Psychiatric Annals

CORRECTIONAL PSYCHIATRY: EFFECTIVE AND SAFE LINKASE OF MENTALLY ILL OFFENDERS 

Antisocial Personality Disorders In and Out of Correctional and Forensic Settings

Amin N Daghestani, MD; Stephen H Dinwiddie, MD; Daniel W Hardy, MD, JD

Abstract

Prominent features of antisocial personality disorder involve a pattern of violating the rights of others, often manifested by lack of conformity to social norms, deceitfulness, impulsivity, irritability and aggressiveness, recklessness, irresponsibility, lack of remorse, and the presence of conduct disorder before the age of 15 years. Many conditions, however, may be associated with such "antisocial" behavior; indeed, the high prevalence of severe mental illness in correctional settings has been repeatedly demonstrated.1 The occurrence of antisocial behavior should not be exclusively during the course of a schizophrenic or a manic episode.

It has been estimated, with the use of DSM-IIIR criteria, that 5.8% of men and 1.2% of women will merit the diagnosis of antisocial personality disorder during their lifetimes, with approximately half reporting ongoing antisocial behavior in the year prior to interview.23 Antisocial personality disorder is associated with high rates of lifetime use of psychoactive agents, including opiates, central nervous system stimulants, and solvents, as well as with an elevated lifetime likelihood of injection drug use.4"8

Antisocial behavior may best be conceptualized as representing a continuum of severity, with the diagnosis of antisocial personality disorder representing a threshold that is fundamentally arbitrary, rather than a nosologically discrete entity. Consistent with an apparent lower prevalence than antisocial personality disorder, it may be that the "psychopath" may anchor the more severe end of this spectrum, with cases of socalled "adult antisocial behavior" representing a milder and, by definition, subdiagnostic version of antisocial personality disorder that imperceptibly blends into individuals who are not affected on the other, milder extreme. Because the latter group has milder illness, it is assumed to be more amenable to treatment and would, tend to have a better outcome.

It is generally believed that individuals with antisocial personality disorder tend to "burn out" over time. Long-term follow-up studies are few, but are consistent with the observation that criminal behavior tends to decrease with age, suggesting that there is at least a decrease in such behavior over time.911 This burnout factor is significant to correctional psychiatrists as they assess the risk for dangerousness or make recommendations for parole.

ETIOLOGY

The biological heritability of liability factors for antisocial personality disorder is well established, based on family, twin, and adoption studies.12 Another line of evidence suggesting that biological factors may convey vulnerability to antisocial personality disorder comes from studies of electrodermal responses, resting heart rate, and electroencephalogram findings of cortical underarousal.13,14 Perhaps related to these findings, antisocial personality disorder has been associated with impairment in a variety of neuropsychological tasks, especially those that require passive avoidance or inhibition of previously punished behavior.15'16 Because many adults with antisocial personality disorder have a history of attention deficit hyperactivity disorder,17 the possibility of some success using somatic therapies exists as more is learned about the neurobiology of antisocial personality disorder.

CONSIDERATIONS IN THE TREATMENT OF THE INDIVIDUAL WITH ANTISOCIAL PERSONALITY DISORDER

The treatment of antisocial personality is typically complicated by comorbid conditions, which may be successfully treated even if underlying personality disorder cannot be. is mounting evidence that this is the case for substance abuse. Good outcomes may be seen with the treatment of alcoholism and other drug dependency among individuals with antisocial ity disorder, particularly if cognitive-behavioral techniques are employed.18-19

Given the base rate of drug abuse among viduals with antisocial personality disorder, presence of depression alone in this appears to be relatively uncommon. Rather, viduals are likely to present with lifetime noses of antisocial personality disorder, one several substance abuse diagnoses, and toms of depression. Thus, treatment of sion in this group has apparently not intensely studied, although there is reason believe that…

Prominent features of antisocial personality disorder involve a pattern of violating the rights of others, often manifested by lack of conformity to social norms, deceitfulness, impulsivity, irritability and aggressiveness, recklessness, irresponsibility, lack of remorse, and the presence of conduct disorder before the age of 15 years. Many conditions, however, may be associated with such "antisocial" behavior; indeed, the high prevalence of severe mental illness in correctional settings has been repeatedly demonstrated.1 The occurrence of antisocial behavior should not be exclusively during the course of a schizophrenic or a manic episode.

