Personality Considerations and Antisocial Behavior: Implications for Treatment

Personality Considerations Personality Considerations Relevant to Antisocial Behavior: Relevant to Antisocial Behavior: Implications for Treatment Implications for Treatment Nancy McWilliams, PhD. ABPP Distinguished Affiliate Faculty, Rutgers University Graduate School of Applied & Professional Psychology Norwegian Association of Forensic Psychologists December 1, 2022

Background of the DSM criteria for Background of the DSM criteria for Personality Disorders Personality Disorders The 1980 revision of the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-III) was oriented toward scientists rather than clinicians. Researchers pressed for present-versus-absent criteria for diagnoses and often had not been trained in clinical inference. The new manual was proudly depicted as neo-Kraepelinian that is, descriptive rather than inferential, and categorical rather than dimensional. Although dimensionality has slowly crept back into DSM diagnosis (e.g., the autistic spectrum, the schizophrenic spectrum), subsequent versions retain its overall descriptive, categorical, non-inferential premises. Because everyone has elements of different personality tendencies, and because designating a personality as disordered is essentially a matter of degree of rigidity, primitivity, or maladaptation, personality disorders are particularly hard to depict by either-or criteria. In fact, they were something of an afterthought in the development of the DSM, whose constructors were more interested in delineating Axis I disorders: conditions such as severe anxiety, depression, eating disorders, and addictions.

Some Specific Problems with the DSM Some Specific Problems with the DSM Diagnosis of Antisocial Personality Disorder Diagnosis of Antisocial Personality Disorder The DSM description of Antisocial Personality Disorder relied heavily on the work of Lee Robins, an academic sociologist who tried to describe criminally inclined individuals in terms of externally observable qualities. An implicit assumption was made equating what had previously been called psychopathy with criminal behavior, and so DSM-III was normed on prison inmates. This decision has had numerous problematic implications for people responsible both for public safety and for efforts to treat people with backgrounds of criminal and socially destructive behavior.

Problems with Conflating Criminality and Problems with Conflating Criminality and Psychopathy Psychopathy Prison inmates cannot all be assumed to be psychopathic. Other sources of criminal behavior include addiction, poverty, socialization to antisocial norms, post-traumatic states, and loyalty to fellow criminals and the conventions of law-breaking subcultures. Because poor people in the United States are more likely to be incarcerated than wealthy people who can afford good legal representation, the DSM overdiagnoses psychopathy in poor, minority, and traumatized populations and underdiagnoses it in individuals of higher socioeconomic status.

Lee, B. (2017). Lee, B. (2017). The dangerous case The dangerous case of Donald Trump: of Donald Trump: 27 psychiatrists and mental health experts assess a president. New York: St. Martin s Press.

And not all psychopathic behavior And not all psychopathic behavior equals personality disorder: Some is equals personality disorder: Some is situational situational Most people will act psychopathically if they are in situations in which authorities seem to be arbitrary, ruthless, capricious, negligent, or abusive, and/or when ordinary norm-respecting behavior is either ignored or punished. For example, a majority of doctors in the United States admit lying to insurance companies on behalf of their patients well-being.

Original DSM Original DSM- -III Criteria III Criteria 1. Inability to sustain consistent work behavior; 2. Inability to function as a responsible parent; 3. Failure to accept social norms; 4. Inability to maintain enduring attachment to a sexual partner; 5. Irritability and aggressiveness; 6. Failure to honor financial obligations; 7. Failure to plan ahead (impulsivity); 8. Disregard for the truth (repeated lying); 9. Recklessness (e.g., speeding, driving drunk).

These externally observable criteria omit all the These externally observable criteria omit all the internal internal elements that had previously defined elements that had previously defined psychopathy, including: psychopathy, including: Profound disorder of attachment (inability to love); Profound absence of a moral compass ( superego lacunae ); Omnipotent control as an organizing defense; Orientation toward power above all else; Treatment of others as objects to manipulate rather than subjects to respect; Self-esteem based on getting over on others; Restricted range of affects, with rage and envy predominating; High threshold for stimulation; Lack of capacity for remorse.

