Antisocial Personality Disorder: A Practitioner's Guide to Comparative Treatments

Rotgers and Maniacci present experts in the field of various models of treatment, among them Adlerian, biosocial-learning, motivational interviewing, Rogerian and psychopharmacological, to identify treatment goals, select assessment tools, conceptualize progression, pinpoint pitfalls, develop techniques, and move toward a successful therapeutic completion. By providing a brief overview of APD, discussing the ongoing controversies regarding the construct of APD, and assessing the responses to the same set of questions posed to each expert, the authors offers a glimpse into the difficult world of antisocial personality disorder.


Short presentation of the case
A 46-year-old patient with a psychiatric background comes with the ambulance to the emergency room; the ambulance was requested by the patient, for delusional ideas of transparency of thought and insertion of the follow-up thoughts with auditory, commentary hallucinations and insulting psychotic anxiety; conscience of the disease is absent.The symptomatology started suddenly a few days ago, according to the patient's statements.The patient accepts the hospitalization and signs the informed consent: "I was talking in my mind, someone was answering me, he heard me" "It is possible that I had a microchip in my head when I had lipoma surgery."Regarding his collateral hereditary antecedents, we noticed that his father had a stroke.From physiological, pathological personal history: behavioral disorders in childhood; early school dropout; deficiencies in knowledge acquisition; cranial brain trauma at age 40 with loss of consciousness.He has been under surgery 3 weeks ago on the parieto-frontal-excision level.
In what concerns his living and working conditions: he is legally employed at a service company, following a few periods of abandonment of the job or its absence.He lives alone.He is unmarried, without children.He studied 10 classes + professional school + qualification courses as security guard, then he has been a waiter.
Regarding his additive behaviors, he claims a chronic ethanol consumption 2-3 doses of 330ml / day.Background medication administered before hospitalization: Non-compliant to treatment: "For one year I do not take treatment."

History of the disease
2019 -The 46-year-old patient with a psychiatric history comes to the hospital by himself for delirious symptomatology amidst a therapeutic negligence and potentiated by ethanol consumption.
History in the clinic where he is currently admitted: He physically assaulted a nurse in a previous hospitalization, claiming that he confused the person.
Criminal record: He served 1.8 years in a prison for theft and outrage against moral behavior: "They gave me something to drink while I was in the bathroom."The facts took place between 1997-2005.14 criminal files opened for physical violence "I was not guilty."2018 -The patient, aged 45, known with multiple hospitalizations in psychiatry for a behavioral pathology suggesting a behavioral disorder, with indices since adolescence in this respect, difficult schooling and conflicts with the law, is currently returning to the ward.the guard due to a pathology of mental and behavioral disorders due to alcohol consumption, at present the profile of an organic personality disorder is highlighted.Specialized treatment is established under which the evolution is favorable.It is externally improved.
Earlier in 2018-Patient with a psychiatric history, relatively recently discharged from the psychiatric service, is brought to the police and ambulance ward in acute ethanol poisoning for a behavioral syndrome with physical and verbal heteroaggressivity, irritability, low frustration tolerance, impulsivity.After remission of ethanol intoxication, the patient is quietly psychomotor, compliant to treatment, and cooperative.Later he begins to sketch a delusional idea of persecution with modified psychotic behavior and possible elements of auditory, neurosensory productivity.
In the summer of 2018 -The patient, aged 45, known with multiple hospitalizations in Psychiatry for a behavioral pathology suggesting a behavior disorder (indices since adolescence in this respect, difficult schooling, conflicts with the law), is currently returning to the emergency room due to a mental disorder and behavioral disorder due to alcohol consumption.Specialized treatment is established under which the evolution is favorable.
In Spring of 2018, second hospitalization -patient known as an abusive consumer of alcohol, diagnosed with Mixed Personality Disorder, discharged from the psychiatric clinic on 17.07.2017from a Drug Addicts Clinic, returns to the hospital brought by the ambulance and the police for a behavioral syndrome, accompanying of destruction and threats to the block neighbors and the police after acute ethanol consumption.An alcohol proof and anxiolytic treatment are established.It is outsourced upon request, contrary to the medical opinion.
In Spring of 2018, first hospitalization -A patient aged 45 years, known with a psychiatric history, with numerous hospitalizations in psychiatry, a chronic ethanol user, is brought to the emergency room at his request for: psycho-motor anxiety, psychotic intensity anxiety, irritability, marked affective lability, bizarre behavior, unusual outward appearance, symptoms accentuated by the abuse of ethanol.
2017-second hospitalization -Patient known with psychiatry problems, recently discharged from the Clinic of Addictions, returns to the hospital brought by the police for a violent behavioral syndrome with threat, visual violence against the neighbors and destruction caused by alcohol consumption during the active day.
2017-first hospitalization -The patient, known with mixed type personality disorder, predominantly impulsive explosive, with intermittent expressions potentiated by alcohol consumption, presented multiple hospitalizations in psychiatry, most being voluntary and lasting between 7-10 days, from those several times being brought into acute ethanol intoxication and after committing aggressive acts, behavioral and violent pathology.Currently comes in the same situation -acute ethanol intoxication, behavioral pathology to a neighbor: "I knocked on the door to a neighbor.I wanted what every man wants," "I heard voices in my head two years ago, they said obscenities, sexual stupidities, I can't tell them."The police requesting non-voluntary hospitalization due to several criminal files opened for committing type acts: assaulting a neighbor, breaking the door, threatening, etc. From the mother's statements, the patient would still have since childhood indices of cerebral organicity (learning with difficulty, poor school results, impulsive manifestations).
2016-second hospitalization -A 43-year-old patient, known with a psychiatric background, is brought by the Police for the following symptoms: psychomotor agitation, verbal and behavioral heterogeneity and in the context of acute ethanol poisoning.
2016-first hospitalization -A 43-year-old patient, known with a psychiatric history, recently discharged from the hospital, is admitted for psychomotor agitation, irritability, physical and verbal heteroaggressivity, threatening behavior, symptoms that have emerged in the context of acute ethanol poisoning.
Thought: Slightly inconsistent speech, with the weakening of free associations, thinking is slightly disorganized, tangential, circumstantial responses (Barnes, 2013).
Delirious idea of persecution, injury and prosecution, summary and relationship: "They have cameras put at my house and on the TV you can have video cameras, microphones, they implanted a chip in my forehead."Delirious ideas of grand-mania: "I have this chip in me because I know too much, but I can't tell you what I know because it's secret" (Burt, 2014).
Intrusive thoughts and transparency of thoughts: "I have the impression that you all hear my thoughts and try to change them." Behavior: Physical heteroaggression marked by multiple criminal records for acts of violence.Explosive potential, impulsivity, unpredictability, danger.

