Objectives

• What are the DSM-IV criteria for the antisocial personality?

• What is psychopathy and how does it differ from the antisocial personality? What is the difference between psychopathy and sociopathy?

• The adventurer and dissenting personalities are normal variants of the antisocial. Describe their characteristics and relate them to the more disordered criteria of the DSM-IV.

• Do antisocial women show a pattern of behavioral pathology different from the pattern of antisocial men?

• Explain how different personality styles combine to form each of the subtypes of the antisocial personality.

• What is the historical significance of the terms moral insanity and psychopathic inferiority?

• The behavior of antisocials appears to be highly influenced by biological factors from early on. What is Lykken's position as to the most effective parenting for a child with strong temperamental qualities? What is the meaning of semantic aphasia?

• Summarize the biological evidence for the antisocial personality.

• What is meant by the psychoanalytic notion that antisocials lack a mature superego?

• Why is the interpersonal behavior of the antisocial characterized as "pure interpersonal hostility" and "irresponsible"?

• How does the antisocial cognitive style, which appears to be highly vulnerable to the influence of immediate rewards and gratifications, contribute to the overall expression of this personality disorder?

• What are the core beliefs of the antisocial?

• Antisocials share characteristics with other personality disorders. List these other disorders and explain the distinction between each and the antisocial.

• Why is substance abuse so prevalent among antisocials?

• Why are countertransference issues so important in therapy with antisocials?

• List therapeutic goals for the antisocial personality.

In the antisocial personality, badness and madness seem to shade together. Sometimes, antisocials' crimes are so incomprehensible and morally repugnant that the act alone makes us doubt their sanity. For example, the normal person has no way of identifying with Jeffrey Dahmer, who killed, had sex with, and ate the bodies of many of his victims, or with Herman Mudgett (see Stone, 1993), whose evil adventures ended when he was hung just before the end of the nineteenth century. Mudgett, a graduate of the University of Michigan's Medical College and a practicing pharmacist in Chicago, excelled at insurance fraud and the seduction of young women, at least 27 of whom were killed after signing papers that made Mudgett the recipient of their insurance and savings. Drugged with chloroform after a night of prenuptial sex, each would awaken trapped in the elevator shaft of an elaborate three-story office building, specially designed by Mudgett to conceal his nefarious activities. This building, outfitted with trap doors, soundproof rooms, peepholes, enormous furnaces, and vats of acid to dissolve human remains was dubbed his "Castle." Savoring the terror of the trapped girls, he would pump in poison gas and then haul their lifeless bodies onto the dissecting table for the removal of parts that held for him a special fascination.

Fortunately, Dahmer and Mudgett are extreme examples. In fact, not all antisocials are criminals (Alexander, 1930), and not all criminals are antisocials. Serial killers, in particular, are extremely rare (Hare, 1993), despite public fascination with them. In fact, only a minor subset of the antisocial pattern comes into conflict with the law. Cast in scientific clinical terms, the social consequences of the disorder are not necessarily repugnant. In fact, individuals with normal-range antisocial traits are often rewarded by our competitive society, where the ability to act tough and bend the rules is admired as necessary for success and survival in a dog-eat-dog world. Between the extremes of normal adjustment and the most brutal abuse of human life lie many shades of gray. Some anti-socials jealously guard their autonomy, striking preemptively at anyone who might restrict or condemn their behavior. In contrast, although normal variants do sometimes impulsively transgress social standards, most find a place for themselves in the rugged side of business, military, or political life.

Consider the case of Toni, a 23-year-old female introduced in Case 5.1. Like most antisocials, Toni has a reputation of being "difficult to get along with." She probably likes it this way, and she probably feels that anything else would be a sign of weakness and others would only take advantage of her. In fact, she works hard at creating a formidable and aggressive image (see criterion 4 in Case 5.1), thus identifying her to the world as someone to be taken seriously—someone you'd better keep your distance from. Her posture, clothes, attitude, and remarks cultivate that image. She wants to impress the listener with her callousness and self-sufficiency. Not surprisingly, Toni has a police record; possession and theft seem to be her favorites, though an arrest for prostitution also appears, probably in connection with a drug habit. The immediate cause of her problems, however, is a peace disturbance for fighting with her neighbor. Ask her why, and she'll tell you, "I don't take anybody's shit," without ever breaking eye contact.

Toni's problems go back a long way. Like many antisocials' families, her history includes a conspicuous absence of prosocial role models. Toni's father died of mysterious

Toni presented for therapy as mandated by court order.1 She was recently charged with disturbing the peace, after a fight with her neighbor escalated into punching and shouting, and with possession of narcotics with intent to sell. People in her apartment building describe her as "impossible to get along with, with a real chip on her shoulder." She puts forward an image of provocation and challenge that the other residents find intimidating. She dresses the part well, with a black leather jacket, numerous body piercings, and tattoos on every knuckle. Her hostility and penchant for lying about every detail from the important to the insignificant make history-taking difficult. When asked what started the fight that led to her latest arrest, she replies, "Cause I don't take anybody's shit."