From moral insanity to From moral insanity to psychopathy to sociopathy to psychopathy to sociopathy to antisocial personality disorder antisocial personality disorder Henderson, D. K. (1939). Psychopathic states. New York: Norton. Cleckley, H. (1941). The mask of sanity: An attempt to clarify some issues about the so-called psychopathic personality. St. Louis, MO: Mosby. Meloy, J. R. (1988). The psychopathic mind: Origins, dynamics, and treatment. Northvale, NJ: Jason Aronson. Hare, R. D. (1999). Without conscience: The disturbing world of the psychopaths among us. New York: Guilford.

DSM DSM- -IV addition IV addition In response to extensive complaints from clinicians, who saw the lack of guilt as the core diagnostic feature of psychopathic personality, in the 1994 edition of the DSM, a diagnostic criterion was added: Lack of remorse. To the extent that regret is present in psychopathic individuals, it is regret that they failed to get away with their exploitive or destructive agendas. In fact, many perpetrators express sadistic glee at the damage they have accomplished. This was the first internal DSM criterion for Antisocial Personality Disorder, inferential rather than descriptive in that it represented an assessment of the diagnosed individual s subjective world.

DSM DSM- -5 Criteria 5 Criteria 1. Manipulativeness 2. Callousness 3. Deceitfulness 4. Hostility 5. Risk-taking 6. Impulsivity (actually, this is not distinctively characteristic of psychopathy) 7. Irresponsibility

Implications for Treatment Implications for Treatment Some people with significant psychopathy, especially those with histories of violence, are untreatable. Treatment has a better prognosis the older the patient is and the more the person s psychopathic behaviors have not been rewarded. The therapeutic relationship must be based on respect for power rather than conventional empathy. Therapist must be brutally honest. Therapist must have very clear boundaries and enforce them relentlessly. Therapist must emphasize the cost to the patient of psychopathic behavior.

Malignant Narcissism and Psychopathy Malignant Narcissism and Psychopathy http://img1.wikia.nocookie.net/__cb20120114230704/villains/images/c/ca/Hannibal_Lecter.jpg Kernberg, O. F. (1984). Severe personality disorders: Psychotherapeutic strategies. New Haven, CT: Yale University Press.

Psychodynamic Diagnostic Manual, Second Edition: PDM-2

Levels of Personality Organization Levels of Personality Organization The Psychodynamic Diagnostic Manual attempts to help clinicians to differentiate levels of severity. Implications for treatment can be profound. Empirical research using the PDM-2 has found that clinicians of a range of theoretical orientation find it useful to distinguish between healthy or normal, neurotic-level, borderline-level, and psychotic-level personality organizations. There follows some text from the section on Adolescence. Gordon, R. M. (2009). Reactions to the Psychodynamic Diagnostic Manual (PDM) by psychodynamic, CBT, and other non-psychodynamic psychologists. Issues in Psychoanalytic Psychiatry, 31, 55-62. Gordon, R. M., & Bornstein, R. F. (2017). Construct validity of the Psychodiagnostic Chart: A transdiagnostic measure of personality organization, personality syndromes, mental functioning, and symptomatology. Psychoanalytic Psychology, 34(1), 1-9.

Example: Levels of personality organization PA Axis of PDM-2 Normal Emerging Personality Patterns (Healthy) These adolescents demonstrate a cohesive emerging personality organization in which their biological endowments, including their temperamental vulnerabilities, are managed adaptively within developmentally appropriate relationships with families, peers, and others. In relation to their stage of adolescent development, they have an increasingly organized sense of self comprised of age-appropriate coping skills and of empathic, conscientious ways of dealing with feelings about self and others. Barring unforeseen, unmanageable adversities, such adolescents likely grow into a rich array of healthy characters. Mildly Dysfunctional Emerging Personality Patterns (Neurotic) These adolescents demonstrate a less cohesive emerging personality organization in which their biological endowments, including their temperamental vulnerabilities, are managed less adaptively. Early in life, their primary caregivers may have had trouble helping them manage these constitutional dispositions. Thus, relationships with families, peers, and others are more fraught with problems. Such adolescents do not navigate the various developmental levels, enumerated below, as successfully as those with less problematic endowments and/or more responsive caregivers. However, their sense of self and their sense of reality are pretty solid. As development proceeds, their adaptive mechanisms may be apparent in moderately rigid defensive patterns, and their reactions to adversities may be somewhat dysfunctional.

