The Evolutionary Neurodevelopmental Perspective

Although perspectives are necessary to knowledge, no single perspective ever tells the whole story. Both antisocials and narcissists may be thought of as independent types who turn only to themselves to derive rewards from life (Millon, 1969). Although the DSM-IV presents the personality disorders as separate syndromes, in the evolutionary theory (Millon, 1990), antisocial and narcissistic personalities can be viewed as existing on a continuum. In the normal range, both are oriented to the satisfaction of their own needs and desires. In the pathological range, they not only put themselves first, but also satisfy their own needs and desires to the exclusion, expense, or injury of others.

Despite their similarities, the two personalities also have differences. Narcissists turn passively to themselves for gratification, exhibiting a sublime self-confidence deeply rooted in a belief that they are superior human beings. They expect others to defer to them automatically, contributing to their notorious sense of entitlement. In contrast, antisocials are actively oriented to satisfying themselves by intruding on and manipulating the social environment, often through aggression, threat, or intimidation. Their independence stems not so much from a belief in self-worth as from a mistrust of others to protect their own autonomy or control others preemptively. Finally, narcissists often have a childhood history of parental indulgence, in contrast to many antisocials' history of neglect or abuse. Antisocials usually have a history of conduct disorder before the age of 15 (see criterion C in Case 5.2 box); narcissists typically do not.

Any individual who is primarily self-oriented risks running afoul of social standards. In the disordered range, enlightened self-interest easily slips into total self-interest. When self-concern takes criminal expression, either narcissistic or antisocial features may dominate. Some individuals will be more narcissistic than antisocial, and some will be more antisocial than narcissistic. Viewed as opposite ends of a continuum, every individual may be located between these two extremes, so that combinations of traits become the rule rather than the exception. In contrast, the DSM-IV depicts these two personalities as separate syndromes. These two variants of antisocial behavior were referred to by Millon (1969) as representing the narcissistic and antisocial psychopaths, the former being essentially the primary psychopath described in the tradition of Cleck-ley and Hare.

Similarly, the distinction between psychopathy and sociopathy, inner constitutional versus external socializing causes of antisocial behavior, need not be mutually exclusive. The evolutionary model maintains that personality is the patterning of variables across the entire matrix of the person. For some antisocial individuals, biological determinants dominate. A deficit in the ability to process the meaning of emotional experiences, for example, may lead to psychopathy even when the individual comes from a "good home" (Cleckley, 1950). For other antisocials, socializing influences dominate. An otherwise physically normal child, for example, may experience intense, hostile abuse and neglect; develop a baseline of hostility and resentment as a result; receive rejection from other children in school; fall in with a deviant peer group; and eventually develop a delinquent pattern. For most antisocials, however, environment and biology interact in almost inextricable ways. Some, for example, may be born with a choleric temperament that puts them at the upper end of a normal distribution for anger and irritability (Lykken, 1995), leading to abuse and neglect by already stressed caretakers. Figure 5.2 puts the antisocial and narcissistic personalities at opposite ends of a continuum, illustrating their relationship with psychopathy and

Focus on Research

Differences in Developmental Pathways Once a Criminal, Always a Criminal?

There has been tremendous interest in developing models to explain the different pathways for developing antisocial behaviors and personality that clinicians have observed. Predicting which kids who commit crimes as juveniles will continue to commit crimes as adults has long frustrated psychologists, school officials, the justice department, and the community at large. Just as not all antisocials are criminals and not all criminals are antisocial, by no means do all kids who commit juvenile offenses grow up into offending adults. However, most offending adults also committed crimes as juveniles. In recent years (see Silverthorn & Frick, 1999, for an excellent review), several theorists have offered up compelling models to explain two distinct trajectories for the development of antisocial behavior in boys. In one trajectory, the onset of severe antisocial behavior begins in childhood; in the other, the onset is not until adolescence (Hinshaw, Lahey, & Hart, 1993; Moffitt, 1993).

