2. OVERVIEW
Introduction
Historical Aspects And Evolution Of The Concept
Epidemiology
Different Perspectives
Comorbidity
Course And Prognosis
Assessment
Management
Ethical Issues
3. A MODEL OF PSYCHIATRIC DISORDERS
1. Disorders of brain chemistry/brain functioning:
Schizophrenia Bipolar disorders
Anxiety disorders Major depressions
2. Disorders of self in relation to others:
Personality disorders
Addictions
Disorders related to trauma
3. Disorders of self in relation to community and society:
Dissocial personality disorders
Conduct disorder
4. INTRODUCTION
Dissocial personality disorder:
Personality disorder usually coming to attention because
of a gross disparity between behaviour and the prevailing
social norms
Anti-social Personality Disorder:
A pervasive pattern of disregard for and violation of the
rights of others
5. PSYCHOPATH SOCIOPATH
1% of general population 4% of general population
Highly heritable
Minnesota twin study showed 60%
heritability
They are simply “ That way”
Origin lies in environment and
upbringing
Defective parenting style
Highly educated and have good
career
Uneducated and unable to have a
steady job
Controlled behaviour Erratic
Manipulative Impulsive
Unable to form an personal
attachment
Can form an attachment to a
particular group
Take calculated risks, minimize
evidence
Spontaneous crimes, tend to leave
evidence
6. PSYCHOPATHY VS SOCIOPATHY VS
ASPD
The terms “sociopath” and “antisocial personality” refer to
behavior and its consequences
“Psychopath” to inner experience
Most sociologists, criminologists believe that ASPD is caused
by social conflicts and thus prefer the term Sociopathy
Those who believe that a combination of psychological,
biological, genetic and environmental factors all contribute to
the ASPD are more likely to use the term psychopathy
7. 1.Gross disparity between behaviour and the prevailing
social norms
2.Flagrantly and pervasively violate the rights of others
Dissocial
personality
disorder
Psychopathy/
Sociopathy
Antisocial
personality
disorder
9. STYLE VS DISORDER
PERSONALITY STYLE PERSONALITY DISORDER
Own value system above that of the
group
Consistently violates social norms
through illegal activities
Spin objective events to its advantage
without engaging in outright deception
Deceive to achieve its own ends
Style is naturally spontaneous and self-
indulgent
Too impulsive to consider the
consequences of its actions
Assertive in creating a felt physical
presence
Irritable and aggressive to the
point of repeated fights or
assaults
Remain free of external constraints
spend on the joys of the present rather
than save prudently for the future
Consistently irresponsible as to
work and financial obligations
Aggressively or impulsively self-serving,
but within moral, social, and legal
boundaries
Lacks a conscience and
rationalizes exploitation of others
10.
11. HISTORICAL ASPECTS AND EVOLUTION
OF CONCEPT
Psychopathy was described by Theophrastus a student of
Aristotle
1800:Philosophical debate between free will and
determinism
Philippe Pinel (1801,1806):
1. Form of madness known as “la folie raisonnante”
2. manie sans delire (insanity without delirium)
3. Unimpaired intelligence and full awareness of actions
4. Intended to be descriptive, not value-laden
12. HISTORICAL ASPECTS AND EVOLUTION OF
CONCEPT
Prichard (1835): Moral Insanity
Despite understanding the choices before them, their
conduct was swayed by overwhelming compulsions
“Can these individuals understand the consequences or
individuals are defective in character and therefore, worthy
of moral condemnation”
13. HISTORICAL ASPECTS AND EVOLUTION OF
CONCEPT
Specific cerebral center controlled morality (Maudsley,1874)
Koch (1891): Psychopathic inferiority
