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For references, see the Bibliography page |
Essential Feature
The essential feature of the antisocial personality disorder is a pervasive pattern of disregard for, and the violation of, the rights of others. This pattern begins in childhood or early adolescence and continues into adulthood (DSM-IV, 1994, p. 645).
The ICD-10 (International Classification of Diseases) refers to APD as the dissocial personality disorder. It is characterized by a disregard for social obligation and a lack of concern for the feelings of others. There is a pattern of disparity between behavior and social norms. Behavior is not readily modifiable by negative consequences. There is a low tolerance for frustration and a low threshold for discharge of aggression (ICD-10, 1994, p. 226).
Many authors use the terms antisocial personality disorder and psychopathic personality interchangeably. Robert D. Hare, Ph.D. (1993, p. 25) differentiates the two by stating that all psychopaths are antisocial but not all individuals with APD are psychopaths. He notes that the DSM-III-R? criteria for APD was limited to a cluster of criminal and antisocial behaviors. He defines psychopathy, on the other hand, via a cluster of both personality traits and socially deviant behaviors. Hare believes that most criminals are not psychopathic and many psychopaths manage to stay out of jail. The Hare Psychopathy Checklist addresses this differentiation by being comprised of two scales; the first addresses emotional and interpersonal issues -- the second is made up of items concerning social deviance.
The emotional/interpersonal scale looks at indications of:
- glibness and superficiality
- egocentricity and grandiosity
- lack of remorse or guilt, lack of empathy
- deceitfulness and manipulativeness
- shallow emotions
The social deviance scale looks at indications of:
- impulsivity
- poor behavior controls
- lack of responsibility
- early behavior problems
- adult antisocial behavior (Hare, 1993, pp. 3-4).
The DSM-IV? (1994, pp. 645-650) criteria for APD includes deceitfulness and lack of remorse but continues the emphasis on deviant behavior via failure to conform to social norms, impulsivity, aggression, reckless disregard for safety, and irresponsibility. In the narrative, it is noted that the APD pattern has also been referred to as psychopathy, sociopathy, or dissocial personality disorder (ICD-10). It is under the DSM-IV? "e;Associated Features and Disorders"e; that individuals with APD are described as lacking empathy and being callous, cynical, and contemptuous of the feelings, rights, and suffering of others. They may have an inflated and arrogant self-appraisal, display a glib, superficial charm, and be verbally facile. These features are seen as particularly distinguishing of APD in prison or forensic settings. Hare does not agree that these features are limited by setting and clearly believes the criteria for APD should include the associated features.
A NIMH Epidemiologic Catchment Area study reported that only 47% of those who met the APD criteria had a significant arrest record. However, up to 80% of men and 65% of women in American prisons meet the criteria for APD (Black & Larsen, 1999, p. 29). Many individuals with APD work as bartenders, waiters, entertainers, or carnival workers. They are also found in medicine, law, politics, and the clergy; many become psychotherapists (Black & Larsen, 1999, pp. 50-51). Hare (1993, p. 112) adds that individuals with APD can function reasonably well as academics, mercenaries, police officers, cult leaders, military personnel, businesspeople, writers, artists, and entertainers. However, Hare does not refer to these individuals as "e;successful psychopaths"e; because their success is often illusory and always at someone else's expense. He calls them "e;subcriminal psychopaths."e;
Black & Larsen (1999, p. 41) state that about 40% of boys and 35% of girls with conduct disorder go on to develop adult APD. They also note that individuals with APD may show signs of considerable anxiety including tension, jitteriness, panic attacks. Depression and attempts at suicide are not rare; about 5% of individuals with APD eventually succeed -- compared to 1% in the general population (Black & Larsen, 1999, p. 92).
Up to 75% of individuals with APD show early and lasting alcohol dependency; as many as half abuse other drugs (Black & Larsen, 1999, p. 91).
Self-Image
Millon states that the APD self-image is one of autonomy. These individuals see themselves as unconventional and disdainful of the customs of society. They are unfettered by the constraints of personal attachments and unconfined by persons, places, obligations, and routines. They are comfortable with the deception and manipulation needed, in any situation, to do what they believe is right for them regardless of the impact on others (Millon, 1996, p. 447).
