Ever wondered what goes on in the mind of someone with antisocial personality disorder Join us, Linton and Stacy, as we untangle the web of behaviors and traits that mark this complex condition. In our latest installment of the demystifying disorder series, we lay bare the DSM-5-TR diagnostic criteria for APD, highlighting the fine line between it and other personality disorders like narcissism and borderline personality disorder. We're not just talking theory; our conversation brings in vivid anecdotes and cultural examples that illuminate the everyday implications of APD and its portrayal in media.
Our journey into the world of APD doesn't stop at diagnosis; it's about understanding the person behind the behaviors and navigating the treacherous waters of treatment. We stress the crucial role of therapy boundaries, the setting of realistic goals, and the instances when it's necessary to involve authorities to ensure safety. Threaded throughout our discussion are the nuances of early signs, the significance of comprehensive history, and the challenges therapists face in the treatment room. Get ready for an eye-opening episode that promises to enrich your understanding of APD and the delicate art of managing it.
If you need to study for your national licensing exam, try the free samplers at: LicensureExams
This podcast is not associated with the NBCC, AMFTRB, ASW, ANCC, NASP, NAADAC, CCMC, NCPG, CRCC, or any state or governmental agency responsible for licensure.
Ever wondered what goes on in the mind of someone with antisocial personality disorder Join us, Linton and Stacy, as we untangle the web of behaviors and traits that mark this complex condition. In our latest installment of the demystifying disorder series, we lay bare the DSM-5-TR diagnostic criteria for APD, highlighting the fine line between it and other personality disorders like narcissism and borderline personality disorder. We're not just talking theory; our conversation brings in vivid anecdotes and cultural examples that illuminate the everyday implications of APD and its portrayal in media.
Our journey into the world of APD doesn't stop at diagnosis; it's about understanding the person behind the behaviors and navigating the treacherous waters of treatment. We stress the crucial role of therapy boundaries, the setting of realistic goals, and the instances when it's necessary to involve authorities to ensure safety. Threaded throughout our discussion are the nuances of early signs, the significance of comprehensive history, and the challenges therapists face in the treatment room. Get ready for an eye-opening episode that promises to enrich your understanding of APD and the delicate art of managing it.
If you need to study for your national licensing exam, try the free samplers at: LicensureExams
This podcast is not associated with the NBCC, AMFTRB, ASW, ANCC, NASP, NAADAC, CCMC, NCPG, CRCC, or any state or governmental agency responsible for licensure.
Linton:
Hello all you therapists out there and welcome to our podcast here at Licensury Exans. I'm Linton.
Stacy:
And I'm Stacey. Today, as part of our demystifying disorder series, we'll be taking a close look at antisocial personality disorder. The DSM-5TR diagnostic criteria used to make this diagnosis, how you can distinguish it from other disorders with similar features, like narcissistic personality disorder and borderline personality disorder, and treatment planning.
Linton:
Let's start off by reviewing the criteria for antisocial personality disorder. First of all, you'll be looking for a persistent and persuasive pattern of disregard for and violation of the rights of others that's been present since the age of 15.
Stacy:
Right, and that pattern manifests in a variety of ways. The person has to exhibit three or more of the following A failure to obey laws and norms by engaging in behavior like deceitfulness, impulsivity, aggressiveness, recklessness and irresponsibility. A lack of empathy, remorse or guilt. Impulsivity and failure to plan ahead. Irritability and aggressiveness To disregard for safety of self or others. Consistent irresponsible behavior in repeatedly failing to maintain employment or fulfill financial duties. And the last one is a lack of remorse for hurting, mistreating or stealing from others. So, linton, as I'm saying all of these things out loud, I'm thinking didn't you tell me once that your parents kept you in a straight jacket to keep you in bed and on a leash when they took you anywhere when you were a kid?
Linton:
Well, yeah, they did, but it wasn't because I lacked an empathy or exhibited aggressiveness.
Stacy:
What about the impulsivity and disregard for safety of self criteria?