Even the DSM-IV has incorporated this conception of two distinct and meaningful pathways by distinguishing Childhood-Onset Type versus Adolescent Onset Type as subtypes of conduct disorder. One reason for the success of these models is that they provide good predictive validity. It has been found repeatedly that children who develop severe conduct problems prior to adolescence are the most likely ones to continue showing these symptoms into adulthood (Frick & Loney, 1999; Loeber, 1991). Juveniles with childhood-onset typically demonstrate more aggression; possess what seems more analogous to adult conceptualizations of antisocial personality disorder with a cold, callous, and suspicious interpersonal style; and come from families with higher rates of pathology, conflict, and dysfunctional parenting practices.

However, these models were developed solely on the male pattern of antisocial behavior. Do these same trajectories apply to females as well? Silverthorn and Frick (1999) think that at least in part they do, but require some serious modifications to be a useful model for conceptualizing antisocial girls. After reviewing the limited research that has been published on antisocial girls, they hypothesize a third developmental pathway for girls they label "delayed-onset." They found that while many of the mechanisms that are thought to contribute to the development of antisocial behavior (i.e., cognitive and neu-ropsychological deficits, conflict-ridden family environment, parental pathology, and a cold and callous interpersonal style) are operating throughout childhood, in girls, antisocial behaviors are not expressed until adolescence for a variety of speculated social and biological reasons. They predict that this delayed-onset pathway in girls in analogous to childhood-onset in boys in terms of predicting future course and outcome and that there is no comparable pathway in girls to the adolescent-onset in boys.

Biological Determinants

Active Self-Oriented

Biological Determinants

Active Self-Oriented

Passive Self-Oriented

Social Determinants

FIGURE 5.2 Psychopathy, Sociopathy, and the Antisocial and Narcissistic Personalities.

Passive Self-Oriented

Social Determinants

FIGURE 5.2 Psychopathy, Sociopathy, and the Antisocial and Narcissistic Personalities.

sociopathy. Table 5.1 summarizes the antisocial personality in terms of eight clinical domains.

Contrast with Other Personalities

Most personalities share certain essential traits. Some psychologists have complained that this overlap makes the personality disorders difficult to understand and contributes to situations in which three, or even more, personality disorders are diagnosed in the same subject. Understanding the diverse roles that the same or similar traits may play in different personalities, however, is an important part of any clinical education. Where two or more personalities have several traits in common, the key lies in understanding the function of each trait in the context of the total personality. Two different personalities may possess the same trait for different reasons, just as two individuals sometimes behave in exactly the same way, but with different goals in mind.

The antisocial and the paranoid share numerous characteristics. Both tend to be hypersensitive and may interpret innocent or benign comments as thinly veiled insults. Likewise, both are readily angered, are often overly concerned with protecting their own self-determination, and sometimes run into problems with the law or with other social norms of behavior. Moreover, both read malevolent motives into the actions of others, thus justifying preemptive aggression. Antisocials, however, often find themselves in trouble for any number of impulsive actions, ranging from minor thefts to gratuitous violence. Their enemies are created through their own malevolent behaviors. In Oscar's case, his coworkers and family have all been targets of his aggressive behavior and unempathetic outlook. Further, antisocials often put up a fa├žade of apathy

TABLE 5.1 The Antisocial Personality: Functional and Structural Domains

Functional Domains

Structural Domains

Expressive Behavior

Impulsive

Self-Image

Autonomous

Is impetuous and irrepressible, acting hastily and spontaneously in a restless, spur-of-the-moment manner; is shortsighted, incautious, and imprudent, failing to plan ahead or consider alternatives, much less heed consequences.

Sees self as unfettered by the restrictions of social customs and the constraints of personal loy0alties; values the image and enjoys the sense of being free, unencumbered, and unconfined by persons, places, obligations, or routines.

Interpersonal Conduct

Irresponsible

Object-Representations

Debased

Is untrustworthy and unreliable, failing to meet or intentionally negating personal obligations of a marital, parental, employment, or financial nature; actively intrudes on and violates the rights of others, as well as transgresses established social codes through deceitful or illegal behaviors.