Individuals with APD believe that they are special and deserve dispensations and immediate effortless gratification; Kantor describes this stance as narcissism "e;intensified and gone underground"e; (Kantor, 1992, p 269). Meloy describes it "e;aggressive narcissism"e; (Meloy, Gabbard, ed., p. 959).
The fondest APD image of self reflects unrealistic notions of superiority. When they encounter evidence that they are only human, they will attempt to restore self-esteem by exerting power. Individuals with APD have learned that they can, or should be able to, ignore the needs of others, do whatever feels compelling, and seduce or bully others to avoid adverse consequences (McWilliams, 1994, p. 158).
View of Others
APD is identified as an independent rather than a dependent personality; individuals with APD have an inclination to turn to themselves rather than others as the primary source for need fulfillment. Millon refers to these individuals as "e;active independents"e; with aggrandizing personalities; they are driven by a need to prove their superiority. Their independence does not come from their belief in their self-worth as much as from a mistrust of others. They have faith only in themselves and are most secure when free of those who may harm or humiliate them (Millon, 1996, p. 429). They see the world as fraught with frustration and danger. They must be on guard against the malevolence and cruelty of others who will attempt to abuse, exploit, and dispossess them. Other people are seen as wanting to dominate and brutalize. Individuals with APD believe they must take the power that others command so that no one can use that power against them (Millon, 1996, p. 447). On the other hand, individuals with APD view others who are not able to dominate or control as weak and vulnerable and available for exploitation (Beck, 1990, pp. 48-49).
The diagnosis of antisocial personality disorder refers to a basic failure of human attachment; others are valued for their utility only. The organizing preoccupation for these individuals is "e;getting over on"e; (consciously manipulating) others (McWilliams, 1994, pp. 151-153). Even so, individuals with APD usually believe that their problems are either other people's inability to accept them or the desire that others have to limit the APDs' freedom (Beck, 1990, p. 153).
Relationships
Millon describes the interpersonal conduct of individuals with APD as irresponsible, untrustworthy, and unreliable; they frequently fail to meet marital, parental, employment or financial obligations. Individuals with APD have few feelings of loyalty and may be treacherous and scheming beneath a veneer of civility (Millon, 1996, p. 445). Stone describes individuals with APD as potentially being either aggressive or more passive-parasitic (Stone, 1993, p. 297). Millon notes that these individuals can be gracious, cheerful, and clever then things go their way; however, they are easily provoked and inclined to become demeaning, dominating, and vindictive (Millon, 1981, p. 199 ). They will victimize others by manipulating observed weaknesses and will, in turn, feign being a victim to absolve themselves from blame (Millon, 1981, p. 199).
Individuals with APD evidence an inappropriate and unmodulated desire to control others; they are able to effect interpersonal control with both detachment and a willingness to use aggression. With their strong need for independence, they resist being controlled by others (who are usually held in contempt). Even friendly, sociable behavior from people with APD is accompanied by a baseline position of detachment and indifference; they do not care what happens. Their patterns within relationships include use of uncaring aggression, affection that is controlling and detached, reckless self-indulgence, blaming others for their own behavior, and an insistence on autonomy for themselves (Benjamin, 1993, p. 203).
APDs form relationships that are multiple, transient, and superficial. Their interpersonal style is antagonistic; they show a reckless disregard of others' safety; they are highly competitive, slick and calculating. Because their relationships are superficial, they can be callous about the pain and suffering of others (Sperry, 1995, p. 16). They are not concerned about what others think of them. Individuals with APD do not evidence low self-esteem as they are able to protect themselves with the defense of blaming (Birtchnell, Costello, ed., pp. 186-190).
Issues With Authority
Millon suggests that the most distinctive characteristic of APD is an inclination to flout conventional authority and rules; these individuals are disdainful of traditional ideals. They do not conform to social norms and are often contemptuous of ethics and values. They experience pleasure in transgressing social codes via deceit or illegal behavior and gain special joy in taking power and possessions from others. These individuals are untroubled by guilt or loyalty and may develop a talent for pathological lying. Individuals with APD place their personal desires against those of others; they believe that they alone deserve every advantage and become adroit at feigning innocent victimization to absolve themselves from blame (Millon, 1996, pp. 445-447).
