The discussion of antisocial personality disorder (ASPD) allows a sobering look at the field of clinical psychiatry in general, and its research endeavours in particular. An extremely important aspect in the overall perception of this disorderis the cultural dimension. The very term ‘‘antisocial’’ reflects the inherence of environmental factors. Cultural relativism plays an important role, particularly in the light of the media and the general public’s tendency to easily introduce clinical terms into everyday jargon [1]. Antisocial is a very broad term; antisocial behaviour can be a coping mechanism to deal with an adverse milieu in large cities and small towns alike, in modern Western world metropolis, and in tiny villages in the Sahara desert, the Australian jungles, or Andean communities in Latin American countries [2]. Furthermore, there are the ‘‘charming’’ or ‘‘acceptable’’ psychopaths, many of them living not precisely in the darkness of jails or in the fringes of a society that considers itself ‘‘normal’’. It is important to realize the enormous influence of social and cultural
aspects in what Robert Cloninger calls ‘‘self-aware, immaterial aspects of human personality’’, and subsumes under the concept of psyche. By the same token, it is legitimate to support, as Cloninger does, the notion of different types of antisocial personalities. The hard core criminal may be at one extreme of this true clinical spectrum, and the charming businessman or politician at the other. The severity of levels (and the need to measure them as accurately as possible) are critical factors, with both diagnostic and therapeutic implications.It is almost paradoxical that some comorbidities make the antisocial personality disordered patient more amenable to therapeutic interventions. This issue is important in that we need to, first, prove whether it is true, and second, what aspects of these interventions may contribute to the relatively better prognosis of multi-morbid ASPD patients. It is logical to speculate that the psychological predispositions (and their neurophysiological underpinnings) of these individuals can make some of them more receptive to reflection, interpersonal transactions, introspection, relearning processes, capacity to self-transcend, and other concepts cogently examined by Cloninger. Yet, the beautiful correlations between temperament, existing diagnostic categories, and factors such as motivation and goal accomplishment, are somewhat blurred when postulating that any of these temperament configurations can occur ‘‘in people with either mature or immature
Mayo Psychiatry and Psychology Treatment Center, Rochester, MN, USA characters’’. Isn’t immaturity a critical feature of personality disorders? If so, isn’t it also legitimate to wonder whether we are then talking about ASPD as a diagnosis, or whether the antisocial behaviour is simply a defective (therefore, hopefully correctable) coping mechanism for individuals affectively or emotionally compromised? The diagnostic placement of ASPD is another controversial matter. While in recent years the efforts of the authors of DSM and ICD have strengthened the descriptive aspect, it is important to keep in mind Jablensky’s comment that the clinical use of this label reflects a trend towards ‘‘typologizing’’ conditions that are essentially multidimensional [3]. Even Cloninger’s dimensional terms have fallen into the typological, descriptive, categorical usage to which clinical practitioners are so adept. This is not only a reflection of an ‘‘occupational deformity’’ by hurried clinicians, but also the result of the complexity of a disorder that uses descriptive adjectives more generously than any other existing clinical condition. Even Cloninger’s terminology abounds in this kind of terms, for both the depiction of ASPD and his novel ‘‘coherence therapy’’ approach. Moreover, to define a personality disorder as a ‘‘description of someone whose thoughts and human relationships are usually lacking in self-awareness’’ may strike some as too broad or simplistic to be of any use in research.