Internalized representations comprise degraded and corrupt relationships that spur vengeful attitudes and restive impulses that are driven to subvert established cultural ideals and mores, as well as to devalue personal sentiments and to sully, but intensely covet, the material attainments of society denied them.

Cognitive Style

Deviant

Morphologic Organization

Unruly

Construes events and relationships in accord with socially unorthodox beliefs and morals; is disdainful of traditional ideals, fails to conform to social norms and is contemptuous of conventional values.

Inner morphologic structures to contain drive and impulse are noted by their paucity, as are efforts to curb refractory energies and attitudes, leading to easily transgressed controls, low thresholds for hostile or erotic discharge, few sublimi-natory channels, unfettered self-expression, and a marked intolerance of delay or frustration.

Regulatory Mechanism

Acting-Out

Mood/ Temperament

Callous

Inner tensions that might accrue by postponing the expression of offensive thoughts and malevolent actions are rarely constrained; socially repugnant impulses are not refashioned in sublimated forms, but are discharged directly in precipitous ways, usually without guilt or remorse.

Is insensitive, irritable, and aggressive, as expressed in a wide-ranging deficit in social charitableness, human compassion, or persona remorse; exhibits a coarse incivility as well as an offensive, if not reckless, disregard for the safety of self or others.

Note: Shaded domains are the most salient for this personality prototype.

Note: Shaded domains are the most salient for this personality prototype.

about the possibility of arrest or punishment, that is, real action against them by the agents of society.

In contrast, paranoid personalities are intrinsically suspicious and hypervigilant. They have great difficulty relaxing, as they are always guarding themselves against the deceitful machinations of imagined enemies. This tense or edgy quality is unusual in most antisocials and even more unusual in the glib and charming psychopath. Moreover, the desire of the paranoid to uncover hidden motives imparts an intermediate step between impulse and action that many antisocials do not possess. Whereas the paranoid acts rationally given his or her assumptions about the world, the impulsive antisocial is better characterized as arational. Although it is commonly said that "paranoids have enemies, too," their problems tend to arise from the interpersonal aversiveness that others experience from being cast in the role of plotter or persecutor. Unlike antisocials, most paranoids are too fearful and guarded to give others a legitimate basis for taking action against them.

Antisocials, histrionics, and borderlines are often manipulative and impulsive, and all three tend to act out dramatically at times. However, they do so for different reasons. In antisocials and psychopaths, manipulation reflects a need to dominate, seize power, gain material reward, or satisfy some concrete need. In borderlines, manipulation usually reflects some desperate attempt to evoke support and nurture from others. In histrionics, manipulation usually reflects some attempt to occupy and hold the center of attention or a means of getting others to provide them with some resource or reward. The histrionic pulls, and the antisocial pushes. As such, histrionics do not characteristically exhibit the overt hostility and socially repugnant behaviors of the antisocial.

All three personalities also exhibit impulsivity. In the antisocial, however, impulsivity reflects a shortsighted fixation on immediate gratification. Borderlines sometimes fixate on short-term gratification, but become impulsive in reaction to anxious feelings of emptiness or depersonalization. In the histrionic, impulsivity is part and parcel of a scattered cognitive style. Attention moves from one thing to the next, each of which receives its own emotional dramatization. Although all three personalities act out dramatically at times, the antisocial and borderline are characteristically more intense. In the antisocial, acting-out takes the form of intense verbal threat or violence, but in the borderline acting-out often takes the form of suicidal gestures. Finally, borderlines often engage in self-mutilation, damaging themselves; antisocials and psychopaths are more likely to damage others.