Syndrome as an “congenital or acquired inferiority of brain
constitution”
Kraepelin (1905) classified ‘Personality disorder’
Schneider(1923):
Individuals with ‘psychopathic personalities’ as those who ‘suffer
through their abnormalities or through whom society suffers’
14. HISTORICAL ASPECTS AND EVOLUTION OF
CONCEPT
Psychopathy:
Literally meaning “Psychological Pathology”
First three decades of the twentieth century
Hervey Cleckley’s The Mask of Sanity (1941)
Hare developed the Psychopathy Checklist Revised (PCL-R)
which was influenced by the previous work of Cleckley
15. HISTORICAL ASPECTS AND EVOLUTION
OF CONCEPT
DSM-I in 1952 included the diagnosis of Sociopathic Personality
Disturbance
1. Antisocial sociopaths referred to common offenders
2. Dissocial sociopaths included white collar criminals
The diagnosis evolved to reflect the changing attitudes of the era
Criminality was due to environmental factors in particular a lack
of socialization
In 1980 with the publication of the DSMIII only the term ASPD
was used
17. EPIDEMIOLOGY
Condition is much more prevalent among men
The lifetime prevalence in two North American studies was
4.5% among men and 0.8% among women
(Robins et al.,1991)
Two European studies found a prevalence of:
1. 1.3% in men and 0% in women (Torgensen et al., 2001)
2. 1% in men and 0.2% in women (Coid et al., 2006)
Women have:
1. Greater severity of problems
2. More complex comorbidities for both Axis I and Axis II
disorders
3. Poor outcomes
18. PRISON SETTING
Worldwide- Prevalence of 47% for
men and 21% for women
In the UK- Prevalence is:
1. 63% for male remand prisoners
2. 49% male sentenced prisoners
3. 31% female prisoners
The prevalence of Psychopathy in
UK prisoners is:
1. 4.5% using a PCL-R score of 30
2. 13% using a score of 25
(Fazel & Danesh, 2002, Hare et al., 2000,Singleton et al., 1998)
19. BIOLOGICAL PERSPECTIVES
Inborn temperaments-Aggression, Fearless, Impulsive
Cleckley (1950):
1. Semantic aphasia
2. Inborn inability to understand and express the meaning of
emotional experience
3. Struggle to learn the emotional mechanics of interpersonal
communication
Siever, klar, and coccaro (1985) suggest that:
1. Less cortically aroused but more motorically
disinhibited
2. Tend to act before they can take time to reflect
Low serotonin and high cortisol and testosterone
20. PSYCHODYNAMIC FACTORS
The ego develops, but the superego does not
Total personality remains dominated by the infantile id and its
pleasure principle (friedlander,1945)
Characteristics of “id”
Completely centered on its own immediate needs
Dominated by sex and aggression
Demands immediate gratification
No tolerance for frustration
Lack of conscience is the most important characteristic
21. INTERPERSONAL PERSPECTIVE
According to Kiesler (1996), the antisocial personality
represents almost pure interpersonal hostility
People with ASPD are oppositional, irritable, and rude
They are quick to argue, ignore the feelings of others, resist
cooperation, and readily provoke disputes
Defiant and ruthlessly attack, torment, and abuse others who
thwart their intentions
Antisocials also seek to control others, while vigorously
resisting any and all attempts by others to control them
22. How does the antisocial personality develop
from the interpersonal perspective?
Children exposed to neglect, indifference, hostility, and
physical abuse are likely to learn that the world is a cold,
unforgiving place
Such infants lack normal models of empathic tenderness
Future people with ASPD never learn to control aggression
adequately
They learn that physical intimidation and violence can be
used instrumentally with peers and siblings to coerce their
behavior
23. What shifts the child down a specifically
antisocial pathway?