Oldham notes that individuals with APD know right from wrong -- they just don't care. They have little compassion for others and can justify cruel, destructive, malicious, or manipulative behavior (Oldham, 1990, p. 237).
Antisocial Personality Disorder Behavior
The APD behavioral style is impulsive, irritable, and aggressive. These individuals are noted for their hostility, deceitfulness, and cunning. They are forceful and engage in risky, thrill-seeking behaviors (Sperry, 1995, p. 16). Many people avoid individuals with APD because they seem callous, argumentative, and contentious. They can be abusive, intimidating, brusque, and cruel (Millon, 1981, p. 198).
Individuals with APD are also noted for their irresponsible parenting, poor job performance, repeated substance abuse, persistent lying, delinquency, truancy, and violations of others' rights (Sperry, 1993, p. 322).
Individuals with APD will appear to others as entitled in their attitudes and behavior. APD entitlement refers to the belief that personal needs are more important than the needs of others and includes rationalization for negative behaviors (Ries, TIP #9, 1994, p. 62). Kernberg sees individuals with APD as possessing the fundamental features of the narcissistic personality with the addition of ego-syntonic aggression directed toward others and a paranoid orientation (Millon, 1996, p. 439).
APD impulsiveness relates to the insufficient control of thoughts and behavior. These individuals engage in motor impulsivity (acting without thinking); cognitive impulsivity (making up one's mind precipitously); and poor planning impulsivity (lack of thought for the future) (Barratt, Costello, ed., 1996, pp. 91-96).
Individuals with APD evidence low tolerance for frustration. They act impetuously and cannot delay or forgo immediate pleasure. When things are not going their way, they are brash, arrogant, and resentful (Millon, 1996, p. 445).
Affective Issues
APD affect lacks subtlety, depth, and modulation. Individuals with severe APD appear to live in a presocialized emotional world; feelings are experienced in relation to self but not to others. Such individuals are unable to experience emotions such as gratitude, empathy, sympathy, affection, guilt, or mutual eroticism that depend on the perception of others as whole, real, and meaningful. Dominant emotions are anger, sensitivity to humiliation, envy, boredom, contempt, exhilaration, and pleasure through dominance (Meloy, Gabbard, ed., p. 962).
Individuals with APD are frequently described as irritable. This irritability is defined as a disposition toward anger and aggression. Here, aggression is the APD behavior intended to inflict discomfort, hurt, harm, injury, or destruction on others (Lish, Costello, ed., 1996, p. 24). Oldham suggests that even if individuals with APD improve later in life, they remain irritable, angry, and tense (Oldham, 1990, p. 239).
Millon suggests that these individuals show a tendency to blurt out feelings and vent urges directly. They appear to have an impulse to explore the forbidden (Millon, 1996, p. 448).
Defensive Structure
The more severe the APD, the more primitive the defenses, including: projection rationalization, devaluation, denial, projective identification, omnipotence, and splitting (Meloy, Gabbard, ed., p. 961).
Millon suggests that individuals with APD use acting out and projection as regulatory mechanisms. These individuals appear to have exploitative and resentful dispositions that are discharged directly and precipitously. The projection is expressed through interpretation of incidental behaviors and remarks of others as attacks. People with APD then justify their outbursts as a reasonable response to the malevolence of others. When they are able to see themselves as innocent bystanders subjected to unjust persecution and hostility they are free to counterattack and gain vindication (Millon, 1996, p. 448).
Millon goes on to describe the internal controls on behavior or impulses in individuals with APD as weak and ineffectual. They have a low threshold for both deviousness and irresponsible action, as well as for hostile and erotic discharge. There is also a hedonistic need to experience things that provide immediate pleasure (Millon, 1996, p. 448).
McWilliams believes that acting out defines individuals with APD; they experience internal pressure toward action. While these individuals do feel anxiety, they act out so fast to relieve such toxic feelings that an observer has no chance to see it. The pressure toward action may diminish with age through changes in hormonal levels, but the loss of physical power that occurs at mid-life may also be related to the easing of precipitous acting out (McWilliams, 1994, pp. 154-155).