Levels of personality organization PA Axis of PDM-2 Dysfunctional Emerging Personality Patterns (Borderline) These adolescents demonstrate vulnerabilities in reality testing and sense of self. Such problems may be manifested by maladaptive ways of dealing with feelings about self and others. Their defensive operations may distort reality (e.g., one s own feelings may be perceived in others, rather than in oneself; the intentions of others may be misperceived, etc.). Severely Dysfunctional Emerging Personality Patterns (Psychotic) These adolescents demonstrate significant deficits in their capacity for reality testing and forming a sense of self, manifested by consistently maladaptive ways of dealing with feelings about self and others. Their defensive operations interfere with basic capacities to relate to others and to separate one s own feelings and wishes from those of others.

Implications of thinking dimensionally Implications of thinking dimensionally In every personality type that has inspired a clinical literature, there is a range from healthier to more troubled psychological organization. For example, Kernberg construes self-defeating psychologies as on a spectrum from a mild tendency toward self- deprecation, to repeated submission to domination, to psychotically determined, compulsive self-harm. With respect to narcissism, he depicts a range from normal narcissistic concerns to malignant narcissism to antisocial personality. The research of Carla Sharp and her colleagues supports his positing a general severity dimension that cuts across specific personality disorders. In courts of law, in contrast, a categorical distinction is drawn between the DSM or ICD psychotic disorders and antisocial personality disorder, as there are serious legal consequences to determining whether a person was delusional when committing a crime. But realistically and commonsensically, psychosis and psychopathy are not either-or categories. Serial predators like Charles Manson and Jeffrey Dahmer seem to be both psychopathic and psychotic. Specifically, they fall at the psychotic end of a continuum of individuals who will stop at almost nothing to reassure themselves of their power, a spectrum that includes, at the high- functioning end, highly successful individuals who treat others as objects to manipulate rather than subjects to engage. Sharp, C., Wright, A. G. C., Fowler, J. C., Frueh, B. C., Allen, J. G., Oldham, J., & Clark, L. A. (2015). The structure of personality pathology: Both general ( g ) and specific ( s ) factors? Journal of Abnormal Psychology, 124(2), 387-398. Sharp, C., & Wall, K. (2021). DSM-5 level of personality functioning: Refocusing personality disorder on what it means to be human. Annual Review of Clinical Psychology, 17, 313-337.

A possible remedy for forensic evaluators A possible remedy for forensic evaluators Carl Wernicke s concept of extreme overvalued ideas as explicated by Rahman, Meloy, & Bauer, 2019: Individuals with extreme overvalued beliefs often carry out abhorrent and inexplicable acts of violence. They hold odd and bizarre beliefs that are shared by others in their culture or subculture. This creates a dilemma for the forensic psychiatrist because the definition of delusion may not be adequate. We discuss the evolution of the term overvalued idea first described in a forensic context by neuropsychiatrist Carl Wernicke in 1892. The overvalued idea is invoked in British scholarship as a definition for beliefs seen in anorexia nervosa, morbid jealousy, paranoid litigious states, and other disorders. This is sometimes referred to as delusional disorder by psychiatrists in the United States. The concept of an extreme overvalued belief has recently been validated and is separate from an obsession or delusion. It plays an important role in identifying fixation as a warning sign in threat assessment. We use this definition in three well-known cases (i.e., Anders Breivik, John Hinckley, Jr., and Ted Kaczynski) to emphasize how form and content of beliefs are critical to understanding the mens rea in violent criminal acts. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, would be enhanced by the addition of extreme overvalued belief as a definition to differentiate it from idiosyncratic, fixed, false beliefs seen in delusion. J Am Acad Psychiatry Law 47(2) online, 2019. DOI:10.29158/JAAPL.003847-19 See also: Meloy, J. R., & Rahman, T. (2020). Cognitive-affective drivers of fixation in threat assessment. Behavioral Sciences & the Law, 39(2), 170-189.

Relevant Classic Literature on Relevant Classic Literature on Personality and Criminality Personality and Criminality Bursten, B. (1973). The manipulator: A psychoanalytic view. New Haven, CT: Yale University Press. Kernberg, O. (1984). Severe personality disorders: Psychotherapeutic strategies. New Haven, CT: Yale University Press. Meloy, J. R. (1988). The psychopathic mind: Origins, dynamics, and treatment. Northvale, NJ: Jason Aronson. Meloy, J. R. (1992). Violent attachments. Northvale, NJ: Jason Aronson. Meloy, J. R. (2001). The mark of Cain: Psychoanalytic insight and the psychopath. Psychiatric Annals, 27, 630-633. Babiak, P., & Hare, R. D. (2007). Snakes in suits: When psychopaths go to work. New York: Harper Paperback. Stone, M. (2009). The anatomy of evil. New York: Prometheus Books. Clarkin, J., Fonagy, P., & Gabbard, G. (2010). Psychodynamic psychotherapy for personality disorders. Washington, DC: American Psychiatric Association.