Neglect and abuse are rather
nonspecific factors, implicated in the
early childhood of many personality
disorders
Benjamin- “context of parenting”
Parents of future people with ASPD
are neglectful and stern
disciplinarians
24. COGNITIVE PERSPECTIVE
Beck et al. (1990) hold that the core beliefs of antisocials are
organized around a need to see themselves as strong and
independent
World is seen as an intrinsically hostile place
Survival demands survival-oriented core beliefs
“I must look out for myself”
“If I am not the aggressor, then I will be the victim”
“It’s okay to take advantage of someone who allows it”
25. CONTRAST WITH OTHER PERSONALITIES
Antisocial Borderline Histrionic
Manipulative Need to dominate,
seize power
Attempt to evoke
support and
nurture
Attempt to occupy and
hold the center of
attention
Impulsivity shortsighted
fixation on
immediate
gratification
impulsive in
reaction to anxious
feelings of
emptiness or
depersonalization
Impulsivity is part of
emotional
dramatization
Acting out intense verbal
threat or violence
acting-out often
takes the form of
suicidal gestures
26. ASPD VS NPD
Share a tendency to be tough-minded, glib, superficial,
exploitative and lack empathy
Narcissistic personality disorder(NPD) does not include
characteristics of impulsivity, aggression, and deceit
Individuals with ASPD are not needy of the admiration and
envy of others
Persons with NPD usually lack the history of conduct
disorder in childhood or criminal behavior in adulthood
27. ASPD AND COMORBIDITY
Swanson and colleagues (1994) community study showed:
Increased prevalence of nearly every other psychiatric
disorder:
1. 90.4% having at least one other psychiatric disorder
2. Substance misuse is the most important Comorbidity
Epidemiological Catchment Area (ECA) study:
1. Five times more likely to misuse alcohol and illicit drugs
2. Half have co-occurring anxiety disorders
3. Quarter have a depressive disorder
28. COURSE AND PROGNOSIS
Antisocial behaviours have their onset before age 8 years
Nearly 80% of people with ASPD developed their first
symptom by age 11 years
Boys develop symptoms earlier than girls
Robins observed that a child who makes it to age 15 without
exhibiting antisocial behaviours are less likely to develop
ASPD
An estimated 25% of girls and 40% of boys with CD will later
meet criteria for ASPD
Subset of antisocial adults have no history of childhood CD
29. COURSE AND PROGNOSIS
ASPD is more common in men and more likely to persist when compared
with women
Guze (1976) found that male felons were still antisocial by interview at
follow-up (87% at 3 years, 72% at 9 years)
Martin and colleagues (1982) found that among women:
1. 33% were engaging in criminal behaviour at 3 years
2. 18% at 6 years
Black and colleagues (1995) longitudinal follow up study in Men showed
that”:
1. Reduced impulsive behaviour and criminality with time
2. Continued to have significant interpersonal problems throughout their
lives
30. PREVENTIVE MEASURES
Secondary prevention with principles of primary prevention
Applied to people who are markedly at risk or who show its very early
signs
Interventions tend to focus on the reduction of risk and strengthening of
resilience
Risk factors:
Poverty, unemployment, inadequate transportation, sub-standard
housing, parental mental health problems and marital conflict
Elmira Project:
Early intensive nurse home visitation intervention worked well to
prevent child maltreatment in the early years and delinquency at 15
years’ follow-up
31. PRESENTATION IN HEALTHCARE
Rarely present in healthcare settings requiring help to deal
directly with problems arising from their personality disorder
‘Treatment rejecting’ rather than ‘treatment seeking’
People antisocial personality disorder present for treatment:
1. Comorbid condition and/or they have been coerced into
treatment
2. By a relative or some external authority in a crisis
32. RISK ASSESSMENT
Psychopathy Checklist Revised (PCL-R; Hare, 1991)
1. It is a measure of psychopathy
2. Shown to correlate highly with violence risk
3. Widely used in violence risk assessment
4. Measure of severity for antisocial personality disorder
Screening version (PCL-SV) - 12 items providing a score
from 0 to 24 (Hart et al., 1999)
Violence Risk Assessment Guide (VRAG)
Offender Group Reconviction Scale (OGRS)
33. TREATMENT AND MANAGEMENT
Pharmacological treatments
The research evidence justifying the use of these interventions
is limited
DSM diagnosis has limited uses for treatment planning
(Livesley, 2007), Soloff (1998) recommended a symptom-
orientated approach:
1. Impulse–behavioural
2. Affective
3. Cognitive-perceptual
SSRIs and antimanic drugs for impulsive dyscontrol
SSRIs and other antidepressants for emotional dysregulation