It has been estimated, with the use of DSM-IIIR criteria, that 5.8% of men and 1.2% of women will merit the diagnosis of antisocial personality disorder during their lifetimes, with approximately half reporting ongoing antisocial behavior in the year prior to interview.23 Antisocial personality disorder is associated with high rates of lifetime use of psychoactive agents, including opiates, central nervous system stimulants, and solvents, as well as with an elevated lifetime likelihood of injection drug use.4"8

Antisocial behavior may best be conceptualized as representing a continuum of severity, with the diagnosis of antisocial personality disorder representing a threshold that is fundamentally arbitrary, rather than a nosologically discrete entity. Consistent with an apparent lower prevalence than antisocial personality disorder, it may be that the "psychopath" may anchor the more severe end of this spectrum, with cases of socalled "adult antisocial behavior" representing a milder and, by definition, subdiagnostic version of antisocial personality disorder that imperceptibly blends into individuals who are not affected on the other, milder extreme. Because the latter group has milder illness, it is assumed to be more amenable to treatment and would, tend to have a better outcome.

It is generally believed that individuals with antisocial personality disorder tend to "burn out" over time. Long-term follow-up studies are few, but are consistent with the observation that criminal behavior tends to decrease with age, suggesting that there is at least a decrease in such behavior over time.911 This burnout factor is significant to correctional psychiatrists as they assess the risk for dangerousness or make recommendations for parole.

ETIOLOGY

The biological heritability of liability factors for antisocial personality disorder is well established, based on family, twin, and adoption studies.12 Another line of evidence suggesting that biological factors may convey vulnerability to antisocial personality disorder comes from studies of electrodermal responses, resting heart rate, and electroencephalogram findings of cortical underarousal.13,14 Perhaps related to these findings, antisocial personality disorder has been associated with impairment in a variety of neuropsychological tasks, especially those that require passive avoidance or inhibition of previously punished behavior.15'16 Because many adults with antisocial personality disorder have a history of attention deficit hyperactivity disorder,17 the possibility of some success using somatic therapies exists as more is learned about the neurobiology of antisocial personality disorder.

CONSIDERATIONS IN THE TREATMENT OF THE INDIVIDUAL WITH ANTISOCIAL PERSONALITY DISORDER

The treatment of antisocial personality is typically complicated by comorbid conditions, which may be successfully treated even if underlying personality disorder cannot be. is mounting evidence that this is the case for substance abuse. Good outcomes may be seen with the treatment of alcoholism and other drug dependency among individuals with antisocial ity disorder, particularly if cognitive-behavioral techniques are employed.18-19

Given the base rate of drug abuse among viduals with antisocial personality disorder, presence of depression alone in this appears to be relatively uncommon. Rather, viduals are likely to present with lifetime noses of antisocial personality disorder, one several substance abuse diagnoses, and toms of depression. Thus, treatment of sion in this group has apparently not intensely studied, although there is reason believe that a subgroup of such individuals benefit from vigorous treatment of depression.20

In terms of achieving lasting change in the sonality of the individual with antisocial ality disorder, it should be kept in mind that ment of personality disorders in general is all-or-none; substantial amelioration of toms short of full remission is often an or desirable outcome. Given the nature of condition of the individual with antisocial sonality disorder, it is to be expected that examples of dishonesty and manipulative behavior will arise during treatment, and that the individual will at some point attempt to invoke his or her status as a patient as a way of evading responsibility for his or her actions.