There is some evidence that APDs have more basic aggression than others. Individuals who become antisocial seem to have inborn tendencies toward aggressivity and a higher than average threshold for excitement. Individuals with APD act instead of talk; service providers will not be able to connect with these clients by reflecting feelings (McWilliams, 1994, pp. 151-153).
The Antisocial Personality Disorder Coming Into Treatment
Individuals with APD will probably only be in treatment as a result of legal involvement. Even self-referrals often have pending legal problems that could be ameliorated by "e;voluntarily"e; seeking treatment or rehabilitation. Family pressure to change destructive behavior may or may not carry sufficient leverage to bring individuals with APD into treatment settings.
Once in treatment, change may be possible for those individuals with APD who are sufficiently functional to understand the utility of changing behaviors that create legal problems. For individuals with APD who can experience anxiety, depression, or attachment, the prognosis is considerably improved. If they insist, on the other hand, that their problems are a result of other people behaviors or expectations, the prognosis is substantially less optimistic.
If individuals with APD seek treatment in a mental health setting, it is imperative to determine the level of substance use or abuse. While collaborative sources may be needed to obtain accurate information, the incidence of co-occurring substance abuse with APD is sufficiently high to warrant a thorough investigation of the history and current status of involvement with drugs and alcohol. Another confounding factor in the diagnosis of APD is the possibility that substance abuse or dependence has resulted in antisocial behavior that would ameliorate if the individuals were to become abstinent. The diagnostic picture is complex and assessment of the personality disorder must always be made in the context of drug and alcohol use.
Medication Issues
There is no medication that can be targeted at altering APD. There are however certain symptoms and behaviors that may respond to pharmacological intervention if medication compliance can be managed through institutional or community supervision. One of those behaviors is that of violence. Meloy suggests that serotonin agonists and anticonvulsants appear to inhibit two different types of aggression. The first of these is affective aggression, a type of violence that is accompanied by high sympathetic arousal and emotion (usually anger or fear) and is a reaction to imminent threat. The second type of violence is predatory aggression, a type of violence that is accompanied by minimal or no sympathetic arousal and is planned, purposeful, and without emotion. He goes on to suggest that serotonergic dysfunction may account for many psychopathic symptoms, particularly impulsivity, emotional dysregulation, assaultiveness, and dysphoria (Meloy, Gabbard, ed., pp. 964-965).
Lish also suggests that Lithium, anticonvulsants such as carbamazepine, antidepressants such as fluoxetine and sertraline, buspirone, and antipsychotic medication all appear to have some usefulness in reducing aggression (Lish, Costello, ed., 1996, p. 37). Although antidepressants and antianxiety medicines have been used to treat aggressive individuals, there are studies that seem to suggest that some of these medications can actually lead to increased aggressive behavior. Tricyclic antidepressants have been associated with increased impulse dyscontyrol in subgroups of individuals with personality disorders (Lish, Costello, ed., 1996, p. 37).
It should be emphasized, however, that individuals with APD would not find any of the above medications interesting or pleasant (with the exception of the antianxiety drugs). Compliance would be such a difficult problem that the usefulness of the psychopharmacology may be irrelevant.
Another significant problem with individuals with APD in mental health treatment is drug-seeking behavior. Many of these clients in outpatient mental health clinics actively determine which symptoms result in the prescription of their favored drugs and describe themselves accordingly. Personnel in the medication clinics often face antagonistic, even threatening, behavior if clients with APD are not provided with the specific medications they are demanding. Reportedly, one dually diagnosed individual in a state hospital in the Commonwealth of Virginia successfully brought a human rights complaint (for withholding of needed treatment) against a psychiatrist for refusing to prescribe benzodiazepines for anxiety. The client won the dispute and was provided with the drug he wanted. This incident was described as taking place several years ago; hopefully, a more informed approach is available today.
