Millon and others have argued that the DSM only provides a checklist of "bad boy" behaviors, and skips over the inner workings of the disorder. Thus, the diagnostic criteria are very behaviorally based and it is possible to over-diagnose this disorder. Clinically, we distinguish between an Antisocial Personality Style and Antisocial Personality Disorder. People with Antisocial Personality Style show some of the characteristics, but those with the Disorder show more or all of them, and show them in a more severe form.
Examples of Antisocial Personality Disorder and Style
The stereotypic successful but cutthroat businessman who is willing "to step on others to make it to the top," "buy and sell people" in the workplace, engage in unethical but generally legal business practices, and adopt a "work hard: play harder" lifestyle. Think Bill Gates.
Think of the good-looking and popular frat boy who says whatever is needed to get a girl drunk and alone, then slips the "date rape" drug into her drink to have sex with her. He feels no "remorse" until caught.
Think of the computer geek who writes viruses to destroy people's computer files and systems for the feeling of power, who argues no "thing" is destroyed so it isn't a crime, and rationalizes that by doing this is he doing the world a "favor" by exposing vulnerable computer system flaws.
Think of the "Investment Deal of a Lifetime" businessman who bilks old people out of their life savings and then disappears to another state to do the same when the law is about to close in.
Any of these examples can represent a Style or a Disorder.
Characteristics of Antisocial Personalities
|Personality Style||Personality Disorder|
|Cognitive Style||Shows superficial charm and easily make friends. Decision making is externally oriented. They show poor judgment and sometimes impulsive behavior, and justify and rationalize, and have difficulty learning from mistakes. They resent authority, tend to be competitive, but are poor losers.||Charm develops into a tendency to lie and "con" others for profit or enjoyment. Decision is more rigid and inflexible, and can be motivated by "getting even" for real or perceived "slights." Externalize responsibility for behavior, and blame all problems on others. Resentment of authority can take on an aggressive quality|
|Emotional Functioning||Lacks a sense or empathy as well as responsibility for the consequences of their actions. Often have a feeling emptiness and seek excitement to relieve the boredom. Assume the worst in others so can be argumentative and easily irritated.||Lack of empathy develops into a lack of guilt, shame, or even basic remorse for the harm they cause to others. Impulsivity and emptiness can lead to recklessness with no appreciation for the danger. Can be violent and abusive when they feel frustrated.|
|Relationships||Adept at reading social situations and cues; uses this information to persuade others into meeting their needs. Assume others are like them, so seldom honest and open.||Reads others to manipulate them because they see others as basically ways to gratify their desires. No real loyalty or accountability to "loved" ones. Assume others are like them, so highly distrustful; likely to see environment as a "dog-eat-dog world" and think it's best to "get" others before they "get" you.|
|History||Irresponsible with money sometimes, but able to work and support themselves, may be quite successful sometimes||Spend money carelessly, fail to honor financial obligations, can't maintain stable work due to the discipline this requires; leave one job without another|
Development of Antisocial Personalities
There are several models for how Antisocials develop. They aren't exclusive, so feel free to "mix and match" what you need to understand them.
Meloy discussed the "stranger self-object." When the Antisocial was a child, he perceived his parents as being cold, uncaring, and likely to harm him. His introject, or basic template for people, does not include attachment, empathy, or trust. Without this, empathy can not develop, as well as shame or remorse.
Without an empathic and nurturing parent, they also don't develop an internalization for the rules of society, and instead follow their own more primitive rules of "what feels good is good" and "you know it is bad if you get caught."
A best-case scenario includes what Kernberg (I think) called "superego lacunae" or holes in their conscience; they may possess some moral reasoning in some areas but not in others. Think of the drug dealer who thinks it morally wrong for you to sell his drugs and keep some of the profit for yourself, but who has no qualms about the business of drug sales.
There is some evidence that Antisocials may develop from difficult temperament children or abused children. Both can show attachment difficulties and irregular arousal patterns. The child with attachment difficulties might follow the process above.
The children with irregular arousal patterns could become aggressive if the thresholds for stimulation are too low; thus they are quick to sense threat or danger. Alternately, the "cold criminal" mentality could results from thresholds for stimulation being too low; thus they lack the sense of danger or anxiety that gives others indication of mistakes or bad judgment.
Sociopathic behavior becomes reinforced, and as a result of deficient parenting and modeling, the child begins to take care of himself. He is likely to distrust adults and authority, and then to try to gain power over others to prevent them from gaining power over him.
