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Anti-Social Personality Disorder

Antisocial Personality Disorder: George

In the first case study we explored antisocial personality disorder; the clients name is George.   George is hospitalized with symptoms of APD, and states that he came to the hospital because “my mind got so bad, no one could tell me what to do”.  He goes onto to describe what he means by this statement.  George admits to holding a gun to his father’s head, holding his mother’s face and calling her names, and didn’t care about anything; including himself, father, mother, or his children. George admits to distributing drugs on the street “to others who are sick people; he didn’t he had a sickness”.

As the interview progresses, the interviewer asks George if he has engaged in any fights with weapons and at what age. George states that he was in multiple fights as young as 11 years old. He describes an event where he used a knife in a fight, and that his mother worked for the courts so he received a good deal. George describes his past volatile behavior by describing his past actions. George states that he used to throw bricks and bottles at people’s heads, “to bust their heads”.  He describes carrying and using 13 inch switch blades. The interviewer asks if he meant to hurt them, and George replies “Yes, I didn’t care about it, I had no feelings for nobody, if I felt like killing somebody, fuck him in the hospital, I didn’t care about it”. George’s “lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another (Criterion A (7) is evident by the above statement.

  George goes on to describe additional past events, such as; stealing from his daddy, stealing valuable comic books at school and sold them. George had an inappropriate smirk, smile, when he admitted to the value of the comic books. George’s deceitful behavior “as indicated by repeated lying, use of aliases, or coning others for personal profit or pleasure” (DSM-IV-TR, 200) is evident by his stealing and selling his mothers comic books for personal profit or gain; money (Criterion A, (2), DSM-IV-TR, 2000).  The interviewer went on to ask about other behaviors, such as torturing animals. He states he loves animals, and would never hurt an animal; but a person, “I’d do something to a person, I have hatred inside me, the more I hit somebody, the more anger I get inside”. George presents with symptoms of “irritability and aggressiveness, as indicated by repeated physical fights or assaults, Criterion A (4).

It is evident that George has a “pervasive pattern of disregard for and violation of the rights of others occurring since age 15years”, (DSM-IV-TR, 2000), as evidence by his repeated fighting as young as 11 years old, his involvement and trouble with the law for fighting, selling drugs, stealing, brandishing a gun to his father’s head, and other violent behaviors (Criterion A).     

Axis I             292.9   Substance-Related Disorder (Unknown substance)

Axis II             301.7   Antisocial Personality Disorder

Axis III           None                          

Axis IV           Current Psychiatric Hospitalization, problems related to interaction with the legal system/crime; problems related to primary support group; problems related to the social environment; educational problems; potential occupational problems, economic and housing problems.

Axis V             40

Comparison

Mr. Y is a 26-year-old man transferred from prison to the psychiatric unit as a result of a suicide attempt. This is Mr. Y’s 4th suicide attempt. He has had problems with the law in his early teens which resulted in arrests of theft, possession of illegal drugs, and assault. His trouble with the law landed him in prison. His extreme violent behavior is evident as early as 9 years old when he threw his baby brother out of a first floor window, causing several fractures. His “reckless disregard for safety of self or others” (DSM-IV-TR, 2000) is evident by the above statement (Criterion A, 5).

His past history includes: his mother was a prostitute and drug addict, he had serious conduct problems from a young age (Criterion A); he engaged in fights at school on a daily basis.  Unlike George, Mr. Y tortured animals. He has spent much of his life in group homes, foster homes and at his maternal grandmother’s home where 8 other children were being cared for. Mr. Y began using drugs at the tender age of 10 years. He joined a gang in his early adolescent years, selling drugs, running numbers, and became a father at the age of 13 years old. By the age of 23 he fathered 5 children. Both George and Mr. Y engaged in gang involvement, using drugs, assaults, and theft. Mr. Y has been hospitalized several times for his depression, drug overdoses, and suicide attempts, unlike George. This was George’s first hospital admission. Mr. Y appears to have a pattern of behavior that he exhibits when he is hospitalized. He appears to get better right away, and engages in friendly contact with other patient’s. His manipulative, charming, demeanor convinces and attracts the attention of the other patients who go along with Georges requests for smoking privileges, passes, and the need for medication. This causes problems on the unit.

Furthermore, George has also been caught having intercourse with an elderly patient.  “Individuals with APD may display a glib, superficial charm and can be quite voluble and verbally facile (e.g., using technical terms or jargon that might impress someone who is unfamiliar with the topic)” (DSM-IV-TR, 2000). Mr. Y used this feature on the other patients in the psychiatric unit to collide with him in order to cause disorder.
            Both George and Mr. Y have evidence of conduct disorder before the age of 15 years (Criterion C), and their occurrences appear to be not exclusively during the course of schizophrenia or a manic episode (Criterion D); however, further assessment and evaluation is warranted.  

Differential Diagnosis: Antisocial Personality Disorder

It has been suggested whether APD should be considered a mental disorder.  According to the DSM-IV-TR, there is concern that individuals with APD would not be responsible for their actions.  Features such as deceitfulness, irresponsible and impulsive behavior are among some of the symptoms that clinicians deal with when treating these clients. It is difficult knowing whether a client is being sincere or deceitful in order to manipulate a situation, or a desire met. APD is often co-occurring with other personality disorders, such as; narcissistic personality disorder, borderline personality disorder, in addition to substance use disorders and potential adult antisocial behaviors. “When antisocial behavior in an adult is associated with a substance related disorder, the diagnosis of antisocial personality disorder is not made unless the signs of APD were also present in childhood and have continued into adulthood” (DSM-IV-TR, 2000).

Other potential disorders include bipolar disorder and schizophrenia. “Antisocial behavior that occurs exclusively during the course of schizophrenia or a manic episode should not be diagnosed as antisocial personality disorder” (DSM-IV-TR, 2000).  These disorders can be ruled out by further investigation, assessment and evaluation.  

Cross Cultural Issues

The prevalence of APD in gender is approximately 3% in males vs. 1% in females. According to the DSM-IV-TR; “prevalence estimates within clinical settings have varied from 3% to 30% depending on the predominant characteristics of the populations being sampled”.  In addition, “The prevalence is higher in substance abuse treatment centers, prisons or other forensic settings” (DSM-IV-TR, 2000).   APD appears to be a universal disorder. Research shows a connection between a genetic predisposition, and environmental factors to play a role in developing the condition; In addition to biological evidence, such as an alteration in neurotransmitters and other neuro-hormones, such as serotonin, dopamine, and testosterone.  Traumatic stress has been “implicated as a factor in the development of APD” (Barlow & Durand, 2009).

 References

American Psychological Association (2000). Diagnostic Statistical Manual of Mental Disorders. (4th Ed.) Test Revision. DSM-IV-TR. Washington DC. American Psychological Association.

 

Frances, A., M.D., Ross, R., M.A. (2001). DSM-IV-TR Case Studies; A clinical Guide to Differential Diagnosis. Washington DC. American Psychiatric Publishing Inc.

 

Barlow, D. H., Durand, V. M., (2009) Abnormal Psychology; An Integrative Approach (5th Ed.) Belmont. Wadsworth/Cengage Learning.

 

 

 

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