The ambulance doors opened, and the male figure on the stretcher was flailing and fighting the attendants as they attempted to wheel him into the emergency room. "Lie still, Mister. You'll be okay. Everything will be okay. Just take it easy."
"You son of a bitch! Get me the hell out of here! Oh, crap, it hurts. My chest hurts like hell."
The new ER (emergency room) admission, now a patient, is a 71-year-old man named Mickey H. He has been transported to this inner-city hospital from a nearby bar, where he is known as a regular. Late into the night, and after much drinking, things turned ugly and an altercation began between Mickey and another man at the bar. Blows were exchanged to the amusement of the other patrons. Suddenly, Mickey let down his guard and clutched his chest. Crumpling to the floor, he hit his head on the metal base of the barstool. At first his opponent and nearby onlookers thought "Old" Mick was pulling a fast one on them, as he was known to do. But it soon became apparent that his chest pains and falling to the floor were real. At least the blood flowing from a gash to his forehead and down his nose was real. So the police were called, and they in turn called for the ambulance.
The ambulance attendants were no strangers to this bar. They were called to it fairly regularly, especially late into weekend nights. They were used to responding to near comatose patrons, and to those who were surly and belligerent. They knew how to talk them down while applying pressure to a wound and starting an IV line. They were not, however, familiar with Mickey. While a regular at the bar, he was not one of the emergency medical technicians' (EMTs) regulars. Mickey was known to throw a good punch and then walk away. He could stay and fight if he had to, but he seldom had to. He was savvy about who he took on. He took care of the cuts and bruises himself. He never clutched at his chest or got transported to the ER. When he did go to the ER, it was under his own steam and for his own purposes, either to get drugs or to avoid being followed or apprehended. At those times, he would convincingly feign severe upper abdomen pain and nausea, accurately describing the symptoms of acute pancreatitis. Admitting to being alcoholic, he was rewarded with IV pain relief. When the acute attack subsided, he was usually discharged with a refillable prescription for a painkiller.
At other times he would present with severe signs of alcohol withdrawal (delirium tremens) and win a hit with a benzodiazepine and a prescription for the road, as he promised this time to follow up with attendance at AA meetings.
Kicking and screaming, literally, Mickey announced his intention as he was being transferred from the stretcher to a gurney in the ER. "Get me the hell out of here! Clean me up and get me the hell out of here!" However, having collapsed at the bar and complained of chest pains, facts the EMTs had conveyed to the ER staff, Mickey would require a cardiac workup in addition to sutures for his lacerations. It appeared he would also need to be detoxed.
He calmed down enough for the nurses to clean his wounds and deliver an injection to assure he would stay calm. The attending physician was then able to suture his head and face wounds. Mickey was resting after the procedure, still under the effect of the medication, when it was decided to transfer him to a medical floor for a thorough cardiac workup. He dozed through the transfer, and that was the last of quiet and calm on the unit.
Mickey grew up in the city, born to a single mother who worked, when she was able to work, as a hairdresser. She was addicted to street drugs and would spend her money on drugs as often as on food. Hunger and malnourishment were constant companions for her and her son. She often did not notice, but little Mickey did. When times were especially rough for his mother, and she took off, leaving her young child alone and unattended, her own mother would take the boy in. A sick woman, a heavy smoker and chronically short of breath, Lil was not happy with her daughter's lifestyle nor with being too regularly burdened with rescuing her grandson. Although she couldn't run after him or watch him carefully, she did at least provide enough food. So Mickey spent his early years between the two apartments; one with his mother and one with food.
By the time he was in grade school he had developed a pattern of behaviors that defined him as a troubled kid and a school problem. He was untrustworthy and lied excessively; he was aggressive and he was destructive. He became the playground bully, beating up on smaller kids, and threatening others, forcing them to be his accomplices. A natural leader, he would create opportunities for vandalism and get others to go along with his ideas. When a street sign near the school went missing, right or wrong, Mickey was the first one the authorities suspected. If a kid were naive enough to show Mickey money he had brought from home, he would be relieved of it in a flash. If the child threatened to tell, Mickey would threaten to beat him up. If the child then broke down and cried, Mickey would laugh and walk off.
Perhaps most troubling was a behavior that the school did not know about and that Mickey did not share with the other kids, but did alone. If he came across an injured animal, or a baby animal separated from its littermates, he would take that animal to a special spot in his neighborhood, a private alleyway with the unusual distinction of not being regularly used by people from the streets, and he would set the little animal on fire. Killing it, watching it die a horrible death, felt just about right to Mickey, just about how he felt inside. This was as close to empathy as Mickey would ever get.