Treatment Provider Guidelines
Individuals with APD respect power and will not relate well to a powerless service provider. The clinician needs to demonstrate independent strength verging on indifference. If there is apparent helping professional investment in client change or improvement, individuals with APD will take great delight in sabotaging treatment just to demonstrate the service provider's impotence (McWilliams, 1994, pp. 159-164). Accordingly, the most important feature of APD treatment is service provider incorruptibility. Individuals with APD do not experience or understand empathy. They are not grateful to or appreciative toward service providers. They use and manipulate other people and will take pleasure in any triumph over a clinician who wavers from the strict boundaries of professional ethics and the treatment contract. It is at least possible to win the respect of clients with APD by being tough-minded and exacting (McWilliams, 1994, p. 161). Related to incorruptibility is the service provider's uncompromising honesty, i.e., being clear, straightforward, keeping promises, making good on threats or statements of consequences, and persistently addressing and identifying reality.
Given the manipulative and exploitative qualities of APD behavior, it is important to note that honesty does not mean self-disclosure (McWilliams, 1994, p. 162). Meloy also points out that "e;the treatment rule"e; for APD treatment is rigorous honesty without self-disclosure (Meloy, Gabbard, ed., p. 963).
One issue in providing services for individuals with APD is when not to offer community-based treatment. The major consideration regarding community-based APD treatment is safety. This is a concern for the service providers, other clients in group or milieu treatment, and the larger community. There are antisocial personality disordered individuals for whom community-based treatment is not a choice that can be made within the larger context of personal and public safety. McWilliams notes that some individuals with APD are so damaged, dangerous and determined to destroy the objectives of treatment that working with them is futile and naive (McWilliams, 1994, p. 160).
Meloy identifies five APD features that contraindicate treatment of any kind; these are: 1) a history of sadistic and violent behavior; 2) total absence of remorse; 3) intelligence two standard deviations from the mean; 4) no history of attachments; and 5) fear of predation by experienced service providers without overt threat from the individual with APD (Meloy, Gabbard, ed., p. 962).
Meloy goes on to suggest using the Hare Psychopathy Checklist to determine the severity of disturbance in individuals with APD. As stated above, the Checklist items include many of the elements found in the DSM-IV? criteria for APD. Other factors are considered as well. The checklist of features to be evaluated include: glibness, superficial charm, grandiose self-worth, high need for stimulation, pathological lying, manipulativeness, lack of remorse or guilt, shallow affect, callousness or lack of empathy, parasitic life-style, poor behavioral controls, promiscuity, early behavioral problems, no realistic long-term goals, impulsivity, irresponsibility, short-term relationships, juvenile delinquency, revocation of conditional release, and criminal versatility (Meloy, Gabbard, ed., p. 960). The greater the number of the above features expressed by individuals with APD, the poorer the prognosis, and the greater the possibility of aggression against and loss of safety for the service providers.
While there is no definitive answer to when an individual with APD should not be treated in the community, there is considerable agreement in the literature that service providers should not deny, minimize, or ignore their own internal "e;early-warning system"e; if they find themselves fearing predation and violence from an antisocial personality disordered client. Nothing is gained, and much may be lost, if an individual with APD is treated as though he or she is less dangerous than is actually the case.
Transference and Countertransference Issues
The basic transference, according to McWilliams (1994, p. 159), for individuals with APD is the assumption that clinicians are also predatory and will use their position for selfish purposes. Service providers are often dismayed that their identity as a helper is repudiated.
Common countertransference experiences in working with individuals with APD include ominous fear, eerie foreboding, denial or minimization of the threat posed by those APD clients with severe pathology (McWilliams, 1994, p. 159). Sorting out what is countertransference and what is a significant internal warning signal may take assistance through consultation or supervision.
Meloy states that no other client population will compel service providers to face their own aggressive and destructive impulses like the psychopathic antisocial personality disorder. He adds that the most subtle countertransference with these individuals is the clinician's belief that the APD client is as developmentally mature and complex as the clinician. This is particularly common when the individuals with APD have a high IQ (Meloy, Gabbard, ed., p. 964).