A related question is whether Cluster B is the best niche for ASPD. Answering those who question the very existence of Axis II in any nosological classification, it could be said that ASPD may be one of the strongest reasons to keep it even if, for instance, the connections between ASPD and somatization, or with substance dependence in the patient and his/her relatives, have not been fully explained. On the issue of gender, it has been said that ASPD in men is what histrionic personality is among women [4]. Indeed, ASPD stands alone in its complexity, and the difficulties to be appropriately grasped and tested. If we are truly faithful to a multidimensional approach in diagnostic parlance, the notion of spectrum may have, in the antisocial personality, one of its most fertile fields of application. Are only criminals to be labelled as ASPDs? I would submit that the spectrum concept would assist in responding to this question. Moreover, the concept of cluster may even be more precise as it may include features such as narcissism and histrionic behaviour, which are part of other personality types, but seem to be also essential components of ASPD. Do the variations in the spiral movement of selfaware consciousness in ASPD imply clinical variations in the spectrum of antisocial behaviours? Taking from Cloninger’s approach, the ASPD spectrum would have to include areas beyond the pure phenomenological description, and get into aetiopathogenic, diagnostic and therapeutic grounds. The neurobiological approach would have to produce much more persuasive evidence related to the underlying dysfunction or disruption. Neuroimaging and genetic studies may only contribute to the eventual clarification of the most severe cases within the spectrum, which leaves out a significant number of patients whose ASPD label then may or may not be valid. In this context, the issue of differential diagnosis withother conditions, including bipolar disorder, is extremely pertinent. Clinicians all over the world face the problem of labelling ‘‘moodiness’’, ‘‘irritability’’, and ‘‘dysphoria’’ as mood rather than personality features,and a variant of bipolarity rather than an autonomous Axis II entity. This is important also for the effort at translating psychophysiological findings into descriptors of symptomatic remission, and consistent responsiveness
to therapy, i.e. amenability to Cloninger’s ‘‘radical transformation of behaviours’’. The treatment of ASPD is clearly the most challenging and frustrating aspect of this condition. It starts with therapists from different schools, who do not necessarily agree on some of the key descriptive features, such as ‘‘lack of empathy’’, among ASPD patients. How do we explain the fierce loyalty that true antisocials show towards other members of their gangs? Is this a distorted notion of loyalty, or is it loyalty perverted by external pressures and by what are perceived as oppressive realities? Are we talking about antisocials here? Or would reviving the old terms ‘‘asocial’’ or ‘‘dissocial’’ [5] solve these discrepancies? In fact, Gabbard seems to think that
these patients profess significant capacity for empathic discernment, even though it is a rather self-serving feature [6]. The ‘‘otherness’’ of the ASPD may have both a psychological and physiological basis, but neither this somewhat abstract concept nor the current neuro- and psychophysiological findings qualify for a ‘‘physiological marker’’ as suggested by some authors. On the other hand, is the grouping in primary and secondary psychopaths just one way to dress up our varying levels of therapeutic expectations and hopes? Furthermore, the verdict is still out regarding the use of wellstructured environments and the setting in which they take place (correctional schools, prisons, and the military). In short, ASPD embodies all the challenges and complexities of a multidimensional entity, and the need to be truly eclectic in studying its many different aspects. Progress has been made, and yet the trite comment that a lot remains to be done has never been truer than at this point in history. The antisocial behaviour is universal, and yet ASPD patients are unique in their biopsychosocial, cultural, and spiritual contexts. This is an uphill battle that, one would like to think, is being won a little step at a time.
A related question is whether Cluster B is the best niche for ASPD. Answering those who question the very existence of Axis II in any nosological classification, it could be said that ASPD may be one of the strongest reasons to keep it even if, for instance, the connections between ASPD and somatization, or with substance dependence in the patient and his/her relatives, have not been fully explained. On the issue of gender, it has been said that ASPD in men is what histrionic personality is among women [4]. Indeed, ASPD stands alone in its complexity, and the difficulties to be appropriately grasped and tested. If we are truly faithful to a multidimensional approach in diagnostic parlance, the notion of spectrum may have, in the antisocial personality, one of its most fertile fields of application. Are only criminals to be labelled as ASPDs? I would