¶ Understanding Antisocial Personality Disorder and Treatment
Hello all you therapists out there and welcome to our podcast here at Licensury Exans . I'm Linton .
And I'm Stacey . Today , as part of our demystifying disorder series , we'll be taking a close look at antisocial personality disorder . The DSM-5TR diagnostic criteria used to make this diagnosis , how you can distinguish it from other disorders with similar features , like narcissistic personality disorder and borderline personality disorder , and treatment planning .
Let's start off by reviewing the criteria for antisocial personality disorder . First of all , you'll be looking for a persistent and persuasive pattern of disregard for and violation of the rights of others that's been present since the age of 15 .
Right , and that pattern manifests in a variety of ways . The person has to exhibit three or more of the following A failure to obey laws and norms by engaging in behavior like deceitfulness , impulsivity , aggressiveness , recklessness and irresponsibility . A lack of empathy , remorse or guilt . Impulsivity and failure to plan ahead .
Irritability and aggressiveness To disregard for safety of self or others . Consistent irresponsible behavior in repeatedly failing to maintain employment or fulfill financial duties . And the last one is a lack of remorse for hurting , mistreating or stealing from others .
So , linton , as I'm saying all of these things out loud , I'm thinking didn't you tell me once that your parents kept you in a straight jacket to keep you in bed and on a leash when they took you anywhere when you were a kid ?
Well , yeah , they did , but it wasn't because I lacked an empathy or exhibited aggressiveness .
What about the impulsivity and disregard for safety of self criteria ?
Well , okay , maybe I did exhibit those patterns , but that's only two out of the three . You need to be diagnosed with APD and , don't forget , my mom was a nurse , so restraining was what she did with overly active patients all the time .
Oh , overly active patients . That's a good reframe there , but I think if I dig a little deeper I could at least find one more criteria .
Okay , okay , look , let's skip back to the issue at hand here . Okay , let's say you've got a case study on the exam where the client was unable to hold a steady job for one reason or the other . Maybe the economy was tough like it has been recently for the whatever line of work they're in , or maybe they had health issues that caused employment disruptions .
Does that qualify as criteria states ?
No , those are perfectly reasonable situational factors that could understandably cause some job instability . So , with anti social personality disorder , that persistent irresponsible work behavior might manifest as prolonged periods of unemployment even when job opportunities are available , or abandoning multiple jobs without a realistic plan for securing new employment .
So financial irresponsibility could present as behaviors like defaulting on debts , failing to pay child support , not paying back loans or consistently neglecting to financially support dependence .
Right . Well , basically , the disorder really centers around violation of social norms and laws , with deliberate deceitfulness , aggressiveness and lack of concern of consequences . That wasn't my situation there , Stacy .
You know I sense a little public story though coming up next Linton .
Well , I guess it was sort of like when I was at Publix the other day and some guy picked up a pre-packaged sushi , believe it or not , opened the container , ate part of the sushi roll and stuck it back in the refrigerated display .
Oh no , oh man , I wish somebody got that on camera .
Yeah , right Now . That's just rude , and not to mention hygiene issues raises for the next shopper that might have been you .
Yes , exactly , jeez . So when we talk about the pattern of behavior of disregard for and violation of the rights of others , if you've ever seen the movie Hannibal or Gone Girl then you will understand what we're talking about here . But remember Hollywood has a tendency to showcase really extreme examples of disorders .
Clients with antisocial personality disorder have a high likelihood of engaging in criminal behavior , but not all of them are of a violent nature , like you typically see in the movies . Clients may maybe have a history of robbery , fraud or something a little less intense like drug dealing .
You know , didn't we do a whole thing up about using movies for a way of determining or getting a picture of what diagnoses look like ?
We did , as I recall it was on our Pinterest page . We had a board called I think it was called Real to Real Mental Health .
Yeah , I think it was called that . And so these two that you mentioned , what were they again ?
Yep , hannibal , that's that one about . You know the well antisocial , psychopathic tendencies Guy that was a while back . Gone Girl's a little bit more of a modern . You know it's based off of a book within the past five years or so , I think .
Exactly Well . What about the client's age , though ? Can you diagnose antisocial personality disorder in like a teenager , for example ?
I'm glad you asked so remember this if you run across a personality disorder case on the exam . Antisocial personality disorder is the only personality disorder with a specific age limitation . The only one , so the client has to be at least 18 years old .