Treatment Techniques
Comprehensive treatment planning of APD involves: 1) determining the severity of psychopathic factors active in individuals with APD with a clinical focus on their capacity to form attachments; 2) determining if there is any evidence of superego disturbance in these clients; 3) identifying any treatable Axis I mental or substance abuse disorders; 4) delineating situational factors that may aggravate or worsen antisocial behaviors; 5) identifying legal problems or involvement; 6) engaging in treatment only if it is demonstrably safe and effective; and 7) paying careful attention to all countertransference reactions (Meloy, Gabbard, ed., p. 968).
In assessing individuals with a possible diagnosis of APD, do a thorough history; seek information regarding: 1) family history; 2) childhood fire setting, animal abuse, and bed-wetting; 3) sexual history; 4) the individual's ability to bond with others; 5) possible parasitic relationships, e.g. exploitation of others; 6) history of head injuries, fighting, and being hit; 7) AOD use; and 7) HIV status (Ries, TIP #9, 1994, pp. 63-64).
There is substantial speculation in the literature about whether or not time is actually the best treatment for individuals with APD. The thinking is that APD symptoms ease as the individuals "e;mellow out"e; with age. There is the thought that hormones, loss of physical power, or growing pressure toward social conformity and attachment to others account for the decline in antisocial behaviors. However, Millon proposes that individuals with APD do not "e;age out;"e; he believes that the basic personality is not altered but is expressed in less obviously flagrant and public ways (Millon, 1996, p. 464).
Effective treatment with an APD population includes active, direct confrontation of APD thinking patterns, attitudes, denial or minimization of antisocial behaviors, and specific illegal behavior. One method which can be utilized to diminish pointless treatment-based power struggles is to reflect on how APD behavior is disadvantageous to these individuals both in the present and in the future realization of personal autonomy, freedom, and mastery. It should be pointed out that there are individuals with similar personality structures who can remain free of the criminal justice system by developing their personal strengths in ways that are meaningful and fulfilling. Oldham proposes that non-personality disordered individuals with a similar style to that of APD are the "e;adventurous personalities."e; These are people who are nonconforming; they live by their own internal code. They love the thrill of risk. They are persuasive and good at influencing others. They relish sex and have a basic wanderlust. They can take care of themselves. They are physically bold, tough, and courageous. They do not thrive in a basic 9 to 5 job; they do best when they work for themselves. They live in the present and do not feel guilty about the past or worried about the future. They are action-oriented, extroverted, and do not need others to maintain their own self-esteem (Oldham, 1990, pp. 217-219). People who can be described in this manner, particularly men, are esteemed in this culture. They can express who they are in a manner that is not illegal and can be well rewarded by an American society that values independence, toughness, and non-conformity. The treatment challenge that can be issued to individuals with APD is whether or not they must be self-destructive and engaged in a legal downward spiral or whether they can turn their strengths into advantages and remain free of the criminal justice system. What will not happen is that individuals with APD will become conforming, well-adjusted, compliant members of society. It is pointless to try.
Relapse prevention theory, a structured form of cognitive-behavior therapy, involves the premise that the targeted behavior is learned, motivated, and reinforced by internal factors and external factors. Treatment involves implementation of new cognitive and behavioral strategies to break up the previous, learned cognitive-behavioral chain. For this approach to be particularly effective, individuals with APD have to have felt the practical pain of their antisocial acts and be able to respond to aversive consequences. (Meloy, Gabbard, ed., p. 966).
In the Treatment Improvement Protocol #9, three key concepts or strategies in APD treatment are proposed. These are: corral, confront, and consequences. CORRAL means coordinating treatment and establishing a system of communication with other agencies and professionals, contracting with the APD client to be responsible for their AOD use in recovery, monitoring information about the individuals, and working toward specific treatment goals. Spouses, family members, and friends can be invited to participate as collaterals in the treatment process as well (Ries, TIP #9, 1994, p. 64). CONFRONT means being direct without being abusive. Service providers need to be clear in pointing out antisocial thinking patterns to the client. They should remark on contradictions between what these clients say and what they do. Random urine screens are essential for monitoring and confrontation (Ries, TIP #9, 1994, p. 64). CONSEQUENCES mean that individuals with APD should experience the consequences for their behavior. The treatment provider should record violations of the rules. Reasons for termination from treatment for these individuals include: noncompliance with treatment, continued drug use, aggressive behavior, parasitic relationships with others in treatment, or unsafe behavior. Individuals with APD compulsively try to break rules; consequences must be enforced. It is also beneficial to incorporate positive consequences for positive behavior (Ries, TIP #9, 1994, pp. 64-65).