Cognitive Behavioral theorists say that Antisocials suffer from a number of mistaken cognitive beliefs. They learned these and they were reinforced somewhere. OK so that's not much on how they started, but it's worthwhile to look at the way they think:
1) wanting something or wanting to avoid something is sufficient justification for acting in any way needed to obtain it or avoid it
2) thinking or feeling is a fact, and so if you think it is then it is true; the result is that you are always right
3) undesirable consequences will not happen to you or won't matter
4) you're on your own in this world
5) why worry about tomorrow, focus on today
Antisocials often have histories of abuse, neglectful parenting, and emotional trauma. They experience unpredictable discipline, had parents who were inconsistent and modeled putting their own needs first, learned little about sharing and being interdependent with others, develop a heightened need to establish their own independence from "bad" parents, and control others rather than be controlled.
The emotional trauma they experience often leads to deep feelings of vulnerability and the rejection and lack of love they experience leads to shame. To avoid actually experiencing these feelings, they repress and deny their own feelings to the point that they can not longer empathize with other people because to do so would be to recognize their own painful past.
Psychological Test Results
As long as you are pleasant and "go along" with their rationalizations, the interview can be nice. But, question them about their irresponsible behavior, and they turn rude. They are attention seeking, so they are willing to brag about their accomplishments, so long as they don't have to talk about their failures. (There was a story in the news recently about a criminal who made bond and left the state. He contacted a TV new program offering to sell his "story." Cops got the email from the TV program, set up a sting, and nailed him.)
While they will not admit to having made real mistakes or bad decisions, they may be able to admit that things are not going well for them, and that others are likely to continue to cause them problems until some goal is accomplished. Thus, it is possible to form some kind of alliance with them to work toward some therapeutic goal. However, they lack genuineness and real sincerity in their stated desire to change, so therapy is of little help.
The 4-9 codetype is the most typical. Sometimes you can get minor elevations on 6 and 8, since they are overlapping, as a result of the aggressiveness, distortion in thinking, and paranoid-ish view of the world. Elevations on 2 (depression) and 7 (Anxiety) are uncommon, since real sociopaths don't feel depression and anxiety like other people do. However, those with an Antisocial Style might. Keep in mind that if an Antisocial thinks it is worth the effort to fake on these, he will, and may be able to do a good job of it.
Low to average number of responses, sometimes reject cards, more Pure C (from their impulsiveness), as well as more Animal content and FM than M. You may also see more Popular responses, given their social perceptiveness, and few if any shading, since they don't feel much anxiety or depression.
Stories on the TAT are likely to include juvenile themes where the hero does as he pleases and punishment is absent or very minor. Explanations of the hero's reasoning for acting as he does are likely to be similar to those described above with regard to cognitive distortions. Other people are viewed as "bad" and as acting with malice toward others and the hero. They are caught and punished, however.
Therapy as noted above is most helpful if it is problem focused. Gently awakening the buried feelings in the client and connecting them to current actions is the basic goal and process. However, you won't get very far; experiences that have been repressed for too long aren't going to come to the surface in the limited therapy time you have.
Other modalities may help too to provide experiences that change the way Antisocials see themselves in the world. This basically amounts to teaching sublimation though.
Family therapy can be helpful. However, realize that you are basically working to coordinate the person's environment to work together to "gang up" on the client. If the entire family cooperates to make demands of the patient, and not give them any leeway to begin rationalizing and justifying their irresponsible behavior, the client can make some limited changes. Basically, this amounts to an "it's easier to comply than fight" approach.
Medication to target specific behaviors like impulsivity and aggressiveness may help, but you can't medicate the underlying cause of the disorder.
The best treatment may be time. Antisocials don't come in for treatment much after age 30. They tend to have learned that some behaviors, while completely justified and reasonable for them of course (grin), end up causing more hassle than anything else. Thus, some antisocial behaviors are avoided to avoid the frustration and annoyance they cause.
Narcissistic Personality Disorder:
Antisocial and Narcissistic disorders are close, when you look at the disregard for social rules, distorted thinking, and limited empathy for others. Coupled with their manipulative behavior, they are very close. However, a Narcissist has much more access to emotions than an Antisocial. Further, Narcissists tend to feel more unhappy, depressed, and empty as their life progresses. They also have a sense of entitlement that Antisocials don't have (i.e., "I deserve this and have a right to it" versus "I want it and I'll take it" without any thought to deserving or having a right to it).
Are All Gang Members Antisocial?
Well, not necessarily. A gang member that has some true remorse for his actions, that can admit to making a moral mistake in joining the gang, that can admit to real feelings of anxiety and fear at the idea of leaving the gang, and who can reach and re-experience the childhood history of trauma is not likely to be a "core" Antisocial. They may still have an Antisocial style, but therapy might be effective. On the other hand, real Antisocials are socially skilled, and can "talk a good game" but don't get it.