AntiSocial Personality Disorder, as described by the Diagnostic and Statistical Manual of Mental Disorders 4th Edition, published by the American Psychiatric Association, has the essential feature of pervasive disregard for and violation of the rights of others. This feature begins in childhood or early adolescence and continues into adulthood. Historically, Antisocial Personality Disorder has been referred to as sociopathy, dysocial personality disorder, psychopathy as well as antisocial character disorder. Antisocial Personality Disorder is what will be defined and described in this article. It is diagnosed in individuals who must be at least 18 years of age and have symptoms of conduct disorder predating age 15.

Clinicians, theologians and lawmakers have long tried to understand this form of character disturbance. Individuals suffering from severe Antisocial Personality Disorder are not delusional but, their behaviors make no rational sense. How can one rationally explain the behaviors of a Jeffrey Dahmer or a David Koresh. Historically, the term moral insanity has been applied. Some individuals seem to be born with an irresistible impulse to commit injury or due mischief towards others. New research seems to indicate the presence of inheritable traits that may be involved in the creation of Antisocial Personality Disorder.

For example, people who score high on impulsivity scales with low anxiety in the face of danger, may lack some of the inhibitions that most humans possess. Along with impulsivity and reduced anxiety in the face of danger, the characteristics of high-sensation seeking, lack of empathic capacity with weak control and high-drive intensity, set the stage for a genetic basis for antisociality. Today, most subscribe to an interactional theory. The interaction between the environment one grows up in and the genetic predispositions ultimately creating personality.

In studies of offenders, it has often been noted that violent offenders were more apt to come from unstable/broken homes than from stable homes. Historically, as many as one-half of violent offenses came from sons with the combination of: a mother with at least some emotional disorder plus a father with a criminal record. Although there is no one gene responsible for severe antisociality, characteristics that may be inherited along with environment that can intensify these traits may best explain it. It appears that the intensity and frequency of the inheritable traits is exaggerated by early life trauma or neglect, for example

Jeffrey Dahmer, who confessed to murder by dismemberment of 17 young men, may be a prime example of environment exaggerating inheritable tendencies. His family background includes a mother who suffered a nervous breakdown. Early in his life, he was sexually molested. He grew up in a home that was abusive with constant bitter arguing and a subsequent divorce.

There are certainly other reasons why people act out in an antisocial fashion. For example, Charles Whitman, who shot many from his perch at the tower of Texas, was first described as having an explosive disorder. Later upon autopsy, it was found that he had a walnut-size tumor infringing on the amygdala of his brain. Another example is Joe Willie Simpson, the "Mr. Goodbar" killer. During his adolescence, he suffered from a severe head injury and subsequent to that showed impulsive dyscontrol in thinking and emotion. According to Dr. Michael H. Stone, in his book Abnormalities of Personality, "More commonly, however, our search for positive influences would lead back to parental abuse and neglect, probably in combination with a defect affecting the (postulated) neuropsychological substraints of empathy."

The beginning: conduct disorder

DSM IV describes conduct disorder as "a repetitive and persistent pattern of behavior in which the basic rights of others or major age appropriate societal rules are violated". This pattern of behavior generally falls into four subcategories. These subcategories are:

1. Threats or actual harm to other people or animals

2. Property damage or loss

3. Theft and deceitfulness

4. Flagrant violation of rules

The important aspect of conduct disorder revolves around the fact that it is subtyped based on age of onset. The two subtypes also differ in clinical course. These subtypes are described as:

1. Childhood (early) onset type

2. Adolescent (later) onset type

The childhood onset type is characterized by at least one of the behavioral patterns presenting itself by age 10. Customarily, the behavior will often be there prior to age 8 and often as young as 4 or 5. This particular presentation is generally more serious and persistent. At 18, Antisocial Personality Disorder is often diagnosed.

Adolescent onset subtype of conduct disorder is described by behavioral patterns that occur only after age 10. For example, an individual at age 10, 11, 12 or 13, might start to use drugs or start to change social contacts, have school difficulties, difficulties at home, along with other antisocial behaviors. At 18, this individual may more often have symptoms consistent with antisocial behavior. The difference between the two subtypes can be defined by the difference between character disorder and behavior. A character disorder has a characteristic rigid maladaptive pattern of thought that leads to the behavior that often has at its core, the exertion of power and control over others. antisocial behavior lacks the characteristic abnormalities of thought.

