The Antisocial Personality Disorder represents a long lasting pattern of behavior markedly deviating from an individual’s culture that leads to clinically significant negative repercussions in multiple areas of function such as social, occupational and marital.

Related Psychiatric Disorders

The Antisocial Personality Disorder belongs in Cluster B of the American Psychiatry Association’s listing of diseases published as the Diagnostic and Statistical Manual (DSM).  Other conditions in this eclectic group of emotionally unpredictable dramatic disorders are Narcissistic Personality Disorder, Histrionic Personality Disorder and Borderline Personality Disorder.  Unfortunately some degree of symptom overlap exists and not infrequently a single individual appears to suffer from more than one personality disorder.

Men More Than Women

By a factor of 3-5 fold men display characteristics of the Antisocial Personality Disorder more than women.  Some estimates suggest the diagnosis in 2%-4% of men and 0.5%-1% among women.  Diagnosis of ASPD is limited to adults over age 18.  A forerunner of ASPD almost always exists in children as Conduct Disorder.  With increasing age only some children mature beyond symptoms of the Conduct Disorder.

Antisocial Personality Disorder from WellNowDoctor

Genes

As with so many psychiatric conditions, their precise origin remains obscure.  Genetic factors contribute to ASPD perhaps in as many as half of the cases.  A family history may exist with identical twins often demonstrating similar pathology.  Implicated genes probably become manifest through actions on neuroreceptors or their receptors in the brain.

Childhood Experiences

In addition to the genes, early childhood experiences significantly impact on the ultimate demonstration of ASPD.  Adverse childhood physical, traumatic or sexual events disrupt normal brain maturation and negatively influence hormonal output.  Scattered reports indicate underdevelopment of areas of the brain integral to control of emotions and empathy.

Classification

An informal classification of personality disorders traces its origins to a collection of “psychopathic personalities” published by the American Psychiatric Association (APA) in 1932.  This became more formalized with the publication of the first edition of the DSM and continues to evolve even with the current fifth edition.

Since no serologic, imaging or genetic tests exist to establish the diagnosis of the Antisocial Personality Disorder, the clinical definition varies somewhat between healthcare providers.  This ungainly situation creates a lack of consistency and uniformity in labeling.  Continued modification of the criteria underlying the diagnosis leads to further confusion.

Symptoms

While a checklist of symptoms remains the standard for diagnosis, marked variation exists among those exhibiting ASPD.  Societal and cultural influences remain necessary considerations in evaluating individuals for ASPD. 

Among the main characteristics from the DSM are manipulativeness, seduction, charm, glibness and deceitfulness as manifest by dishonesty, fraud and self-embelishment.  The core of ASPD also include callousness, lack of concern for the feelings of others, lack of guilt or remorse and often both aggressive behavior and sadism.  People with ASPD are hostile, frequently express anger and irritability especially in response to relatively minor slights or insults.  Their behavior often can be classified as mean, nasty or vengeful.

In addition they are irresponsible, fail to honor financial or other obligations and fail to fulfill their promises.  Impulsive actions without consideration of the effect on themselves or others and risk taking behavior also rank as core components. An increased tendency to boredom regularly leads to further impulsive activities meant to alleviate their state.

The lack of empathy for others generally precludes long term intimate relationships.  Relationships tend to be superficial, exploitative and often involve deceit, dominance and coercion.  They are ego-centric and goal directed based on personal gratification and need to gain power or pleasure.

People with ASPD appear unaware of right or wrong, are extremely opinionated and manifest a sense of superiority.  They need to be thought of infallible. They are unreliable, insincere and may possess fair to good intelligence.

Shifting Definition

Due to shifting emphasis on constituents of ASPD and desire to expand the definition, the most recent edition of the DSM adds several other features leading the definition closer to what some consider a psychopathic disorder or simply psychopaths.  Among these features are low levels of fear or anxiety, a shallow affect and dramatic features.

Conduct Disorder as a Precursor

ASPD is a diagnosis of adults beginning about age 18.  During childhood and adolescence, the presence of Conduct Disorder represents the forerunner to ASPD.  Most symptoms of Conduct Disorder spontaneously resolve before age 18.  Of those with Conduct Disorder during youth, an estimated 25% of females and up to 40% of males mature into ASPD during adulthood.  A relatively benign course appears more common in those with milder symptoms with the onset after age 10.

Conduct Disorder represents youthful ASPD with major symptoms involving aggressive conduct, intimidating behavior, bullying, cruelty and non-consensual sexual activities.  Destructive conduct, intentional destruction of property or vandalism and deceitfulness are frequent.  Other common symptoms include lying, theft, shoplifting and delinquency.  These youths violate societal norms, engage in pranks or mischief and may either run away from home or periodically fail to attend school.

Children with conduct disorder are irresponsible, may steal and cause physical harm to other individuals and even animals.  Some engage in fire-setting or other deliberate destruction of property.  They demonstrate lack of remorse, low levels of fear and readily manifest hostility and aggressive behavior.

As with ASPD, many children with Conduct Disorder suffer a variety of other psychiatric conditions including attention deficit hyperactivity disorder (ADHD), anxiety, depression and substance abuse. 

Dissocial Personality Disorder out of the U.S.