Treatment Goals
Adler proposes that treatment goals for all individuals with personality disorders should include: preventing further deterioration, establishing or regaining an adaptive equilibrium, alleviating symptoms, restoring lost skills, and fostering improved adaptive capacity. The focus of treatment is adaptation, i.e., how the personality disordered individual responds to the environment. Goals do not necessarily include characterological restructuring (Adler, Adler, ed., 1990, pp. 26-27).
Another treatment goal for the APD client population is to assist family members and significant others to set limits. Typically, family members and others involved with individuals with APD have minimized, ignored, or acted inconsistently in response to APD behavior (Sperry, 1995, p. 31).
McWilliams (1994, p. 165) notes that it is significant in APD treatment if these individuals: 1) use words for self-expression rather than manipulation; 2) inhibit impulses; and 3) experience any pride in self-control.
Beck, in the cognitive behavioral approach, outlines the treatment goal of altering typical cognitive distortions of individuals with APD; frequent APD cognitive distortions include: believing that wanting something justifies any action to get it; believing thoughts are accurate simply because they are there; believing that they, as individuals, are infallible; believing they always make good choices; thinking that if they feel right about what they do, it must be the right thing to do; experiencing other people as irrelevant; and, believing that negative consequences will not happen or will not matter (Beck, 1990, p. 154).
Cluster B: Incidence of Co-Occurring Substance Abuse Disorders
Cluster B has the highest incidence of co-occurring substance abuse disorders of the three DSM-IV personality disorder clusters (Nace, O'Connell, ed., 1990, p. 184).
Various studies have linked APD with substance abuse disorders. Actually, the diagnostic criteria for the two are quite similar. Antisocial behavior can be caused by or exacerbated by substance abuse. The key difference between the two disorders is that APD behavior occurs independent of obtaining or using drugs (Widiger, Livesley, ed., 1995, p. 110). Abstinence, in true APD, does not result in diminished expression of antisocial attitudes or behavior.
Cognitive style, affective temperament, activity level, interpersonal style, and tolerance for intense emotions are all areas of behavior and experience that are mediated, albeit ineffectively, through a personality disorder and provide for specific vulnerabilities to addiction. Personality disorders involve failures in self-regulation and self-soothing; drugs and alcohol become alternative solutions to life problems in the absence of more effective means to manage difficulties. Individuals with APD are specifically prone to substance abuse and addiction because of their need for a high level of stimulation (Richards, 1993, pp. 240-241). APD inability to connect negative consequences with their behavior, contempt for authority, laws, and social norms, as well as their inclination toward impulsive action all support the use of drugs and alcohol. These individuals will stop AOD use/abuse only if they become convinced that it is in their own best interest. They see no problem with use of substances in any other context.
Drugs of Choice for the Antisocial Personality Disorder
Many individuals with APD engage in a polydrug pattern of use involving alcohol, marijuana, heroin, cocaine, and methamphetamines. The illegal drug culture is exciting to these individuals; it makes the world a fast-paced and dramatic place that enhances their self-image. Overall, individuals with APD tend to prefer stimulants, e.g. cocaine and amphetamines when choice is available (Ries, TIP #9, 1994, p. 55). Their need for stimulation can also lead to involvement with erotized violence. They may speak of verbal or physical rages as providing a high that compares to what they experience with cocaine. Cocaine and anger both enhance highly pleasurable feelings of dominance and sexuality. Benjamin proposes that working with individuals with APD is ineffective without a focus on the intensely self-reinforcing (euphoria inducing) nature of erotized violence (Benjamin, 1993, p. 219).
One clinician reports that substance abuse, for individuals with APD, is about power, control, and boosting feelings. There is no issue of self-medication although he believes that there is a subculture of individuals with APD who use herion to control their aggression.