Linton:
Well, okay, maybe I did exhibit those patterns, but that's only two out of the three. You need to be diagnosed with APD and, don't forget, my mom was a nurse, so restraining was what she did with overly active patients all the time.
Stacy:
Oh, overly active patients. That's a good reframe there, but I think if I dig a little deeper I could at least find one more criteria.
Linton:
Okay, okay, look, let's skip back to the issue at hand here. Okay, let's say you've got a case study on the exam where the client was unable to hold a steady job for one reason or the other. Maybe the economy was tough like it has been recently for the whatever line of work they're in, or maybe they had health issues that caused employment disruptions. Does that qualify as criteria states?
Stacy:
No, those are perfectly reasonable situational factors that could understandably cause some job instability. So, with anti social personality disorder, that persistent irresponsible work behavior might manifest as prolonged periods of unemployment even when job opportunities are available, or abandoning multiple jobs without a realistic plan for securing new employment. So financial irresponsibility could present as behaviors like defaulting on debts, failing to pay child support, not paying back loans or consistently neglecting to financially support dependence.
Linton:
Right. Well, basically, the disorder really centers around violation of social norms and laws, with deliberate deceitfulness, aggressiveness and lack of concern of consequences. That wasn't my situation there, Stacy.
Stacy:
You know I sense a little public story though coming up next Linton.
Linton:
Well, I guess it was sort of like when I was at Publix the other day and some guy picked up a pre-packaged sushi, believe it or not, opened the container, ate part of the sushi roll and stuck it back in the refrigerated display.
Stacy:
Oh no, oh man, I wish somebody got that on camera.
Linton:
Yeah, right Now. That's just rude, and not to mention hygiene issues raises for the next shopper that might have been you.
Stacy:
Yes, exactly, jeez. So when we talk about the pattern of behavior of disregard for and violation of the rights of others, if you've ever seen the movie Hannibal or Gone Girl then you will understand what we're talking about here. But remember Hollywood has a tendency to showcase really extreme examples of disorders. Clients with antisocial personality disorder have a high likelihood of engaging in criminal behavior, but not all of them are of a violent nature, like you typically see in the movies. Clients may maybe have a history of robbery, fraud or something a little less intense like drug dealing.
Linton:
You know, didn't we do a whole thing up about using movies for a way of determining or getting a picture of what diagnoses look like?
Stacy:
We did, as I recall it was on our Pinterest page. We had a board called I think it was called Real to Real Mental Health.
Linton:
Yeah, I think it was called that. And so these two that you mentioned, what were they again?
Stacy:
Yep, hannibal, that's that one about. You know the well antisocial, psychopathic tendencies Guy that was a while back. Gone Girl's a little bit more of a modern. You know it's based off of a book within the past five years or so, I think.
Linton:
Exactly Well. What about the client's age, though? Can you diagnose antisocial personality disorder in like a teenager, for example?
Stacy:
I'm glad you asked so remember this if you run across a personality disorder case on the exam. Antisocial personality disorder is the only personality disorder with a specific age limitation. The only one, so the client has to be at least 18 years old. If they're younger, you can't diagnose them with antisocial, but you could consider a diagnosis of conduct disorder.
Linton:
Mm-hmm, okay, I got it. Well, how about this? Can a client be diagnosed with more than one personality disorder at the same time?
Stacy:
Yes, comorbid diagnoses are possible with antisocial personality. For example, your client could potentially meet criteria for both antisocial personality and narcissistic personality disorder. But as a therapist you really need to take care not to overdiagnose. Some symptoms inherent in antisocial personality disorder, like the lack of empathy, insincerity and manipulative behavior, could appear narcissistic in nature, but the core motivation tends to be really different between those. So people with antisocial personality engage in behaviors to serve their own interests, often without the concern for consequences. Narcissism, on the other hand, really stems from underlying feelings of inferiority, an extreme need for validation and admiration.
Linton:
What about your favorite kind of client Stacy? What about borderline personality disorder? It shares some of the same common features with antisocial, like manipulative behavior.