As opposed to the case for treatment of substance dependence, there is little information to suggest that any form of treatment, either psychotherapeutic or psychopharmacologic, is particularly effective in bringing about long-term change in antisocial attitudes and behaviors. Psychodynamic approaches appear, in general, not to be of much help, perhaps because the minimal level of anxiety seen in individuals with antisocial personality disorder lowers their motivation for therapeutic change. The egocentricity associated with antisocial personality disorder is another barrier, and there is evidence that impaired capacity to establish a therapeutic relationship is a negative prognostic indicator.21 Group modalities and therapeutic communities have been reported as having some success, but they have not been subjected to carefully designed, large-scale studies.22'23

However, one exception to this general rule should be mentioned. Behavior modification approaches can work well, at least in settings where significant control over the milieu can be exerted (ie, inpatient settings).

A GENERAL APPROACH TO TREATMENT

Assessment

A thorough psychiatric assessment is particularly important for patients with antisocial personality disorder to both determine the severity of the personality disorder and ascertain comorbid, potentially treatable syndromes. Because the disorder first manifests in adolescence, a detailed accounting of the patient's childhood and adolescent behavioral patterns is essential, including a history of symptoms of attention deficit hyperactivity disorder. As for any other patient, family history and medical history must be probed. Given the association of antisocial personality disorder with psychoactive substance use disorders, careful attention should be paid to the possibility of hepatitis, human immunodeficiency virus, or other blood-borne illnesses, as well as sequelae of an often violent lifestyle. In addition to prior and current symptoms of alcohol and other substance abuse, criminal behavior, legal history, and indications of major mental illness should all be systematically elicited.

Because the patient is likely to have pervasive and ongoing difficulties in interpersonal relationships and employment, a particularly careful inquiry into his or her work history and marital or other romantic relationships should be made. Likewise, considering the strong association between antisocial personality disorder and domestic violence,24-25 careful inquiry should be made about function as a parent and the risk to children, a domestic partner, or both. When possible, such information should be corroborated by family members and also by reviewing police reports, previous medical records, and military service records. This is of particular importance in forensic settings where there may be a greater motivation to mislead the assessing clinician. Contrary to popular belief, if a careful interview is performed, individuals with antisocial personality disorder who do not have a clear incentive to dissimulate are generally consistent in their self-report of antisocial symptoms.26

An examination of mental status should ascertain the level of reactive anxiety, remorse potential, empathie capacity, and the ability to form attachments. Impulse control mechanisms and risk for violence should be assessed.

Treatment Planning

Treatment is determined by the patient's presentation and the nature of the setting. In general clinical settings, motivation for treatment typically is transient, vanishing with the resolution of the psychosocial stressor that initially prompted presentation. One significant exception to this is substance abuse treatment. Objectives of treatment are to address any significant medical illnesses, stabilize the patient's home and job situations, and treat comorbid psychiatric conditions, particularly psychoactive substance use disorders.

It is generally wise to explicitly discuss with the patient what the treating clinician is and is not willing to tolerate in the treatment setting. It is particularly important for the patient to understand that treatment cannot be used as an excuse for continuing antisocial behavior and that the clinician will not shield the patient from the consequences of his or her behavior. Indeed, particularly in inpatient settings, consideration should be given to pressing charges (eg, for assault), should the occasion arise. However, this should be part of a treatment plan proactively designed to place limits on the patient's antisocial behavior and with the patient made aware of this consequence beforehand, rather than it being a punitive institutional response to a specific incident.

Psychotropic medications may be of benefit, but, as previously noted, there is little to guide the clinician. Thus, it seems wise as a general rule to restrict prescriptions to specific indications, with careful monitoring of target symptoms. Drugs with significant abuse potential should be avoided unless clearly indicated and, ideally, with independent corroboration of symptoms. Quantities should be carefully monitored and the clinician should be alert to the possibility of the patient's obtaining additional prescriptions from other sources.