By his early adolescence, Mickey was frequently truant from school, and would run away from home, especially when he was under Lil's watch. The first few occasions she reported his absence to the police, but over time, she stopped reporting these disappearances. Mickey dropped out of school the day after his 16th birthday. He got a job as a commercial cleaner and supplemented his paycheck with money taken from Lil's pocketbook after she cashed her Social Security check. Thinking about his mother, and hating what she had become, he stayed away from street drugs, but developed a taste for alcohol and took up smoking, regularly relieving Lil of her smokes as well as her cash.
Mickey also developed a taste for, and then an addiction to, gambling of all sorts. This brought Mickey into a new network of associates, from the seamier side of the streets and from the organized underworld. He was identified by them as a potentially useful character, who had no respect for property, person, or feelings, and who disregarded rules and social convention. And if someone had to get hurt, that didn't bother him either. He was in the job for the paycheck and to do what he liked. A fairly good-looking guy, now with cash in his pocket, he enjoyed the company of any number of women. Smooth talking, he exploited them all for his own purposes, taking their money and using them not only for sex but also for protection. When the law came looking for him, a woman would often be his alibi. He had been with her at the time.
He didn't drink on the job, but he did at night and bar brawls became a regular social event. When, at some point in his 40s or 50s (his memory was hazy and his reporting was unreliable), Mickey began to supplement the alcohol with a little stuff, which was easily procured through his work associates.
He remained remarkably healthy and his need for doctoring was negligible. His major health problems were trauma related. He believed, to the extent that he thought about the future at all, that he would die on the streets, probably in a fight he had miscalculated or by being blindsided in a payback act. When he did require medical attention, such as to get an occasional antibiotic, he would use the hospital ER as his private health center, pushing his way past others to get at the head of the line. He always knew what he needed and could size up the attending staff member quickly and swing into one of his two dominant modes of getting it. He could act tough, cool, and efficient, with the tacit message of "This is what we both know I need. Give it to me and I'll get out of your space and your face. You wouldn't want me in your face." Or he'd turn on the charm and wheedle what he needed out of the staff. When the staff member was a woman, he knew how to sexualize the encounter or pull for a maternal response or a rescue fantasy. He was highly skilled at assessing situations quickly, and being who he needed to be.
This time, however, he could really be ill. The chest pains were different for him and were probably real, but he would not cooperate with the medical staff on the floor as they attempted to do a cardiac workup. They had his name and hospital number, as well as the information about the bar brawl, but that was it. He responded to their questions either with a caustic comment, an obvious lie, or the directive to "Get the hell away from me unless you're here to spring me from this place." They were not able to determine how much he'd been drinking, what drugs he was currently using, or any medical history that could possibly have implications for his heart. When asked about his parents' health history, Mickey snorted loudly and then looked away. The only procedure he would cooperate with was the start of an IV to prevent the DTs, a condition he knew enough about to want to avoid, and the promise of a drug infusion that he liked. He was verbally abusive to the pulmonary resident, a gentle young fellow trying to explore possible shortness of breath episodes. When the sedating drug would start to wear off, Mickey would scream and become especially abusive to the staff. It was a tough hour's wait before the next drug dose could be administered. Terms and phrases entered in his chart by the nursing staff included "obnoxious," "demanding", "unreasonable expectations," "will not obey rules," and "nasty to anyone trying to help." The institutional and individual countertransference to this horrendously difficult patient was frustration, then anger, and fantasies of how to get rid of him. It took all their collective and individual will not to lose their temper or professional demeanor, and not to do bodily harm to Mickey. The staff responded in a passive-aggressive way in not facilitating the workup either by reducing the number of steps and procedures or by speeding up the evaluation schedule. Ultimately Mickey left the hospital against medical advice with an incomplete workup. It was never determined if his cardiac symptoms were in fact real, or another ruse to end a bar brawl he was losing without losing face. This act also would have the secondary gain of getting some legal and legitimate drugs, at the taxpayers' expense.
