A friend of mine who works in a parole out-patient clinic emailed me as to my opinion of an historical diagnosis of Antisocial Personality Disorder for a guy who just completed 19.5 years in prison for murdering a rival gang member as a youth. What are we talking about here when we speak of personality disorders? According to the DSM-V, these are “enduring patterns” of impairment that develop early in life that “deviate markedly from the expectation of the individuals culture” and are “pervasive and inflexible” impairments that incorporate themselves into the individual. And what is “antisocial?” It is a “pervasive and inflexible” pattern of “failure to conform to social norms,” meaning legally, financially (often referred to as a “parasitic lifestyle”), and inter-personally (e.g. indifference to the rights, safety, property, etc. of others).
A further categorization is reserved for those forensic patients who distinguish themselves for the viciousness of their cruelty, serial repetitiveness, and the extent of their depraved indifference, and this is referred to as “psychopathy.” Typically, this term is best typified by individuals such as Ted Bundy, the BTK Killer, and Richard Ramirez, but seems equally applicable to someone like serial financial victimizer Bernie Maddoff. In a fascinating interview with New York Magazine in 2011, Madoff takes great exception to being referenced to in the media as a “monster,” despite being responsible for the financial ruin of thousands:
And finally, there is also a categorization for what is termed Adult Antisocial Behavior which is not a mental disorder in and of itself, but what the DSM-V terms “Other Conditions That May Be a Focus of Ciinical Attention, in this case, “adult antisocial behavior that is not due to a mental disorder (e.g., conduct disorder, antisocial personality disorder). Examples include the behavior of some professional thieves, racketeers, or dealers in illegal substances.” In other words, crime! Not to belabor the point, but I was dismissed from jury duty because a prosecutor believed mental health professionals are incapable of distinguishing between mental disorder & criminal behaviour. As I departed, I was able to distinguish for her the difference between a jackass and a donkey. Back to the story…
And so, sitting alone with his therapist, in the prison khakis he irons himself, he seeks reassurance. “Everybody on the outside kept claiming I was a sociopath,” Madoff told her one day. “I asked her, ‘Am I a sociopath?’ ” He waited expectantly, his eyelids squeezing open and shut, that famous tic. “She said, ‘You’re absolutely not a sociopath. You have morals. You have remorse.’ ” Madoff paused as he related this. His voice settled. He said to me, “I am a good person.”
Attached to my friend’s email are the comments of her former supervisor (for good measure?) advizing adminstering the Hare PCL-R, the only validated instrument to rate psychopathy in a male forensic population, “and get the diagnosis to stick.” Prison is the only place on earth where the purposely short-term distinction “rule out” can last years and the rationale for suggesting the need to consider the diagnosis long disappeared. For example, amidst the mundanity, I see in the file of a new patient that he was diagnosed with Tourette’s Syndrome, a neuropsychiatric disaster of spastic tics and shouted obscenities. STAT request by psychology to psychiatry. Holy Cow! I’m waiting all day for this guy and… nothing. More tics on my dog. He tells me, “I used to have this habit of cracking my neck,” he sort of flinches left (crack), then right (crack), “but I stopped doing it. Somebody said I’d get arthritis.” Boy, and you can just hear Gunnery Sgt. Hartman to Cowboy, “This ain’t your daddy’s shotgun, Pvt. Cowboy. Move the rifle around your head, not your head around the rifle…” Back to the story…
Despite the fact that the Diagnostic and Statistical Manual of Mental Disorders purports itself to be, in fact, a “statistical” and epidemiological document, it is thin to say the least:
“Greater than 70%” twelve-month prevalence rates in prisons? What? We’ll return to this…
Prevalence: Twelve-month prevalence rates of antisocial personality disorder, using criteria from previous DSMs, are between 0.2% and 3.3%. The highest prevalence of antisocial personality disorder (greater than 70%) is among most severe samples of males with alcohol use disorder and from substance abuse clinics, prisons, or other forensic settings. Prevalence is higher in samples affected by adverse socioeconomic (i.e., poverty) or sociocultural (i.e., migration) factors.