Although Toni is only 23 years old, her tough exterior and hard lifestyle make her appear much older. She scoffs when asked about her religious affiliation: "Jesus don't love nobody, or at least he don't love me. The only religion I have is 'do unto others before they do unto you.'" Her police record corroborates this life philosophy. It includes multiple arrests for possession, theft, and prostitution. Toni is known by a variety of different names throughout the city, some based on stolen identities of real people and some purely invented. She has a collection of driver's licenses and social security cards that help her set up lines of credit across town. She proudly boasts that she has perfected the art of obtaining huge lines of credit in electronics stores based on false identities and then selling the goods for quick cash.

Toni is the middle of five children, including two stepchildren, and she does not maintain contact with any of her siblings. Her father died when she was 5 years old under mysterious conditions, possibly drug-related. Her stepfather paid little attention to the children and worked away from home most of the time. Discipline was administered sporadically and violently by her mother, who would often explode in alcohol-induced rages. During these episodes, Toni usually ran away and stayed overnight with friends, until things "cooled down."

The quality of her home life appears to have deteriorated as the years went on. Her school attendance became irregular when her mother took an early morning job at a bakery near their home to pay the bills. With no one at home to monitor her behavior, Toni found it much more interesting to spend the day at the riverfront than at school. Eventually, she began using marijuana and then selling it casually as a means of supporting her own habit. Robbing strangers, usually women, at knifepoint was something she did "a couple of times a month." By the time she was 15, her visits home became infrequent, which Toni attributes to her mother's explosive temper. By the time she was 18, she had been arrested three times, once for possession, once for shoplifting, and once for animal abuse when she lit a stray cat on fire with hairspray and a cigarette lighter. When asked if she feels guilty for any of this, she says, "No way, no one ever felt guilty for what they did to me." She admits to heroin use and occasional needle sharing and says she is not afraid of HIV. "Whatever happens, happens, you know."

When asked about her family of origin, Toni states, "Don't have one, don't need one!" When asked how she supports herself, she says with a smirk, "I get by." In fact, she has never held a job for more than three weeks. "I'm not the kind of person that can get up in the morning and be somewhere on time," she says, "and besides, who could make it on what they want to give you? I am looking for bigger and better things." As the interview moves on, Toni clearly states that she has entered therapy only to avoid prison time for trying to sell cocaine to an undercover cop. She is quick to rationalize and blame others for her current plight: "The apartment was my boyfriend's. I just knew where the stuff was. That cop was a good actor cause I thought he would kill me if I hadn't sold it to him." To hear her tell it, she was an innocent victim, just in the wrong place at the wrong time.

1Numbers mark aspects of the case most consistent with DSM criteria, and do not necessarily indicate that the case "meets" diagnostic criteria in this respect.

Antisocial Personality Disorder DSM-IV Criteria

A. There is a pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years, as indicated by three (or more) of the following:

(1) failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest

(2) deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure

(3) impulsivity or failure to plan ahead

(4) irritability and aggressiveness, as indicated by repeated physical fights or assaults

(5) reckless disregard for safety of self or others

(6) consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations

(7) lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another

B. The individual is at least age 18 years.

C. There is evidence of Conduct Disorder with onset before age 15 years.

D. The occurrence of antisocial behavior is not exclusively during the course of Schizophrenia or a Manic Episode.

Reproduced with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Copyright 1994 American Psychiatric Association.

causes when she was 5. According to family lore, his death was probably drug-related, a memory that may have somehow encouraged her own drug use. Her stepfather paid little attention to the kids and worked away from home most of the time. Her mother provided only inconsistent discipline and was prone to fly into alcohol-induced rages. For Toni, running away seems to have been a matter of survival, a way of taking time out from a toxic family. Eventually, she found it easier to drop out of school and leave home rather than battle it out. With her mother and father as role models, we can imagine that life must have seemed discouraging, if not futile. Antisocial personality disorder requires evidence of conduct disorder (CD) before the age of 15 (see criterion C in Case 5.1). By this age, we find Toni robbing others at knifepoint and smoking and dealing marijuana on a casual basis to support her own habit. By age 18, her problems have escalated, with arrests for possession, shoplifting, and animal abuse.

Like most antisocials, Toni appears to lack a conscience. Her statement, "No one ever felt guilty for what they did to me," is probably partly true and partly manipulative, intended to evoke pity, give insight into her past, and justify her absence of remorse (see criterion 7) all at the same time. She sneers at religious faith and instead puts forward her own moral principle: "Do unto others before they do unto you." With no obvious prosocial impulses and no internal moral restraints on action, Toni is free to do whatever she wants, whenever she wants. The only barrier to her actions is society itself, and the only constraints she respects are those that society can enforce through its police presence and the threat of punishment or those that others can enforce through their own threats of harm or revenge.