Schizoaffective disorder -Manic episode
The antisocial emphasis and self-confidence mimic anger, through countertransference.The presence of possible auditory hallucinations "I was talking in my mind, someone was answering me, he heard me" "I heard two years ago voices that insulted me."Great delusional ideas "I have this chip in me because I know too much, but I can't tell you what because it is a dissertation" -> Decompensation prevalent delirium (Dolan, 2002).

Organic personality disorder
Possible behavioral disorders in childhood (possible diagnosis of ADHD), the presence at the EEG of some indications of organicity and traumatic brain injury in the past support a possible diagnosis of an organic disorder.Psychological examination supports low IQ (Ficks, 2014).

Evolution and prognosis
The antisocial personality disorder has a chronic evolution but may fade or remit as the individual ages.Given the fact that the patient is 46 years old and requires frequent psychiatric hospitalization, his evolution is not headed for improvement or remission.
Antisocial personality is associated with the risk of anxiety disorders, substance abuse, somatization, or may have psychotic decompensation as in the present case, these being potentiated by alcohol abuse (Jorev, 2014).

Positive prognostic factors:
-the good response to treatment in the past -absence of a family history of psychiatric disorders Negative prognostic factors: -poor compliance with treatment -multiple relapses -chronic alcohol consumption (Bandelow, 2015)