submit that the spectrum concept would assist in responding to this question. Moreover, the concept of cluster may even be more precise as it may include features such as narcissism and histrionic behaviour, which are part of other personality types, but seem to be also essential components of ASPD. Do the variations in the spiral movement of selfaware consciousness in ASPD imply clinical variations in the spectrum of antisocial behaviours? Taking from Cloninger’s approach, the ASPD spectrum would have to include areas beyond the pure phenomenological description, and get into aetiopathogenic, diagnostic and therapeutic grounds. The neurobiological approach would have to produce much more persuasive evidence related to the underlying dysfunction or disruption. Neuroimaging and genetic studies may only contribute to the eventual clarification of the most severe cases within the spectrum, which leaves out a significant number of patients whose ASPD label then may or may not be valid. In this context, the issue of differential diagnosis withother conditions, including bipolar disorder, is extremely pertinent. Clinicians all over the world face the problem of labelling ‘‘moodiness’’, ‘‘irritability’’, and ‘‘dysphoria’’ as mood rather than personality features,and a variant of bipolarity rather than an autonomous Axis II entity. This is important also for the effort at translating psychophysiological findings into descriptors of symptomatic remission, and consistent responsiveness
to therapy, i.e. amenability to Cloninger’s ‘‘radical transformation of behaviours’’. The treatment of ASPD is clearly the most challenging and frustrating aspect of this condition. It starts with therapists from different schools, who do not necessarily agree on some of the key descriptive features, such as ‘‘lack of empathy’’, among ASPD patients. How do we explain the fierce loyalty that true antisocials show towards other members of their gangs? Is this a distorted notion of loyalty, or is it loyalty perverted by external pressures and by what are perceived as oppressive realities? Are we talking about antisocials here? Or would reviving the old terms ‘‘asocial’’ or ‘‘dissocial’’ [5] solve these discrepancies? In fact, Gabbard seems to think that
these patients profess significant capacity for empathic discernment, even though it is a rather self-serving feature [6]. The ‘‘otherness’’ of the ASPD may have both a psychological and physiological basis, but neither this somewhat abstract concept nor the current neuro- and psychophysiological findings qualify for a ‘‘physiological marker’’ as suggested by some authors. On the other hand, is the grouping in primary and secondary psychopaths just one way to dress up our varying levels of therapeutic expectations and hopes? Furthermore, the verdict is still out regarding the use of wellstructured environments and the setting in which they take place (correctional schools, prisons, and the military). In short, ASPD embodies all the challenges and complexities of a multidimensional entity, and the need to be truly eclectic in studying its many different aspects. Progress has been made, and yet the trite comment that a lot remains to be done has never been truer than at this point in history. The antisocial behaviour is universal, and yet ASPD patients are unique in their biopsychosocial, cultural, and spiritual contexts. This is an uphill battle that, one would like to think, is being won a little step at a time.
REFERENCES
1. Alarco´n R.D., Foulks E.F., Vakkur M. (1998) Personality Disorders and Culture. Clinical and Conceptual Interactions. Wiley, New York.
2. Reid W.H. (1985) The antisocial personality: a review. Hosp. Commun. Psychiatry, 36: 831–837.
3. Jablensky A. (2002) The classification of personality disorders: critical review and need for rethinking. Psychopathology, 35: 112–116.
4. Nuckolls C.W. (1992) Toward a cultural history of personality disorders. Soc. Sci. Med., 35: 37–47.
5. American Psychiatric Association (1952) Diagnostic and Statistical Manual of Mental Disorders, 1st edn. American Psychiatric Association, Washington.
6. Gabbard G. (1997) Finding the ‘‘person’’ in personality disorders. Am. J. Psychiatry, 154: 891–893.
7. Frank J.D., Frank J.B. (1993) Persuasion and Healing. Johns Hopkins University
Press, Baltimore.
1. Alarco´n R.D., Foulks E.F., Vakkur M. (1998) Personality Disorders and Culture. Clinical and Conceptual Interactions. Wiley, New York.
2. Reid W.H. (1985) The antisocial personality: a review. Hosp. Commun. Psychiatry, 36: 831–837.
3. Jablensky A. (2002) The classification of personality disorders: critical review and need for rethinking. Psychopathology, 35: 112–116.
4. Nuckolls C.W. (1992) Toward a cultural history of personality disorders. Soc. Sci. Med., 35: 37–47.
5. American Psychiatric Association (1952) Diagnostic and Statistical Manual of Mental Disorders, 1st edn. American Psychiatric Association, Washington.
6. Gabbard G. (1997) Finding the ‘‘person’’ in personality disorders. Am. J. Psychiatry, 154: 891–893.
7. Frank J.D., Frank J.B. (1993) Persuasion and Healing. Johns Hopkins University
Press, Baltimore.
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