Although the sadistic personality was dropped from DSM-IV, comparison with the antisocial is still informative. Both break social norms, damaging the lives of others. Sadistic personalities, however, are more violent and explosive, primarily oriented to the destruction and derogation of others. In contrast, antisocials are not necessarily sadistic, just focused exclusively on their own gratification. When their actions damage or hurt, it reflects their willingness to use others as a means to an end in fulfilling their own desires. Others are regarded more as furniture than as real persons. In contrast, most sadists appreciate the genuine personhood of others, without which their suffering would not be nearly as powerful or satisfying. Moreover, antisocials and psychopaths are more likely to manipulate or deceive others cleverly for personal gain. Sadists manipulate others to effect and then observe their personal grief.

Pathways to Symptom Expression

Although antisocials are usually seen as being emotionally insensitive, they are nevertheless vulnerable to a variety of symptom conditions. As always, it is important to remember that there is a logic that connects the personality pattern with its associated Axis I syndromes. As you read the following paragraphs, try to identify the connection between personality and symptom.

Anxiety Disorders

For some personality patterns, such as the avoidant and the dependent, anxiety tends to build and build without limit. In contrast, antisocials are not disposed to ruminate or reflect on their feelings, much less express feelings verbally. Instead, they find anxiety to be an intolerable poison that must be acted out, usually in some impulsive and thoughtless way. In fact, the aggressive drive that often seems to define antisocial behavior can be seen as anxious energy redirected toward the manipulation, confrontation, or domination of others. Feelings of helplessness are thus discharged by making others feel helpless before the wrath of the antisocial. As such, chronic feelings of anxiety are rare. When they do occur, it is usually because the antisocial finds that some insuperable barrier cannot be knocked down, making discharge impossible. Antisocials may experience intense dread at the possibility of being controlled by others or by circumstances, dread retaliation by those they have damaged, or dread an inevitable prison sentence, for example. Increases in sustained acting-out behavior, therefore, are likely to signal some enduring life circumstance or external constraint not easily overcome through impulsive physical action.

Substance Abuse

Antisocial traits and substance abuse go hand-in-hand. Alcoholics with antisocial personality disorder, for example, usually experience their first intoxication at an earlier age, and their disease has a more severe and chronic course than for alcoholics without antisocial personality disorder (Holdcraft, Iacono, & McGue, 1998).

Many pathways of reinforcement lead antisocials toward drug use. First, antisocials have no moral qualms that might moderate substance use and usually have little regard for any constructive direction in life that might be damaged as a result. Instead, the immediate gratification offered by most substances resonates well with the tendency of antisocials to seek sensation in its raw, uncut form. Second, a variety of substances are usually readily available, providing both a sense of defiance of the ruling culture and a sense of brotherhood in the subculture of a deviant peer group, the only positive feeling that may exist in the lives of some antisocials. Third, substance use diminishes or distracts from residual negative affects, such as anxiety, depression, and guilt. These may be replaced with feelings of confidence and power, thus playing to a strong self-image while allowing fearless displays of aggression. Other antisocials may be attracted to the money, power, and sexual opportunities that dealing in substances provides. Alcohol, marijuana, heroin, cocaine, and other stimulants form a pantheon of substances that might be abused singly or in almost any combination. Finally, substance use may also represent a form of self-medication when the individual has some additional symptom disorder, not only an anxiety or mood disorder but also schizophrenic or dissociative symptoms.

Consider the case of Jim, the drunken father (see Case 5.3). Jim has a long history of substance abuse that stretches back to his teen years, when he was wondering across Kansas, staying with one relative after another. When he joined the Navy, he lied about these activities and apparently entered a relatively abuse-free period. At 30, however, he married a girl 10 years younger, who apparently had her own problems, namely, prostitution to support her heroin habit. Jim couldn't take the nausea of a heroin high, so he started using cocaine and soon began dealing himself, drifting from city to city. Arrested in a sting operation, he turned state's evidence and received a reduced sentence.