If they're younger , you can't diagnose them with antisocial , but you could consider a diagnosis of conduct disorder .
Mm-hmm , okay , I got it . Well , how about this ? Can a client be diagnosed with more than one personality disorder at the same time ?
Yes , comorbid diagnoses are possible with antisocial personality . For example , your client could potentially meet criteria for both antisocial personality and narcissistic personality disorder . But as a therapist you really need to take care not to overdiagnose .
Some symptoms inherent in antisocial personality disorder , like the lack of empathy , insincerity and manipulative behavior , could appear narcissistic in nature , but the core motivation tends to be really different between those . So people with antisocial personality engage in behaviors to serve their own interests , often without the concern for consequences .
Narcissism , on the other hand , really stems from underlying feelings of inferiority , an extreme need for validation and admiration .
What about your favorite kind of client Stacy ? What about borderline personality disorder ? It shares some of the same common features with antisocial , like manipulative behavior .
Just like with narcissistic personality disorder , a big difference between borderline and antisocial is the motivation behind the behavior . The manipulative tactics that are common with borderline are often motivated by an intense fear of abandonment and a desire to maintain relationships .
Someone with borderline personality disorder may make desperate attempts to keep people close by using threatening , suicide or self-harming behavior .
Right , I've seen that .
And , in contrast , manipulation in antisocial personality disorder serves more self-centered goals . So it's really to help them get what they want , whether that's money , power , something like that . Without the regard for others , manipulation in relationships is really a means to an end , rather than stemming from attachment fears or emotional dependency issues .
Okay , now that you've painted a really good picture of antisocial personality disorder , let's talk about how someone with that kind of disorder ends up in your office Stacy .
Yeah , good point . It doesn't really seem like someone with antisocial would be inclined to seek therapy on their own , does it ?
No , uh-uh . Usually there's some kind of external motivator compelling them into therapy . Often they've got into legal trouble and therapy is mandated as part of a probation or parole program .
A judge may order therapy sessions to avoid jail time or and a family member , like a spouse , may threaten to leave or cut off financial support unless the person with antisocial personality disorder gets some counseling . Additionally , some end up in therapy with comorbid issues like depression or substance abuse . When it finally gets the upper hand .
The depression or hitting rock bottom with substance use leads them to therapy .
I see , so they don't usually choose to be there voluntarily .
Nope .
Well , what tends to happen when someone with antisocial actually engages in therapy ? How does their disorder manifest itself in sessions ? Linton ?
Okay . Having a client with antisocial personality disorder in therapy sessions introduces really some challenges , and you'll wish you had paid more attention in Dr Seward's class at Syracuse University for sure For one . They often try the manipulator charm the therapist to get what they want . They may lie , minimize their behavior or attempt to elicit sympathy .
It's important that you , as a therapist , identify this and call it out . Additionally , they lack self-awareness of their issues and show little remorse or concern of how their actions will impact others . They may be argumentative and may try blaming external factors for all their problems .
Trying to foster insight and accountability trying to foster insight and accountability tends to prove quite difficult . They also tend to grow bored or impatient with the therapy process . The inward focus on changing their destructive patterns just doesn't appeal at all . It's the last thing they really want to do .
They may reject goals , homework assignments or suggestions , Seeing them as useless or just plain annoying .
So dealing with the manipulation , resistance and apathy does sound really challenging . So what are some strategies that you could use as a therapist that could actually help move therapy forward by the client who's like this ?
Okay , for starters , having realistic therapy goals is critical when working with anti-social personality disorder , since developing empathy , remorse and self-awareness can be extremely challenging .
Practical behavioral goals tend to work the best , rather than aiming to fundamentally change the personality goals target reducing destructive acts , improving relationships or avoiding legal consequences is what you want to be aiming towards .
Right . So it's much more productive to focus goals around practical issues like developing job skills , maybe achieving financial independence or , like you said , linton , avoiding those legal issues .
Right , exactly those are the kind of goals that connect with what really matters to them the most .
Okay , so now a big question here . What about safety concerns ? So you've got someone in your office who doesn't follow the rules or care about consequences . How do you deal with that ?
Well . So essentially , you need to establish firm boundaries and direct communications , which are keys with working with anti-social personality disorders . Be very clear about office policies , payments , scheduling and confidentiality right up front . Define what behaviors won't be tolerated , like intimidation or threats .