There are diagnostic features that will help separate a child onset subtype of conduct disorder from the later onset presentation. A child onset subtype is typically marked by nonnormative peer relations. As this individual matures, power and control become the central themes in any relationship. They may be sexually exploitive and very aggressive. This aggressive behavior can take the form of cruelty to small animals (as in Jeffrey Dahmer's case), fire setting and sadistic predatory treatment of others. Typically, this individual is a loner. Relationships with others often involve manipulation for personal gain. This individual may have a strong sense of entitlement (a narcissistic feature). Certainly a case can be made for a David Koresh fitting into this narcissistic pattern. The adolescent onset subtype generally will have normal peer relationships. Often the antisocial acts that they perpetuate are done in a group format and not as individuals. Their style of aggression certainly may be more passive aggressive as opposed to aggressive and sadistic. These individuals may also present with more personality immaturity and sometimes problems of attachment. In their life, there may be absence of a positive and consistent role model. However, because they are able to bond and because they are capable of showing remorse, they are much better candidates for therapy and are capable of making positive social changes. It is the individual without the ability to form empathic relationships and without the ability to show remorse that seems to create an enigma for change. Without the ability to understand how one's actions affect others and without the ability to form relationships with others, most of the therapeutic approaches known to clinicians today have very little chance of succeeding.

Those suffering from mild antisociality (more consistent with antisocial behavior) where the severe character disorder is absent are more amenable to treatment. Individual and group formats are appropriate. Skill-building formats such as cognitive behavioral therapies, as well as awareness therapies may be helpful. Medications can be used to treat any existing psychiatric disorder. Quite often the crucial problem in treating this individual is the ability to provide wrap-around services. For example, how can these opportunities be made available if the individual lacks education and vocational opportunity? Other interventions such as housing, childcare and strong community-based treatment can add to the chances for positive change.

The presence of a character disturbance presents itself as the degree of antisociality increases. With moderate antisociality, we start to see therapeutic options becoming more limited to the "here and now" behavioral therapies. The clinician will experience a much stronger countertransference, and limit setting becomes increasingly crucial. As the character disturbance becomes evident, we start to see a failure to assume responsibility for one's behavior and a total lack of interest in responsible performance. With moderate antisociality, especially where there is a lack of dangerousness to the community, behavioral therapy may help the individual. In addition, informing outside "observers" will give the clinician adequate objective data. This is critical since the clinician cannot assume that the client tells the truth.

Medications can be used, but generally there is a lack of compliance. In severe antisociality, there appears to be a lack of technology. The trouble with the cognitive-behavioral and insight-oriented treatments is that they are designed for people who recognize that they have a problem and seriously want to change. Severely antisocial individuals enter treatment only because they are forced to by court order or another reason. They do not see any reason to change their attitudes and behaviors to conform to any social standard.

Dr. Robert Hare reports in the September 1995 edition of the “Harvard Mental Health Letter:” In fact, the treated psychopaths are more likely to commit a crime after release than untreated psychopaths. They learn enough psychiatric and psychological jargon to convince therapists, counselors and parole boards that they were making remarkable progress." They use this knowledge to develop new rationalizations for their behavior and better ways to manipulate the system.

At the current stage of understanding, the term antisociality must be looked at with a very broad perspective. There seems to be multiple degrees of antisociality as well as multiple causations. The above article has tried to give an overview of current thinking about the ideology, diagnosis and prognosis of this difficult to understand disorder. If, in fact, genetics play a crucial role in a character disorder, newer technologies must be developed. A clinician may understand genetic counseling but certainly may not know how to counsel a gene. Within the spectrum of antisociality, there are those who with the right opportunity, can make remarkable changes. At the other end of the spectrum, those that are given every opportunity in the world will only exploit the system.

Caldwell C. Nuckols, PhD, is a partner and board member of American Enterprises Solutions, Inc. He is author of 14 books, the latest of which is Healing An Angry Heart, Health Communications, Inc., which he co-authored with Bill Chickering.

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