In contrast to the American Psychiatric Association’s description of ASPD, the World Health Organization in their International Classification of Diseases referenced outside of the United States defines a similar condition as Dissocial Personality Disorder.  Dissocial Personality Disorder further blurs the borderline with psychopathy.  These individuals may be considered amoral and antisocial.  They fail to profit from experience and shift blame to others rather than accepting responsibility for their actions.  At times they attempt to rationalize their perverse actions.

Some psychiatrists consider ASPD as a broad category with psychopaths constituting those more severely affected.  They constitute a small subfraction of this population.  Others argue the diagnoses are separate entities.  In either event the definition of ASPD seems rooted in abnormal behaviors while psychopathic personalities concentrate equally on the personality components.

Psychopaths

Distinction between ASPD and Psychopathic Personality stems from writings of Hervey Cleckly in the early 1940s with his “Mask of Sanity.”  Robert Hare continued to refine the definition of Psychopathic Personality beginning in 1980 with his checklist of features required for diagnosis.  He believes criminal behavior is necessary for the diagnosis while others demur.  Hare adds promiscuous sexual behavior and multiple short term marital relationships.

Other Accompanying Psychiatric Disorders

As with so many psychiatric conditions, those affected with ASPD frequently also host a wide array of other mental infirmities including depression and anxiety, bipolar disorder, impulse control disorder, sexual disorder and substance abuse.  They may develop gambling disorders and complain of many psychosomatic issues. 

ASPD belongs to the Cluster B Personality Disorders.  Included in this group are narcissistic personality disorder, histrionic personality disorder and borderline personality disorder.  True to form many of the defining symptoms merge between groups allowing many patients with one disorder to qualify for other Cluster B disorders.

Patients with ASPD appear at higher risk than the general population for premature death not infrequently succumbing to accidents, traumatic injuries, suicide or infectious diseases including HIV and Hepatitis C.

Seeking Treatment

Individuals with ASPD rarely seek medical treatment by themselves.  Rather it may be be mandated by legal or judicial authorities or by family members.  People manifesting symptoms of ASPD rarely believe their behavior is abnormal and fail to understand the harm associated with their deeds.  At times they may seek care due to trouble associated with one of the related psychiatric conditions.

Treatment

Treatment for personality disorders remains inadequate.  Neither recognized medical nor psychotherapeutic interventions appear widely supported by randomized controlled trials.  Available interventions exist for some of the comorbidities: depression, anxiety, aggressive behavior and lack of impulse control.

Follow-Up

Unfortunately manifestations of ASPD may continue for decades.  While a small portion of patients experience remission, more than 30% experience some modest improvement. More than 40% remain unchanged or worsen.

DJT – Donald J. Trump

Some discussion relates to whether Donald Trump manifests sufficient symptoms to be labeled as a Malignant Narcissist or a mixture of the Narcissistic Personality Disorder combined with the Antisocial Personality Disorder.  While I make no diagnosis, some biographical evidence suggests President Trump merits consideration for inclusion.

DJT – The Early Years

Certainly Conduct Disorder seems in play.  As a youth, his father encouraged him to be aggressive, but decided to send him to military school after Donald and a friend traveled by subway into Manhattan to purchase switchblades.  According to his autobiography he was a “difficult, tempestuous child.  A favorite activity was testing other people from children in his neighborhood to figures of authority.”  Evidently neighbors saw him throw rocks over a fence at a young child in a playpen.

DJT – Suggestive Features

Examples that might indicate ASPD include his use of John Barron, an alias, to bolster his reputation during his New York era.  Then there’s his outright lying about a sexual affair with an adult film star while his wife was pregnant with his child.  Then there are the other women who were paid monetary settlements.  And the bankruptcies in multiple businesses including casinos and hotels.  And the lack of empathy for the more than 150,000 Americans who lost their lives from the coronavirus.  And the lawsuits involving discrimination in against leasing to black individuals or to congressional committees.

Then there are his multiple marriages, commands to police “please, don’t be too nice” to suspects in custody. Then there were his statements from the podium that he would “like to punch him (a heckler) in the face.  And his status as “essentially an unindicted co-conspirator” in the Michael Cohen matter.  And his exposure related to potentially illegal activities causing him to fight against allowing his personal and corporate tax returns to be released from his accounting firm Mazars to the District Attorney in New York City.

DJT – It Never Ends

And then of course his unfounded lying about General Mattis, Rex Tillerson, and Jim Comey.  And his false claim to be ready to release a tax relief package immediately before the 2018 election. No evidence existed that such action was under consideration. 

And his lying about a “full and complete healthcare plan” ready in two weeks many months ago at the same time his government is suing to inactivate the Affordable Care Act.  This would leave a large swath of the public uninsured in the middle of the coronavirus pandemic.  Then there was the birther issue and his public demand for death for the five African American youths known as the Central Park Five. 

And his lack of remorse or apology after they were exonerated based on DNA evidence.  And his failure to compensate contractors the agreed upon price which sent many into financial difficulties or bankruptcy.  And of course his actions in regard to the Washington Post columnist Jamal Khashoggi. 

DJT – What Others Mental Health Professionals Think

These just represent a few actions that might suggest the psychiatrists and mental health professionals who wrote “The Dangerous Case of Donald Trump” might just be correct.

And add to this his niece Mary Trump, a clinical psychologist and author of “Too Much and Never Enough: How My Family Created the World’s Most Dangerous Man.”  Not only does she lend credence to Donald Trump’s psychiatric diagnosis but she is currently suing him for fraud.

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