Treatment implications for individuals in the healthy Treatment implications for individuals in the healthy through neurotic ranges of personality structure through neurotic ranges of personality structure A positive therapeutic alliance can usually be established relatively easily. The patient will tend to appreciate that the therapist is trying to help, even when the content of a communication is painful. The patient will typically try to cooperate with the treatment plan and may be interested in looking at the part of the self that wants not to cooperate, whether the technique of treatment involves free association, dream interpretation, empathic reflection, emotional re-experiencing, cognitive reframing, exposure, homework, or other modes of collaborative work. Regressive and emotionally intense ways of working therapeutically may be useful because of the client s capacity to re-equilibrate afterward. The therapist can expect relatively mild countertransference reactions. The patient will generally not need explicit directives, limits, and contracts. Ruptures of the therapeutic alliance will usually be readily repaired. McWilliams, N. (2011). Psychoanalytic diagnosis: Understanding personality structure in the clinical process, 2nd ed. New York: Guilford.

Treatment implications for the borderline level Treatment implications for the borderline level The therapeutic relationship may be hard to establish and may feel fragile. Explicit boundaries, limits, and contracts may be necessary. Therapists should avoid using regressive techniques, at least early in treatment. Emphasis should be on the here and now. The therapist should expect to experience intense countertransferences. In the therapy process, binary dilemmas will recurrently appear. Ruptures of the alliance may happen abruptly and take a long time to repair. The therapist needs to be somewhat emotionally expressive. Consultation and supervision may be critical to the success of the therapy. Caligor, E., Kernberg, O. F., Clarkin, J. F., and Yeomans, F. (2018). Psychodynamic therapy for personality pathology: Treating self and interpersonal functioning. Washington, DC: American Psychiatric Association. Liotti, G., Cortina, M., & Farina, B. (2008). Attachment theory and multiple integrated treatments of borderline patients. Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry, 36, 295-315. Bateman, A., & Fonagy, P. (2016). Mentalization based treatment for personality disorders: A practical guide. London: Oxford. Meares, R. (2012). Borderline personality disorder and the conversational model. New York: Norton. Mucci, C. (2018). Borderline bodies: Affect regulation therapy for personality disorders. New York: Norton. Gregory, R. J., & Remen, A. L. (2008). A manual-based psychodynamic therapy for treatment-resistant borderline personality disorder. Psychotherapy: Theory, Research, Practice, Training, 45, 15-27. Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford. Young, J. E., Klosko, J. S., & Weishaar, M. E. (2006). Schema therapy: A practitioner s guide. New York: Guilford.

Treatment implications for the psychotic level Treatment implications for the psychotic level Therapy requires a tone that is both realistically authoritative and deeply egalitarian. Issues of safety are paramount in making a therapeutic alliance; the patient s level of terror of annihilation needs to be appreciated. Therapists need to avoid the patient s profound vulnerability to humiliation. Normalizing is usually important for patients with psychotic tendencies. Education is often necessary for patients dealing with psychotic confusions. Therapists of patients with psychotic tendencies need to be especially appreciative of health- seeking aspects of their symptoms. Therapy should be conversational and active. Arieti, S. (1974). Interpretation of schizophrenia (2nd ed.). New York: Basic Books. Atwood, G. E. (2011). The abyss of madness. New York: Routledge. Cosgro, M., & Widener, A. (Eds.) (2018). The widening scope of psychoanalysis: Collected essays of Bertram Karon. Queens, NY: International Psychoanalytic Books. Garrett, M. (2019). Psychotherapy for psychosis: Integrating cognitive-behavioral and psychodynamic treatment. New York: Guilford. Marcus, E. R. (2017). Psychosis and near psychosis: Ego functions, symbol structure, treatment (3rd ed.). New York: Routledge. Werman, D. S. (2015). The practice of supportive psychotherapy. New York: Routledge.

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