If Jim were just an addict, he would not be diagnosed as an antisocial personality. However, his substance use is part of a more general pattern of violation of social norms and illegal activities, including robbery, dealing, domestic violence, lying his way into the Navy, and dishonorable discharge. Thereafter, he seems to have tried to go straight

A 20-year-old female business major sought counseling because her father, Jim, age 50, was arrested by local police outside a bar about 70 miles from his home in western Kansas.1 According to the police report, he was drunk, attempted to provoke a fight with several bar patrons, made lewd and lascivious remarks to two women inside, and seemed confused about his whereabouts and purpose. At the jail, he seemed stuporous, apathetic, and barely capable of communicating. After repeatedly refusing to answer the officers' questions, he was transferred to the state hospital for observation.

Gradually, the sad story of Jim's childhood unfolded in therapy. He had been the third of seven children. His mother was hardworking but died when Jim was 11; his father was a drifter and periodic drunkard who died when Jim was 10. The younger siblings became wards of the state and were eventually placed in foster care. Jim, however, ran away when he was 14, wandering from town to town across Kansas, occasionally staying with relatives until he became so disruptive he was thrown out. In the meantime, he sampled any illicit drug he could lay his hands on.

At 18, Jim enlisted in the Navy, lying about his history of substance abuse. He found the structure stifling and greatly resented taking orders, getting up early day after day, and being forced to be respectful to those in authority. Within 18 months, he was court-martialed for assaulting an officer and being intoxicated while on duty. After a brief stint in the brig, he was handed a dishonorable discharge. Upon release, he took up residence in a rundown part of Kansas City, working irregularly as a dishwasher and cook. Between jobs, he admitted that he sometimes mugged vulnerable elderly women "for fun" and as a means of securing rent money.

At age 30, he met and married an apparently histrionic female barely 20 years old, who occasionally worked as a prostitute to support her own pattern of heroin addiction. Jim tried heroin but found it nauseating and decided to stick with rock cocaine. Together they lived miserably for three years. Their only child was born six months into the marriage. After a particularly brutal marital fight that left the wife with a broken arm and fractured skull and Jim with a month's sentence in jail, Jim's wife left him for a new boyfriend, though they were never legally divorced.

Over the next few years, Jim became more heavily involved in drug-related crime. Drifting from Kansas City to St. Louis to Memphis and finally to New Orleans, he began dealing drugs in earnest. Eventually arrested in a sting operation, he agreed to turn state's evidence in exchange for a reduced sentence of five years.

His relationship with his daughter has been one of broken promises and disappointments. On the rare occasions he would breeze into town, he would make grand promises to her that he had transformed his life and was going to try to win custody of her. He would then describe all of the gifts he was going to buy her and the blissful life they would lead together. He would then disappear just as quickly as he had entered, once stealing her new bike and another time persuading her to steal a ring from her mother's bureau drawer. No matter how desperately she wanted him to love her, he seemed incapable of showing her any affection or feeling.

Currently, Jim has been paroled for four years and again lives on the outskirts of a small Kansas town. He prefers not to bother people and likes to be left alone. About once a year, however, he goes on a binge, spending most of his money, brawling, and landing in jail. He is known by the judge and the local police, who now consider him more as an annoying nuisance than a major threat to society. He is usually confined in the county jail for about a month, after which he is released to alleviate overcrowding. Between these sprees, he is typically sober.

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.

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

but was derailed when he met his wife. After a lifetime centered on substance use, Jim now lives in a small Kansas town. Like most antisocials, his pathology has burned out as he has aged. Apparently to minimize problems, Jim lives at the outskirts of town, where no one can bother him. Nevertheless, he still gets drunk from time to time, becomes belligerent, and wants to fight, but only ends up in jail.

Mood Disorders

Some antisocials exhibit a long history of depression. Vague feelings of helplessness and futility make such individuals even less likely to reflect on the consequences of their actions. Constructive courses of actions are irrelevant, because life cannot be changed, has already been wasted, or presents too many barriers to be overcome in the face of too few resources. Rejection by significant others or residual remorse for past actions may feed into an already irritable mood, exacerbating relationship conflicts and further lowering the threshold for hostile or aggressive action. The net effect is a link between depressive feelings and an increase in the acting-out behaviors that typify the antisocial pattern.

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