Mickey H. can be diagnosed with Antisocial Personality Disorder (ASPD). Individuals with this disorder consistently live outside the law and social convention. They abuse and misuse others, typically without remorse. They behave as if without a conscience, expressing this through the lack of empathy, not feeling remorseful or guilty when they hurt others. According to psychoanalytic theory, the conscience (or superego) normally develops before 5 years of age as the child resolves his (or her) Oedipal (or Electra) complex. Negotiating this requires stable parents, at least a mother figure, who can provide a safe holding environment for the conflict resolution and superego development. The history of most antisocial characters is noteworthy for the absence of such parental consistency and opportunity for healthy attachment.
Individuals with ASPD habitually lie, cheat, and steal, are aggressive and impulsive, and live in the moment, with little or no thought of future consequences. A clinical assessment usually reveals the history of Conduct Disorder, beginning before the age of 15, and a stormy adolescence with significant disregard of social norms and the feelings or well-being of others.
These individuals do not come into treatment voluntarily to work on their personalities, but are frequently encountered in hospital ERs and in prisons. Individuals with ASPD often experience dysphoria, anxiety, and rage attacks, and they typically respond to these affects by acting out or self-medicating with alcohol or drugs, or both. Trying to take a reliable clinical history is nearly impossible as these characters lie and withhold information to advance their cause, whether to appear more frightening and dangerous or more benign, bending the facts so that past behaviors can appear almost reasonable. Individuals with ASPD may claim or fake an Axis I disorder as a "cover" for their antisocial exploits. However, comorbid Axis I conditions are prevalent with ASPD, including Major Depression, Bipolar Disorder, Panic Disorder, and Posttraumatic Stress Disorder (PTSD). Mood disorders are especially likely to develop as the individual reaches middle age. In addition, approximately 70% of people diagnosed with ASPD have a comorbid alcohol or substance use disorder (Black, 2001).
There is no treatment plan for Mickey H. because, once he has left the hospital, he is no longer a patient of any one or of any system. However, as long as he lives, he will be a member of society where he will continue to disregard, and often flout, its rules. While aware of the rules and laws, he does not feel they apply to him. If you or a system is bothered by his behavior, according to Mickey "then it's your problem, not mine." If he meets challenge or resistance, he will fight back, and he can be dangerous. This is why individuals with ASPD make up such a high percentage of the recidivist prisoner population.
Individuals with ASPD are no match for the average mental health clinician. An adequate assessment is nearly impossible. As they lie and do not cooperate with the process, a therapeutic alliance cannot be established. They lie easily because there is no conscience to keep them from lying. Whatever comes out of their mouth is their truth at the moment. It is also difficult to secure collateral or informant data, as they typically do not have a history of intimate or long-standing relationships, either personal or professional. Often their cohort is as socially impaired as they are. Even potentially treatable Axis I conditions are hard to diagnose as they might be faking positive or faking negative to advance their own agenda. Common agendas include securing controlled substances, someone else's money, or avoiding responsibility for their actions, criminal culpability, and apprehension by authorities.
We know nothing about Mickey's father. We do know something about his mother and certain features of ASPD can be seen in her, if not the full disorder. Although the disorder is far more prevalent in men, it presents in women as well. Clinical evidence suggests that there is a strong genetic contribution to this disorder. One major study of twin pairs found that there is a 69% likelihood of a second twin being diagnosable with ASPD if the first twin was so diagnosed (Fu et al., 2002). A meta-analysis of twin and adoption studies of the development of ASPD suggested that the disorder is more strongly influenced by genetic than by environmental and social learning factors (Rhee & Waldman, 2002).
Appropriate treatment options for Mickey H. are between few and nonexistent. If he would agree, the next time he presented at the ER it might be helpful to transfer him from the hospital to an inpatient facility specializing in the treatment of alcohol and substance use disorders. He might agree to this if he needed a safe haven at that time. It is doubtful he would cooperate with the program, but it would be worth a try. He is reaching old age, and some of these characters mellow a bit, becoming less hostile, violent, and impulsive. This could provide a window of opportunity where a previously rejected treatment might now be accepted. An inpatient setting would also enable a diagnosis of any Axis I condition and the implementation of reasonable treatment. Pharmacological treatment is very complicated for the individual with a substance abuse history. Certainly the social factors that contribute to and sustain his antisocial behaviors need to be identified and environmental engineering strategies applied where feasible. Are there socially acceptable ways for him to meet his needs? We know that having a personality disorder means having a limited and rigid repertoire of responses. Perhaps his being older might be used to convince him that things aren't going well for him now and that they can go better and he can get more if he does things differently. Then the challenge would be to help him learn how to do this.
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