Stacy:
Just like with narcissistic personality disorder, a big difference between borderline and antisocial is the motivation behind the behavior. The manipulative tactics that are common with borderline are often motivated by an intense fear of abandonment and a desire to maintain relationships. Someone with borderline personality disorder may make desperate attempts to keep people close by using threatening, suicide or self-harming behavior.
Linton:
Right, I've seen that.
Stacy:
And, in contrast, manipulation in antisocial personality disorder serves more self-centered goals. So it's really to help them get what they want, whether that's money, power, something like that. Without the regard for others, manipulation in relationships is really a means to an end, rather than stemming from attachment fears or emotional dependency issues.
Linton:
Okay, now that you've painted a really good picture of antisocial personality disorder, let's talk about how someone with that kind of disorder ends up in your office Stacy.
Stacy:
Yeah, good point. It doesn't really seem like someone with antisocial would be inclined to seek therapy on their own, does it?
Linton:
No, uh-uh. Usually there's some kind of external motivator compelling them into therapy. Often they've got into legal trouble and therapy is mandated as part of a probation or parole program. A judge may order therapy sessions to avoid jail time or and a family member, like a spouse, may threaten to leave or cut off financial support unless the person with antisocial personality disorder gets some counseling. Additionally, some end up in therapy with comorbid issues like depression or substance abuse. When it finally gets the upper hand. The depression or hitting rock bottom with substance use leads them to therapy.
Stacy:
I see, so they don't usually choose to be there voluntarily.
Linton:
Nope.
Stacy:
Well, what tends to happen when someone with antisocial actually engages in therapy? How does their disorder manifest itself in sessions? Linton?
Linton:
Okay. Having a client with antisocial personality disorder in therapy sessions introduces really some challenges, and you'll wish you had paid more attention in Dr Seward's class at Syracuse University for sure For one. They often try the manipulator charm the therapist to get what they want. They may lie, minimize their behavior or attempt to elicit sympathy. It's important that you, as a therapist, identify this and call it out. Additionally, they lack self-awareness of their issues and show little remorse or concern of how their actions will impact others. They may be argumentative and may try blaming external factors for all their problems. Trying to foster insight and accountability trying to foster insight and accountability tends to prove quite difficult. They also tend to grow bored or impatient with the therapy process. The inward focus on changing their destructive patterns just doesn't appeal at all. It's the last thing they really want to do. They may reject goals, homework assignments or suggestions, Seeing them as useless or just plain annoying.
Stacy:
So dealing with the manipulation, resistance and apathy does sound really challenging. So what are some strategies that you could use as a therapist that could actually help move therapy forward by the client who's like this?
Linton:
Okay, for starters, having realistic therapy goals is critical when working with anti-social personality disorder, since developing empathy, remorse and self-awareness can be extremely challenging. Practical behavioral goals tend to work the best, rather than aiming to fundamentally change the personality goals target reducing destructive acts, improving relationships or avoiding legal consequences is what you want to be aiming towards.
Stacy:
Right. So it's much more productive to focus goals around practical issues like developing job skills, maybe achieving financial independence or, like you said, linton, avoiding those legal issues.
Linton:
Right, exactly those are the kind of goals that connect with what really matters to them the most.
Stacy:
Okay, so now a big question here. What about safety concerns? So you've got someone in your office who doesn't follow the rules or care about consequences. How do you deal with that?
Linton:
Well. So essentially, you need to establish firm boundaries and direct communications, which are keys with working with anti-social personality disorders. Be very clear about office policies, payments, scheduling and confidentiality right up front. Define what behaviors won't be tolerated, like intimidation or threats. Should safety issues arrive, involve authorities when needed and, since manipulation is common, be alert to lies about attending programs and taking medication. You always really have to verify claims with outside sources when possible. Be prepared for charm offenses and attempt to push your buttons. Don't get hooked in and always have a clear pathway to the exit in your office.