Studies of the efficacy of atypical antipsychotics in the treatment of antisocial personality disorder are lacking. Overall, the rationale for prescription should be carefully thought out and specific target behaviors observed over time to determine whether treatment has in fact been of benefit. As mentioned earlier, psychotherapy has not been shown in rigorous studies to be of significant benefit in changing an antisocial personality style. However, this is true of many conditions, and the current lack of evidence is not the same as proof of a lack of efficacy, particularly if goals are modest. The use of newer types of psychotherapy such as dialectical behavioral therapy for certain patients with antisocial personality disorder may be beneficial based on the clinical experience of the authors. However, further studies to corroborate this finding need to be conducted.27

Clinical experience suggests a psychotherapeutic approach emphasizing confrontation. In a short-term treatment setting where the goal is to stabilize the patient and minimize the likelihood of violent behavior, confrontations should be succinct and direct. Although there is no evidence supporting the long-term efficacy of informing patients about the likelihood of pressing legal charges, most forensic psychiatrists will recognize its short-term value.

In a longer-term setting, the clinician can set longer-term goals and work toward significant behavioral change. The first step in such an undertaking is the establishment of a therapeutic alliance, which requires mutual respect, and a realization on the part of the patient that the clinician sees through his or her "con." Confrontation remains the preferred intervention, but is accomplished in a nonthreatening and even appreciative manner, conveying respect for the effort and even the intelligence the patient has devoted to the con.

Once this has been established, two further tasks remain. Attention should be paid to the countertransference feelings of the clinician and the unit staff, because significant deviations from optimal treatment can result from unacknowledged feelings of intimidation, anger, resentment, or even attraction to the patient. These must be dealt with appropriately.

Conversely, the patient's feelings toward the clinician may be benign, because he or she is one of the few individuals in the patient's life whom the patient has respected, in large part because of the clinician's ability to see through the patient's con and call him or her on it. Thus, the clinician may well be the recipient of all of the goodwill that the individual with antisocial personality disorder is capable of mustering.

The second task facing the clinician is to have the patient's desired outcome for therapy coincide with that of the clinician. This often requires the clinician to rethink and scale back the therapeutic goals. We suggest that a reasonable goal for a patient with antisocial personality disorder is to spend as little time in jail or in a forensic hospital as possible, for the rest oí his or her life. This may seem a modest goal to a clinician, but is a consummation devoutly to be wished by any thinking individual with antisocial personality disorder. The difficulty, of course, is that the patient with antisocial personality disorder typically has previously functioned only in respect to short-term goals, and the patient has to appreciate that the clinician's goal is in his or her best interest. Immediate gratification can then begin to give way to longer-term goals.

Specialized Situations

Inpatient Forensic Settings. In inpatient forensic settings, most individuals with antisocial personality disorder are admitted as unfit to stand trial, rather than following an insanity acquittal. Under such circumstances, there is obviously great motivation to appear profoundly ill so as to be found unfit. Thus, in addition to the comorbidity noted earlier, there is the concern that, to a degree much greater than in general clinical situations, the patient is exaggerating or outright malingering his or her complaints. If so, evidence should be carefully collected and the patient confronted with the treatment team's conclusion and proposed response, such as informing him or her that this conclusion will be included in the fitness report to the court.

On the other hand, it should also be kept in mind that such a setting affords a greater degree of control, as well as the possibility of enlisting the legal system as another avenue of establishing motivation for significant behavioral change. If it can be established that the desired behavioral changes are in the patient's self-interest - and that sufficient protection against "gaming" the system on the part of the patient is put into place - significant behavioral change can in fact occur. Of course, once the contingencies are altered, by release or change in legal status, it would be unlikely for the changed behaviors to be maintained.

