder decreases with advancing age, as these people mellow out to become “only” substance users. Death by suicide or homicide is the lot of others.

Generally, the diagnosis of ASPD will not be warranted if antisocial behavior occurs only in the context of substance abuse. Individuals who misuse substances sometimes engage in criminal behavior, but only when in pursuit of drugs. It is crucial to learn whether patients with possible ASPD have engaged in illicit acts when not using substances.

Although these patients often have a childhood marked by incorrigibility, delinquency, and school problems such as truancy, fewer than half the children with such a background eventually develop the full adult syndrome. Therefore, we should never make this diagnosis before age 18.

Finally, ASPD is a serious disorder, with no known effective treatment. It is therefore a diagnosis of last resort. Before making it, redouble efforts to rule out other major mental disorders and PDs.

Essential Features of Antisocial Personality Disorder

These patients have a history dating to before age 15 of destroying property, serious rule violation, or aggression against people or animals (that is, they fulfill criteria for conduct disorder). Since then, in many situations, they lie, con, or give an alias while engaging in behaviors that merit arrest (whether or not they are actually detained). They tend to fight or assault others, and generally fail to plan their activities, relying instead on the inspiration of the impulse. For none of this behavior do they show remorse, other than feeling sorry if caught. They will refuse to pay their debts or maintain steady employment. They may irresponsibly place themselves or other people in danger.

The Fine Print

The D’s: • Duration and demographics (diagnosis cannot be made prior to age 18; behavior patterns are enduring) • Diffuse contexts • Differential diagnosis (physical and substance use disorders, bipolar disorders, schizophrenia, other PDs, ordinary criminality)

Milo Tark

Milo Tark was 23, handsome, and smart. When he worked, he earned good money installing heating and air conditioning. He had broken into that trade when he left high school, which happened somewhere in the middle of his 10th-grade year. Since then, he had had at least 15 different jobs; the longest of them had lasted 6 months.

Milo was referred for evaluation after he was caught trying to con money from elderly patrons at an ATM. The machine was one of two that served the branch bank where his mother worked as assistant manager.

“The little devil!” his father exclaimed during the initial interview. “He was always a difficult one to raise, even when he was a kid. Kinda reminded me of me, sometimes. Only I pulled out of it.”

Milo had picked a lot of fights when he was a boy. He had bloodied his first nose when he was only 5, and the world-class spanking administered by his father had taught him nothing about keeping his fists to himself. Later he was suspended from the seventh grade for extorting $3 and change from an 8-year-old. When the suspension was finally lifted, he responded by ditching class for 47 straight days. Then began a string of encounters with the police, beginning with shoplifting (condoms) and progressing through breaking and entering (four counts) to grand theft auto when he was 15. For stealing the Toyota, he was sent for half a year to a camp run by the state youth authority. “It was the only 6 months his mother and I ever knew where he was at night,” his father observed.

Milo’s time in detention seemed to have done him some good, at least initially. Although he never returned to school, for the next 2 years he avoided arrest and intermittently applied himself to learning his trade. Then he celebrated his 19th birthday by getting drunk and joining the Army. Within a few months he was out on the street again, with a bad-conduct discharge for sharing cocaine in his barracks and assaulting two corporals, his first sergeant, and a second lieutenant. For the next several years, he worked when he needed cash and couldn’t get it any other way. Not long before this evaluation, he had gotten a 16-year-old girl pregnant.

“She was just a ditsy broad.” Milo lounged back, one leg over the arm of the interview chair. He had managed to grow a scraggly beard, and he rolled a toothpick around in the corner of his mouth. The letters H-A-T-E and L-O-V-E were clumsily tattooed across the knuckles of either hand. “She didn’t object when she was gettin’ laid.”

Milo’s mood was good now, and he had never had anything that resembled mania. There had never been symptoms of psychosis, except for the time he was coming off speed. He “felt a little paranoid” then, but it didn’t last.

The ATM job was a scam thought up by a friend. The friend had read something like it in the newspaper and decided it would be a good way to obtain fast cash. They had never thought they might be caught, and Milo hadn’t considered the effect it would have on his mother.

He yawned and said, “She can always get another job.”

Evaluation of Milo Tark

Milo’s behavior persistently affected all aspects of his life: school, work, family, and interpersonal relations. By the time he was 15, he easily met criteria for conduct disorder (ASPD criterion C). Afterwards, he moved on to full-blown adult criminality that persisted through his early 20s: repeated illegal acts (A1), assaults (on Army personnel—A4), irresponsible work record (A6), impulsivity (no planning about breaking into the ATM—A3), and lack of remorse (toward his mother and the girl he impregnated—A7). His symptoms touched on the areas of cognition, affect, interpersonal functioning, and impulse control (see the description of a general PD). Of course, he was now old enough (over 18—criterion B) to qualify for a diagnosis of ASPD.

People with a manic episode or schizophrenia will sometimes engage in criminal activity, but it is episodic and accompanied by other manic or psychotic symptoms. Milo steadfastly denied any behavior suggesting either a mood or a psychotic disorder (D). Patients with intellectual disability may break the law, either because they do not realize that it is wrong or because they are so easily influenced by others. Although Milo didn’t do especially well in school, there is no indication that he was held back because of low intelligence.

Because many addicted patients will do nearly anything to obtain money, substance use disorders are important in the differential diagnosis. Milo had used cocaine and amphetamines, but (according to him) only briefly, and most of his antisocial behaviors were not associated with drug use. Patients with impulse-control disorders will engage in illegal activities, but this is confined to the context of conduct disorder in younger people and fighting or property destruction in intermittent explosive disorder. Patients with bulimia nervosa sometimes shoplift, but Milo had no evidence of bulimic episodes. Of course, many of these conditions (as well as the anxiety disorders) can be encountered as associated diagnoses in patients with ASPD.

Career criminals whose antisocial behavior is confined to their “professional lives” may not fulfill all of the criteria for ASPD. They may instead be diagnosed as having adult antisocial behavior, which would be recorded as Z72.811 [V71.01]. It constitutes part of the differential diagnosis of the PD.

With a GAF score of 35, Milo’s complete diagnosis would be as follows:

Antisocial Personality Disorder (ASPD)