Stacy:
Very good advice. Also, given the high risk nature of this disorder, having a support system is essential. As a therapist, consult with colleagues after challenging sessions and seek peer input on strategies and engage in self-care to manage the stress when working with this population. Address counter-transference proactively, because clients with anti-social personality disorder are master manipulators. They may try to turn things around in sessions to make you feel guilty, incompetent or even threatened. So it's really important that you don't fall into their trap by defending your skills. Instead, reassert session goals and boundaries. With diligence and the right strategies, tailored to what motivates them, you can reduce harmful behaviors and foster that sense of responsibility.
Linton:
Okay. So if you do have a client with anti-social, what assessment tools might even appear on an exam that you should be aware of? Stacey?
Stacy:
All right, the Hair Psychopathy Checklist revised. This is a diagnostic tool used to assess psychopathic traits and tendencies that are often associated with the antisocial personality disorder. This assessment is most often used in institutional and correctional facilities, as well as psychiatric hospitals. Then there's the Hair Psychopathy Checklist, the screening version, and this is really a shorter variation of the Hair Psychopathy Checklist that takes about half the time to administer. As a screening tool, this is used to evaluate the possible presence of antisocial tendencies and, if detected, a more complete assessment should follow to determine a diagnosis. Then we have the Milan Clinical Multiaxial Inventory, or the MCMI.
Linton:
Most people are aware of that one.
Stacy:
Yes, yeah, that one's pretty common. So the MCMI is a psychological assessment that includes scales for several personality disorders, including antisocial personality disorder, and it's a self-report that contains true-false questions. Then there's the other ever-popular Minnesota Multiphasic Personality Inventory, or the MMPI, and the MMPI has subscales related to antisocial tendencies in criminal behavior. Elevations on certain scales may indicate the presence of antisocial traits. Then we have the Structured Clinical Interview for DSM Disorders. This is a semi-structured interview used to systematically assess the presence of antisocial personality based on the diagnostic criteria in the DSM. It allows for follow-up questions by the interviewer. And last but not least there are actually several more, but we just kind of chose the more common ones Right, the Antisocial Process Screening Device. This tool screens for antisocial tendencies in youth. To determine a further evaluation for conduct disorder or emerging antisocial personality disorder is warranted.
Linton:
How about the Beck Depression Inventory?
Stacy:
The Beck Depression Inventory? Tell me more.
Linton:
Would you use that with the Antipersonality Disorder?
Stacy:
No, you piqued my curiosity. No dear no, I know there's some kind of trick here, lyndon.
Linton:
Okay, here's a quick recap before we wrap it up. Antisocial personality disorder is characterized by a persistent pattern of disregard, by inviolation of others' rights, evident since age 15, plus at least three symptoms like deceitfulness, aggression, irresponsibility and lack of empathy. So if you have a client that's like 23, how would you know that if violation of other individuals' rights had happened since they were 15?
Stacy:
Well, that's where taking a good history is gonna come into play. So it's important you know any history that you can get. If you have, you know court history. If you have a family history, if you can get some collateral information from you know family or friends that's gonna help clue you in about their past.
Linton:
But what if you don't have that information?
Stacy:
That's a good question. What if you don't have that information? London.
Linton:
Oh, it's back on me now. Yes, yes, it is. Okay moving along it is only. It is only personality disorder, where the client must be at least 18 years old in order to be diagnosed. Let's go with that, okay.
Stacy:
Don't ask questions if you don't know the answer.
Linton:
Thanks a lot it can also it can also coexist with other mental disorders, including Personality disorders like narcissistic or borderline your favorite. But use caution because it's possible to over diagnose. Make sure that you examine all of the client's personality features and the motivation behind the client's behavior. This information can lead you to determine if you're dealing with just one personality disorder or a combination of personality disorders. The client is usually compiled into therapy by external forces like legal system or family members Symptoms who are usually manifest in therapy through manipulation, lying, blaming and lack of remorse, or Insight or motivation is lacking. Set realistic, practical goals, as these work better than trying to fundamentally change the personality. It's important to set really firm boundaries. Remember that call out manipulation attempts and involve authorities If there is a safety concern.
Stacy:
And remember that having a support system is helpful to consult and address any Counter-transference issues that are resulting from the stress of working with this population and that's anti-social personality disorder, demystified as you study for your exam, remember it's in there.