Low dose antipsychotics for cognitive-perceptual abnormalities
34. THERAPEUTIC TRAPS
For Antisocials therapy is just another annoying encounter with
the constraining forces of society
Antisocials are basically interested in shrugging off external
constraints
Therapy goals are:
1. To develop a sense of conscience
2. Express guilt
3. Express a sincere desire to reform and make amends
They should change slowly and mostly in response to the
searching and confrontive questions of the therapist
35. THERAPEUTIC TRAPS
Duping of therapist by Antisocials by:
1. Seemingly sincere expressions of regret
2. Guilt about the destruction of life and property
3. Existential despair about the wasting own life
Naive therapists get trapped:
1. Those who “need” to cure their subjects
2. Those who might compete against fellow therapists by
displaying their psychopath as one who grew a
conscience
36. THERAPEUTIC TRAPS
Therapists often:
1. Exhibit a variety of intense countertransference
reactions
2. Become suspicious, angry, and resentful
3. They may miss opportunities to catalyze real change
with a genuine therapeutic alliance
37. DEALING WITH THERAPEUTIC TRAP
Beck et al. (1990) suggest:
1. Self-assurance
2. Reliable but not infallible objectivity
3. Relaxed and non-defensive interpersonal style
4. Clear sense of personal limits
5. Strong sense of humor
Frances (1985) suggests that the therapist openly
acknowledge the vulnerability of the therapy setting to the
possibility of manipulation, as many subjects appreciate such
frank disclosure
38. STRATEGIES AND TECHNIQUES
The ultimate goal of therapy is developing a sense of nurturing
attachment (Benjamin, 1996)
The primary objectives of therapy are:
1. To find some way of bonding with the antisocial person
2. To develop a therapeutic alliance
Address the underlying sense of hostility as they are coerced into
therapy
39. INTERPERSONAL THERAPY
Interpersonally Benjamin (1996) suggests that antisocial
subjects lack constructive socializing experiences
Strategies that can be used to help antisocials internalize
values:
1. Sports figures to model warm and benevolent attitudes
2. Put antisocial in a potentially nurturing position
3. Giving a pet or allowed to instruct children in some
supervised context such as a skill or a sport
40. COGNITIVE THERAPY
Beck et al. (1990) and D. Davis describes the use of
cognitive therapy
Move the subject from a primitive to a more abstract level of
moral reasoning
Make subjects recognize that their actions affect others and
have reciprocal consequences for themselves
Delay of gratification and teaching skills necessary to make
enlightened self-interest
41. PSYCHOSOCIAL INTERVENTIONS
Therapeutic community
The therapeutic community movement had a significant
impact on mental healthcare in the mid to late 20th century
(Lees et al., 2003)
Prison service (Grendon Underwood; Snell, 1962) and drug
service
High costs
Absence of convincing evidence for efficacy
42. ETHICAL CONSIDERATIONS IN ANTISOCIAL
PERSONALITY DISORDER
Whether ASPD/Psychopathy/Sociopathy is a disorder at all?
For Philosophers:
Psychopathy is a medical entity to explore issues of moral
reasoning and responsibility
For Psychologists and Psychiatrists:
Whether people with antisocial personality disorder are subject of
medical discourse at all
Implications for criminal responsibility
Much of the current research is used to address this debate
If biological basis- then it is a disorder which needs treatment or at
least intervention
43. ETHICAL CONSIDERATIONS
Conceptual slippage:
‘Antisocial behaviour’ is not the same as criminality or
violence or antisocial personality disorder or psychopathy
Brain research cannot explain why people in general choose
to behave antisocially
All human behaviours are complex
It seems very probable that genetic vulnerability interacts
with environment to produce a neural matrix that contributes
causally to socially significant rule breaking
Only a contribution and not a total explanation
44. ETHICAL CONSIDERATIONS
Researchers and healthcare policy makers need to understand
that:
Problems posed by these people are social ones
There has to be a social/political dimension to the work that is
undertaken
This seems alien to many healthcare professionals and
scientists who see biosciences as politically and morally neutral
Biological model for anti social behaviour is unlikely to change
public attitudes
45. ETHICAL ISSUES- TREATABILITY
The notion of ‘treatment’ raises a number of ethical issues
The assumption that it is a disorder that is amenable to
intervention
A key issue is test of therapeutic outcome
Most ethical arguments about healthcare resources are utilitarian
in nature:
“What will bring about the most good for the greatest
number?”