Her lack of conscience creates and amplifies a variety of other antisocial characteristics. Toni is chronically deceitful (see criterion 2). Her use of aliases and stolen identities is a calculated means of pursuing illegal activities while avoiding detection, either by the law or anyone else. There is no way of knowing for what crimes she might actually be responsible. She also has no conscience where her own safety or that of others is involved (see criterion 5), as indicated by her admission of needle sharing, followed by the irresponsible and frankly stupid statement that she is not afraid of HIV. Toni is also unable to maintain steady employment, preferring to obtain money by racking up huge debts in other people's names with no intention of honoring the obligations (see criterion 6). For her, illegal activities provide much more money and immediate reward than legitimate employment. The concept of creating a satisfying life for herself is probably not even within her scope of contemplating at this point.

Although Toni would qualify for a diagnosis of antisocial personality disorder, the terms psychopath and sociopath also compete for clinical currency in describing individuals who flagrantly and pervasively violate the rights of others. Antisocial personality disorder is currently the official term used in DSM-IV (APA, 1994). However, the terms psychopath and sociopath are often bantered about to describe the people who commit heinous crimes. A writer's choice of one term versus the other is often arbitrary or a matter of preference rather than based on concrete scientific differentiations. However, one often used distinction between psychopath and sociopath is the user's belief in the origins of the disorder. Psychopaths are believed to possess some constitutional disposition to the syndrome. In contrast, sociopaths are biologically normal, but develop antisocial characteristics through incompetent or hostile socialization, mainly defective parenting.

The psychopath and sociopath are probably best viewed as existing on a continuum. Development is always an interaction between the individual and social environment.

Thus, some psychopaths receive defective parenting and maltreatment from infancy, like the sociopath, whereas others come from loving homes. Likewise, some sociopaths could possess a biological predisposition to the disorder, perhaps through an irritable temperament, for example, but nevertheless experience incredible levels of neglect and abuse. The pure psychopath and pure sociopath, then, are really just abstractions, not mutually exclusive syndromes. For any given individual, the focus is not, "Which one?" Instead, understanding the particular person requires understanding the interaction of biological and social influences, starting at conception and running across the life span. Nevertheless, these terms are often used loosely, with all three overlapping one another to some extent. This chapter is concerned primarily with the antisocial personality, but often refers to the psychopath where its empirical literature is more highly developed.

The construct of psychopathy was made famous by Hervey Cleckley's The Mask of Sanity, first published in 1941. Vivid case examples, compelling writing, and a list of defining characteristics combined to make the work an instant classic. Whereas the noxious behaviors of the antisocial are often obvious, Cleckley held that psychopaths often cloak themselves in the trappings of normality. Unlike the stereotype of the common criminal, psychopaths were believed to come from "good homes" with loving parents, but nevertheless damage or destroy lives without remorse, shame, or conscience. Most are pathological liars adept at sizing up situations and feigning sincerity, thus allowing them to literally flourish undetected behind a "mask of sanity." According to Cleckley, such individuals possess a deep-seated inability to understand the emotional dimension of language, particularly those aspects connected with feelings of attachment and empathy.

Unlike the antisocial personality, the Cleckley psychopath gives us a rich appreciation for the inner detachment with which such individuals destroy life. We diagnose the antisocial, but we "know" the psychopath. By subjecting Cleckley's list of defining characteristics to rigorous methods of scale development, Robert Hare and his associates constructed a clinical rating scale, now revised. Twenty items define the psychopathic prototype (Hare et al., 1990); some focus on long-standing personality traits and others on characteristic behaviors and life events. The total portrait suggests an individual who is not only antisocial, as evidenced by early behavior problems, multiple short marriages, juvenile delinquency, a versatile criminal past, a parasitic lifestyle, and sexual promiscuity, but also narcissistic, as evidenced by traits such as egocentricity, grandiosity, intolerance of boredom, lack of empathy, manipulativeness, and an inability to feel remorse. Stone (1993) suggests the additional item of imperviousness to shame to illustrate the psychopath's complete lack of internal behavioral controls.

Given this portrait of Toni, we are now in a position to approach additional issues, which form the plan of this chapter. First, we explore the continuum from normal antisocial traits to the pathological or "abnormal" antisocial personality disorder; then we move on to variations on the basic antisocial theme. After that, biological, psychodynamic, interpersonal, and cognitive perspectives on the antisocial personality are described. These sections form the core of what is scientific in personality. By seeking to explain what we observe in character sketches like Toni's, we hope to move beyond literary anecdote and enter the domain of theory. We present history and description side by side, noting the contributions of past thinkers, each of whom tends to bring into focus a different aspect of the disorder. Developmental hypotheses are also reviewed but are tentative for all personality disorders. Next, the section " Evolutionary Developmental

Perspective" shows how the existence of the personality disorder follows from the laws of evolution. Also included are a comparison between the antisocial and other theory-derived constructs and a discussion of how antisocial personalities tend to develop Axis I disorders. Finally, we survey how the disorder might be treated through psychotherapy, organizing our material in terms of classical approaches to the field: the biological, psy-chodynamic, interpersonal, and cognitive perspectives.

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