General Psychiatric Settings. General psychiatrists frequently encounter patients with antisocial personality disorder who present in hospital settings. In the emergency department of a general hospital, these patients are usually seen due to problems related to alcohol or other drug abuse, such as intoxication or withdrawal. They are also seen as a result of trauma, burns, or motor vehicle accidents, or in relation to interpersonal fights or gang involvement. The consultation-liaison psychiatrist may identify similar patients on trauma floors or in substance abuse treatment programs. While in inpatient psychiatric settings, patients with antisocial personality disorder are admitted due to a coexisting Axis I diagnosis.

The general psychiatrist should consider a consultation with a forensic psychiatrist if the patient is on a conditional release from a forensic facility in relation to a "not guilty by reason of insanity" adjudication, or when further assessments of risk factors for violence or arson are deemed necessary. An Ongoing collaboration between the general psychiatrist and the forensic psychiatrist will ensure that both general psychiatric issues and forensic concerns are safely addressed.

Correctional Facilities. In correctional settings, similar considerations would apply. The motivation for malingering might be different (eg, to spend time in the medical ward rather than in the cell block). The clinician should be aware of this, consider the likely reasons to malinger illness, mental or physical, and be prepared to go beyond relying on the patient's word to substantiate complaints.

In addition, there is the possibility of the patient's entering therapy not to effect fundamental change, but to be able to make a better case in the event of a parole hearing. However, even in such cases, individuals might, at least to some degree, be engaged in the treatment process; conversely, the appearance of even sincere engagement and therapeutic progress may not effect ongoing change after release from the correctional setting.

Outpatient Treatment Programs. Similar considerations apply in the case of outpatient treatment, with the caveat that there is generally less information for the clinician to use, and much less ability to change the environment to effect behavioral change. Once again, a willingness to use all sources of information and to confront the patient with evidence of his or her deceitfulness is vital. In addition, the clinician generally has other resources to assist in adherence to the treatment regimen (eg, parole officers) or conditional release from a forensic hospital with consequent readmission if conditions are violated.

Psychosocial Rehabilitation. Treatment plans for patients with antisocial personality disorder should be based on a thorough evaluation of the predisposing and precipitating biopsychosocial factors that played a role in the psychiatric presentation. The interplay between the Axis I and the Axis ? diagnoses should be considered. Issues of identified "strengths" of the patient should be used in guiding the choice of psychosocial interventions. Educational programs and high school equivalency programs will have a positive impact on the patient's self-esteem, and may motivate him or her to pursue a vocational rehabilitation course, especially later in his or her hospitalization.

Special cultural issues and value systems may be used to enhance the patient's motivation in treatment and involvement in after-care plans. Examples of these issues include how a given culture tends to resolve conflicts and use nonverbal communication. Gender role and "manliness" are often culturally defined issues. If ignored, they will prove to be a stumbling block in treatment. Psychiatrists should make more use of consulting vocational and other rehabilitation centers.

CONCLUSION

There is an impression among psychiatrists that no fundamental change is possible in treating individuals with antisocial personality disorder. However, in certain settings where extensive control is exerted, positive changes in behavior may be seen. Unfortunately, some of these positive changes are unlikely to carry over after discharge.28 The goals of treatment must, of necessity, be modest and include amelioration of comorbid conditions such as substance abuse and lessening of antisocial behavior.

Nonetheless, such treatment may greatly benefit the patient, the patient's family, and society, and the value of such interventions should not be lightly dismissed. Such efforts can be greatly aided by collaboration with other agencies charged with the care of such individuals, particularly those within the legal system. Consistently faced with the unpleasant consequences of their behavior, such as return to prison or a forensic hospital, and aware that prior coping skills, such as talking or "conning" their way out of trouble, are no longer effective, individuals with antisocial personality disorder may be able to substantially change their behavior, if not their underlying attitudes. Whereas unguarded optimism is a notorious pitfall for the clinician charged with the care of a patient with antisocial personality disorder, therapeutic nihilism is likewise not justifiable.

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10.3928/0048-5713-20010701-08

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