Discussion
The act and the passage to the act are important topics both in criminology and in the psychology of criminology.One of the main basic characteristics of the act is that the individual who performs it can be held responsible for it.There are two types of acceptances for the term "responsibility:" a psychoanalytic responsibility and a legal responsibility (Kernberg, 2004).The concept of responsibility is directly related to intentionality, which is a complicated concept in psychoanalysis, as it has found that, besides its conscious plans, the subject also has unconscious intentions and impulses.Therefore, one can very well commit an act after which it is asserted to be unintentional, and analysts can reveal it as the expression of an unconscious desire.
Freud calls these acts parapraxis or missed acts (Verhulst, 2015).However, they are acts that are missed only from the point of view of the conscious action, because they are successful in expressing the unconscious desire that determines them.While in the legal field (of legal responsibility) a subject cannot be found guilty of murder (for example), unless it can be proved that the act was intentional, in the psychoanalytic treatment the subject is confronted with the ethical duty of assuming responsibility, even and in the case of unconscious desires expressed in his actions.He must recognize even seemingly accidental actions as real acts expressing an intention, even if it is of an unconscious nature, and assume that intention.This, however, is an ethical problem that arises only in the case of in-depth analysis of this type of pathology.In reality, the psychopathic individual rarely wants to understand the motivation of his structural defect (Latvala, 2015).
The pattern of psychopathy popularized in North America through the work of Harvey Cleckley had a strong influence.Cleckley identifies the characteristics of the psychopath as follows: "superficial charm and good intelligence, the absence of illusions and other signs of irrational thinking; absence of nervousness and psychoneurotic manifestations; lack of trust; lack of sincerity and truthfulness; lack of remorse or shame; inadequately motivated antisocial behaviors; poor judgment and failure to learn from previous experience, pathological egocentricity and inability to love, general deficiency in major affective relationships; lack of sensitivity in general interpersonal relationships; eccentric and unattractive behavior, with or without alcohol use; suicide attempt rarely completed; impersonal, trivial, with a poorly integrated sex life; failure to follow a life plan" (Cleckley, 2015).
The specialty literature and the research conducted on the psychopathic individual report changes in the amygdala function in particular, which are evidenced by the neurocognitive sciences.
Dysfunction of the tonsil is a central point of the pathology associated with psychopathy.The amygdala is a neural formation consisting of a mass of gray matter found in man in the anterior portion of the temporal lobe (McWilliams, 2014).The amygdala has a direct connection with the manifestation of basic emotional reactions and the formation of behavioral responses to associations of stimuli of the conditioned stimulus typeunconditioned stimulus and conditioned stimulus -reinforcement stimulus.The amygdala influences the level of jerking reflux by stimulating the basal threatening subcortical circuits, as a result of activation through conditioned stimuli.In addition, the amygdala allows conditioned stimuli to elicit unconditional responses.Or, the defects of these functions are powerful indicators of a level of psychopathology in the affected persons (Meloy, 1988).
Among the implications of tonsil dysfunction are the disturbance of moral socialization.In individuals with this dysfunction, the sensitivity is reduced to the emotional representations of the others, their own representations being insufficient to affect the moral issues affective.His affective insensitivity, manifested by the inability to live affectionately threatening a danger, as well as by the lack of empathy, increases the degree of exposure to danger first and foremost of the person, but also of those around him.Various studies over time have shown that in the biophysiological plane, "the noradrenergic (inhibitory) response to stress / threat stimuli can be disrupted in individuals with psychopathy."Other studies have shown that, in antisocial persons, a lower volume of gray matter appears in the prefrontal orbital-frontal area compared to normal individuals, which may be the explanation for the reduced excitability of this cortical area (Shi, 2012).
This anatomic-physiological basis represents the foundation on which in the behavioral plane the affected persons develop as coping mechanisms manifestations such as: duplicity morality, the premeditation of antisocial acts, and the easy acquisition of aggressive existential patterns throughout the development of the personality.One of the main behavioral characteristics of psychopathy is dissimulation, which translates into a voluntary action, premeditated on the basis of a secondary interest, which aims to obtain certain benefits (Van den Bos, 2014).Related to social adaptation and integration, psychopathy is a malignant disorder that expresses the conflict between the instinctive emotional life and the social norm in its raw form, through direct, nonsecondary expression.Essentially, psychopathy is a disorder of affectivity, affecting the mechanisms of selfappreciation and conscious control of one's manifestations, denying the value of social norms and moral-social feelings.The discrepancy between the conserved cognition functions and the altered affective causes the antisocial (psychopathic) individual to seek satisfaction in aberrant acts, of which the malignancy is conscious.The danger of the psychopathic aberrant behavior is the result of the subjective position of the premeditated acts, the affective duplicity, the increased receptivity to the negative psychological inductions, the total indifference to the feelings of others and the incapacity of loyalty.
Other features associated with psychopathy are: incapacity and impossibility of achievement, intolerance to frustration, inadequacy and permanent dissatisfaction leading to social nihilism, inhibition of the ability to contract and maintain stable interpersonal relationships, experienced as a restriction of instinctive freedom (Paris, 2013).
The perverse activities that involve manifest cruelty towards others are frequently present in patients with antisocial personality disorder.Stoller called perversion the erotic form of hatred.The association of the perversions with the antisocial personality disorder makes the individual almost impossible to recover by his own will, since he does not develop symptoms that consciously lead him to regret the facts committed.The evolution of pathology leads to more serious forms of destruction, such as psychosis, dementia and in extreme cases, suicide, as a form of manipulation of others (Reichborn-Kjennereud, 2015).
Although in the specialty literature around the world, the terms "psychopath" and "sociopath" are used either alternatively or as synonyms, lacking a precise conceptual delimitation, the term sociopath was introduced to emphasize the importance of environmental factors between the causes of delinquent behavior.Psychopathy is the result of an imbalance of the person's personality, which leads to the outline of a disharmonious characteristic structure that manifests itself through associative and / or antisocial behavior, representing a structural defect characterized by: the dominance of the instinctive sphere and weak pulsional control, manifested by deviant or delinquent behaviors; disorders of the sphere of affectivity (emotional deficiency and the inability to resonate emotionally); disorders of the volitional sphere; characteristic disharmony and dissocial behavior, which make it difficult or even impossible to adapt the individual to socially accepted environmental conditions.