46. ETHICAL ISSUES OF COERCION IN
RELATION TO ASPD
The only people with capacity who cannot refuse treatment, and
can have treatment forced upon them, are those with mental
disorders who pose a risk to themselves or others
Most libertarian philosophical arguments (Saks, 2003):
Forced medical treatment is only justified to improve a person’s
own health and safety
Insult to dignity is outweighed by the prevention of serious
harm
What is the extent to which societies should coerce people into
treatment that is not of benefit to them directly?
47. ETHICAL ISSUES OF COERCION IN
RELATION TO ASPD
Mental health professionals often argue that they are not
being unethical in two ways:
1. Patients are benefiting even if indirectly
At least they are benefiting from not being allowed to
harm others
Discriminatory—generally competent citizens are
allowed to choose whether they do harm or not, and take
the consequences
2. People who are a risk to others have lost some of their
claims to full exercise of autonomy
48. ETHICAL ISSUES OF COERCION IN RELATION
TO ASPD
Need for distinction to be made between legal coercion and
therapeutic persuasion
Unlikely that all antisocial patients can be coerced into pro-
social thinking or behaviour
Balance between:
The rights of individuals to have liberty
VS
Rights of a community to be protected from potential harm
49. THE ETHICS OF PUBLIC PROTECTION
The extent to which a range of healthcare professionals should be
involved in public protection
Act on knowledge to assist in public protection from a small
number of risky individuals with mental disorders
VS
Make the care of the patient their first concern
A possible ethical and legal solution to the tension is:
Informed consent for both risk assessments and medico-legal
interviews
Clearly advise patients/defendants of the purpose of the interview
The use to which the material will be put
Who will be informed of the outcome
50. ETHICAL ISSUES AND CHILDREN
The prevention of antisocial personality disorder
Justified in terms of beneficial consequences in the future:
1. No (or reduced) antisocial personality disorder
2. Prevention of harm to others and costs to society
Outcomes look very attractive
The question is:
At what cost to human dignity and justice will these benefits
come?
Will the ends justify the harms done in the process?
Most importantly in ethical decision making: who gets to
decide?
51. REFERENCES
1. Book. Theodore. M. Personality disorders in modern life.
Second edition. Florida. Coral gables.
2. Book. Antisocial personality disorder: treatment,
management and prevention. National collaborating centre
for mental health. National institute for health & clinical
excellence. The british psychological society and the royal
college of psychiatrists. 2010
3. Book. Tasman. A. Psychiatry. Fourth edition. John wiley &
sons, ltd.2015
52. They are angry
They make you angry
They need help
You can help them
“ Will you ?”
Thank you
Notas do Editor
First personality disorder to be recognized in psychiatry
Semantic refers to meaning, and aphasia is broadly considered a class of disorders related to the understanding or production of language
Therapist may wish to suggest that because external forces have mandated a course of therapy, the time might as well be used constructively, even though the therapist has no personal investment in the outcome
and involve higher level thinking about motives, beliefs, attributions
It is a general principle of bioethics that respect for the autonomy of patients is paramount and a general principle of law that everyone has control over his/her own body and any treatment interventions that are offered. Under the new Mental Capacity Act
(HMSO, 2005), any person with capacity can refuse treatment, even if this is to
his/her own detriment