Dual Diagnosis Treatment for the Antisocial Personality Disorder
Richards proposes that there are frequent dual diagnosis treatment failures if the treatment process is not directed at the function of the addiction, including the drug of choice, within the context of the personality psychopathology (Richards, 1993, p. 278). The function of APD addiction is often related to stimulation-seeking, being involved in the excitement of the illegal drug culture, and the enhancement of a dramatic, intense, living-on-the-edge self-image. Treatment can appeal to the strengths inherent in this style of personality. As noted earlier, Oldham describes the non-pathological variant of APD as the "e;adventurous personality."e; This personality incorporates many features of the "e;all-American male"e; and can be used to assist individuals with APD to consider what a positive expression of their inclinations can be. Keep in mind that 53% of individuals with APD manage to avoid a significant arrest record and can be effective in law, police work, the military, and business. If the primary motivation of these individuals is, as suggested, to be right, successful, and to sustain an inflated self-image (Ries, TIP #9, 1994, p. 62) (Evans & Sullivan, 1990, p. 101), it is possible to work with their motivation, not against it. To be clean, out of jail, and to be employed can be self-serving goals that lead to more positive behavior (Ries, TIP #9, 1994, p. 62). Appeal to their need to be special and clever to see if whatever talent is available can be directed to legal, high-risk behavior. Evans and Sullivan also note that individuals with APD get clean and sober for their own reasons, not the service providers' reasons. It is important to go for "e;pro-recovery "e; behavior; do not worry about whether or not the motivation behind the behavior has anything to do with compliance to social norms. It may be that willingness to behave in such a way as to stay out of jail is motivation enough (Evans & Sullivan, 1990, p. 104).
The Twelve Step recovery model can be very effective with individuals with APD. Step One is crucial and it is important that individuals with APD learn to identify exactly how their drinking and drugging was out of control. It is helpful to require them to write down or share specific examples of being out of control. It is also important to confront these individuals on their antisocial thinking errors/distortions that they use to justify both their substance abuse and their antisocial behavior. Evans and Sullivan suggest that the key focus of this approach are the questions: How do you blame, manipulate, lie, etc., to justify your use of drugs and alcohol? What are the negative consequences you have experienced for that behavior (Evans & Sullivan, 1990, pp. 103-104)?
Substance abuse programs which help individuals tolerate feelings and conflict without the use of substances, reduce regression and acting out, and support the adaptive functioning of clients provide a model for the development of frustration tolerance, impulse control, and improved self-esteem; as a consequence, they are indirectly addressing the personality disorder issues as well as addiction (O'Malley, Adler, ed., 1990, p. 122). The Twelve Step recovery model is important here as well. It includes a philosophy of living that mirrors the same goals that would be most helpful for persons with personality disorders: responsibility for self, honesty in dealing with feelings, sensitivity to both the needs and the feelings of others, avoidance of impulsive actions, and the ability to tolerate stress and painful feelings (O'Malley, Adler, ed., 1990, p. 125).
Individuals with APD may enter treatment depressed due, primarily, to recent negative consequences for their behavior. They can be at risk for suicide, particularly when intoxicated or in withdrawal. They may need psychiatric hospitalization and detoxification (Ries, TIP #9, 1994, p. 64). However, individuals with APD generally have a poor response to hospitalization. They also have a poorer response to alcohol rehabilitation programs than non-APD clients (Melon, Gabbard, ed., p. 959). Therapeutic communities may be helpful because they provide firm limits, structure, group work with peers, and a work program. Psychoeducation is also usually beneficial (Sperry, 1995, p. 33).
Individuals with APD, in dual diagnosis outpatient or inpatient groups, can be predatory toward other members of the group, By placing these clients with more vulnerable individuals, parasitic relationships, exploitation, and introduction of the less sophisticated group members into the process of obtaining and using drugs may result. Confrontation usual to substance abuse treatment is appropriate and useful with persons with APD. Emphasis needs to be on responsibility for self/behavior, limit-setting, and consequences. Abstinence can be a prerequisite to treatment; use should result in termination from treatment.
Sharon C. Ekleberry, 2000