Should safety issues arrive , involve authorities when needed and , since manipulation is common , be alert to lies about attending programs and taking medication . You always really have to verify claims with outside sources when possible . Be prepared for charm offenses and attempt to push your buttons .
Don't get hooked in and always have a clear pathway to the exit in your office .
Very good advice . Also , given the high risk nature of this disorder , having a support system is essential . As a therapist , consult with colleagues after challenging sessions and seek peer input on strategies and engage in self-care to manage the stress when working with this population .
Address counter-transference proactively , because clients with anti-social personality disorder are master manipulators . They may try to turn things around in sessions to make you feel guilty , incompetent or even threatened . So it's really important that you don't fall into their trap by defending your skills . Instead , reassert session goals and boundaries .
With diligence and the right strategies , tailored to what motivates them , you can reduce harmful behaviors and foster that sense of responsibility .
Okay . So if you do have a client with anti-social , what assessment tools might even appear on an exam that you should be aware of ? Stacey ?
All right , the Hair Psychopathy Checklist revised . This is a diagnostic tool used to assess psychopathic traits and tendencies that are often associated with the antisocial personality disorder . This assessment is most often used in institutional and correctional facilities , as well as psychiatric hospitals .
Then there's the Hair Psychopathy Checklist , the screening version , and this is really a shorter variation of the Hair Psychopathy Checklist that takes about half the time to administer . As a screening tool , this is used to evaluate the possible presence of antisocial tendencies and , if detected , a more complete assessment should follow to determine a diagnosis .
Then we have the Milan Clinical Multiaxial Inventory , or the MCMI .
Most people are aware of that one .
Yes , yeah , that one's pretty common . So the MCMI is a psychological assessment that includes scales for several personality disorders , including antisocial personality disorder , and it's a self-report that contains true-false questions .
Then there's the other ever-popular Minnesota Multiphasic Personality Inventory , or the MMPI , and the MMPI has subscales related to antisocial tendencies in criminal behavior . Elevations on certain scales may indicate the presence of antisocial traits . Then we have the Structured Clinical Interview for DSM Disorders .
This is a semi-structured interview used to systematically assess the presence of antisocial personality based on the diagnostic criteria in the DSM . It allows for follow-up questions by the interviewer . And last but not least there are actually several more , but we just kind of chose the more common ones Right , the Antisocial Process Screening Device .
This tool screens for antisocial tendencies in youth . To determine a further evaluation for conduct disorder or emerging antisocial personality disorder is warranted .
How about the Beck Depression Inventory ?
The Beck Depression Inventory ? Tell me more .
Would you use that with the Antipersonality Disorder ?
No , you piqued my curiosity . No dear no , I know there's some kind of trick here , lyndon .
Okay , here's a quick recap before we wrap it up .
¶ Understanding Antisocial Personality Disorder
Antisocial personality disorder is characterized by a persistent pattern of disregard , by inviolation of others' rights , evident since age 15 , plus at least three symptoms like deceitfulness , aggression , irresponsibility and lack of empathy .
So if you have a client that's like 23 , how would you know that if violation of other individuals' rights had happened since they were 15 ?
Well , that's where taking a good history is gonna come into play . So it's important you know any history that you can get . If you have , you know court history . If you have a family history , if you can get some collateral information from you know family or friends that's gonna help clue you in about their past .
But what if you don't have that information ?
That's a good question . What if you don't have that information ? London .
Oh , it's back on me now . Yes , yes , it is . Okay moving along it is only . It is only personality disorder , where the client must be at least 18 years old in order to be diagnosed . Let's go with that , okay .
Don't ask questions if you don't know the answer .
Thanks a lot it can also it can also coexist with other mental disorders , including Personality disorders like narcissistic or borderline your favorite . But use caution because it's possible to over diagnose . Make sure that you examine all of the client's personality features and the motivation behind the client's behavior .
This information can lead you to determine if you're dealing with just one personality disorder or a combination of personality disorders . The client is usually compiled into therapy by external forces like legal system or family members Symptoms who are usually manifest in therapy through manipulation , lying , blaming and lack of remorse , or Insight or motivation is lacking .
Set realistic , practical goals , as these work better than trying to fundamentally change the personality . It's important to set really firm boundaries . Remember that call out manipulation attempts and involve authorities If there is a safety concern .
And remember that having a support system is helpful to consult and address any Counter-transference issues that are resulting from the stress of working with this population and that's anti-social personality disorder , demystified as you study for your exam , remember it's in there .