Murder, after all, is murder and I certainly do not wish to appear cavalier or to minimize or mitigate the act, but a youthful offense committed in the context of a violent street gang is significantly different than the psychopathic planning and facilitation of serial torture and murder. Likewise, if we accept that a personality disorder is a fundamental “incorporation” of an enduring and inflexible pattern of antisocial malignancy into the makeup of an individual, how is it possible this individual has managed to “contain” his characteristic social non-conformity for nearly twenty years? At the same time, I can make the argument that a prison environment is necessarily an environment of adult antisocial behaviour. Some examples. Both the DSM and the PCL-R weigh highly the symptom of deceit/lying/alias assumption/conning as classic to ASPD/psychpathy. Nevertheless, there is absolutely no value placed on honesty in prison. None. In fact, it is much more likely to cause you problems. Say anything that is vaguely incriminating, threatening, or criminal on the phone, in the mail, or in earshot of any staff and somebody looking for a “bargain” and, buddy, you will find out the real meaning of “anything you say can and will be used against you.” You’re tagged a SNITCH? You have the shelf-life of a “sell by yesterday” carton of milk. Chris Rock asked how the military could find Saddam Hussein in some obscure village hidden in a hole under a piece of plywood, but the cops couldn’t find one witness to who shot Tupac Shakur on the Vegas Strip on a Saturday night? Answer: some folks have been to prison.
The problem, however, is that antisocial behaviour is aggravating like you can’t imagine. As the diagnostic criteria states, it is founded in a pattern of behaviour “occurring since age 15,” and has historically been associated with Conduct Disorder of childhood. In the DSM-V, all of this is now gathered into the single super-annoyance of “Disruptive, Impulse-Control, and Conduct Disorders.” So, from instinct, when we feel the aggravation, the provocation, the limit-testing of ASPD, it is not difficult to relate it to every punk who made our collective childhoods miserable by humiliation, intimidation, or worse, without the slightest bit of acknowledgement or remorse. Or perhaps equally telling, I recall co-facilitating an in-patient adolescent family group where a parent screamed at her Conduct Disordered son, “I just want to come over there and slap you,” and another parent’s feedback to this mother was, “I just want to come over there and slap you.” Now, there are numerous ways to test this theory, but the one I have seen that best makes my point is any effort specifically exerted to impede “the count.” The count is exactly what it implies, several times a day, everything comes to a halt while custody staff verifies that every inmate who is supposed to be there is, in fact, present and accounted for. Want to mess with the whole show? Be late from work/clinic/whatever, drag your feet, “board up” (i.e. cover your windows so you can’t be seen), be disruptive/argumentative, cause a disturbance/distraction, etc. during the count and it will find its way to your chart. Add to this the inability to deal with grief at the death of a loved one, forced divorce or termination of significant relationship, etc. with accompanying reaction formations, blah, blah, blah and antisocial behaviour certainly seems “pervasive and fixed.”
What is my point with all this? It stands to reason that most anyone who is placed in an environment guided by adult antisocial behaviour will assume antisocial behaviour to survive. With the passage, for example, of the “3-Strikes Law” in California, there are a significant number of relatively younger individuals serving life-sentences without the possibility of parole, making it all the more reasonable to suspect an enduring future atmosphere that will be more pathological and more antisocial. At the same time, California is under a federal appeals court mandate to reduce overcrowding and has been forced to release offenders early back into the community. It would likewise stand to reason that if ASPD has not become a “slogan” for typical prison behaviour reframed as personality disorder, we would be inundated with crimes typical of those incapable of conforming to societal norms. We have not not. So, how did I respond to my friend? This is the perfect example of why we maintain a provision to rule out conditions or designate clinical concerns “by history.” Twenty years is a long time to wear the coat of ASPD - which he may never have suspected - but murder + ASPD and no one believes your name without picture ID, and even then…
Since the DSM-V now offers some gender and culture-specific data, I thought I might check as the commentary available for ASPD:
That’s it? C’est ça au total. For what it’s worth, I can tell you that I do not recall ever seeing a woman in a California prison diagnosed with ASPD. BUT, without looking, do happen to recall the graphic that began this post? It’s a “border” marker to refer to Borderline Personality Disorder, which is where we’ll head next.
Antisocial personality disorder is much more common in males than in females. There has been some concern that antisocial personality disorder may be underdiagnosed in females, particularly because of the emphasis on aggressive items in the definition of conduct disorder.