By Donald W. Black, M.D.
It may be hard to believe, but one of the most common and problematic mental disorders is ignored by the public and media alike. People — and reporters — breathlessly talk about depression, substance abuse and autism, but no one ever talks about antisocial personality disorder. Why?
Though better known as sociopathy, antisocial personality disorder, or ASP, affects up to 8½ million Americans and there is no cure, nor are there any good treatments. Psychiatrists like me who are interested in this disorder tend to be ignored and our concerns marginalized. The patients themselves can be difficult, and even unpleasant, and that limits interest. It is hard for people to be sympathetic toward those who tend not to arouse our concern. There are no poster children to point to.
Few mental health professionals are interested in the disorder and some run when a colleague tries to refer an antisocial patient to them. ASP is rarely discussed in medical schools, and few researchers take it on as a cause. Most telling, the National Institutes of Health (NIH), the government’s premier medical research organization, funds a grand total of two projects in which the term “antisocial” appears in the title. By contrast, the NIH funds hundreds if not thousands of studies on more conventional mental health topics such as schizophrenia, depression, anxiety disorders, and autism. How are we — as mental health professionals — to make headway in treating and preventing this disorder when the government does not lead the way?
First, let us consider what ASP is. Briefly, it is a disorder of chronic or serial misbehavior that begins in childhood and continues into adulthood, usually persisting throughout a person’s life. These are the rule breakers who see fit to violate society’s conventions. As children they fight with others, lie to their parents, and steal from the corner store. As adults, they abuse their partners or spouses, are irresponsible toward their children, and some are criminal. In the worst cases, some commit heinous acts of violence. Few of its sufferers are women, as it is predominately a man’s disorder. And sufferer is not the right word, because most antisocial persons do not “suffer” in the usual sense since they rarely believe anything is wrong. Their behavior is not the problem; society and its tiresome rules are the problem.
How did we arrive at this point? First, there is the lack of visibility. ASP is not on the public’s radar screen. While known to psychiatrists and psychologists for nearly 200 years in one form or another, few mental health professionals bother to make the diagnosis or to even make referrals for its evaluation or treatment. The public misunderstands the term antisocial, believing the disorder to relate to shyness, when it really relates to bad behavior directed against society. Finally, researchers tend to go where the money is. Since the NIH directs few funds to investigate ASP, why would an investigator study it? Take autism as an example. The amount of research exploded within the last decade when it became clear that the government was interested in the disorder. That could happen with ASP if the NIH changed its tune. Despite this deliberate indifference, over the past 50 years researchers have — mostly on their own time and money — consistently shown it to be one of the most heritable of disorders and to have a clear neurobiological basis.
Why should I and others care? Though under the radar, ASP isn’t going anywhere. It will continue — over time — to cost us billions and billions though its direct and indirect costs associated with law enforcement and criminal justice. Nearly all of us are victims of an antisocial person’s misdeeds; we fear them and even grapple with the disorder in our families. Now more than ever, psychiatry and society have the means to explore why some people turn bad, but progress will continue to accrue slowly until we begin to see ASP more clearly and commit ourselves to doing something about it.
Understanding the scope of ASP and coming to grips with it requires time and money. The NIH and other agencies must change their tune about funding ASP research and its many facets, particularly crime and violence. Priorities should include wide-reaching projects to explore its origins and search for methods to change its course. Geneticists must continue to investigate genes that might predispose individuals to ASP and determine how they function. Neuroscientists should work to pinpoint brain regions linked to antisocial behavior while identifying the neurophysiological pathways that influence its expression. Mental health professionals must overcome their own resistance to working with antisocial persons in order to develop new treatments. Last, we must focus attention on the group at highest risk of developing ASP: children with antisocial behavior. Improved understanding of their home life and social environment may lead to more effective interventions that may prevent ASP from developing. By treating and possibly preventing ASP, we can have a broad impact that ripples through society, thereby helping to reduce spousal abuse, family violence, and criminal behavior.
Donald W. Black, MD, is the author of Bad Boys, Bad Men: Confronting Antisocial Personality Disorder (Sociopathy), Revised and Updated Edition. He is a Professor of Psychiatry at the University of Iowa Roy J. and Lucille A. Carver College of Medicine in Iowa City. A graduate of Stanford University and the University of Utah School of Medicine, he has received numerous awards for teaching, research, and patient care, and is listed in “Best Doctors in America.” He serves as a consultant to the Iowa Department of Corrections. He writes extensively for professional audiences and his work has been featured in television and print media worldwide.
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Hi, Dr. Black. Have you read all the works of Dr. Dorothy Otnow Lewis? I’ve just read “Guilty by Reason of Insanity” and am now embarking on “Delinquency and Psychopathology”. She has discovered that there is no such thing as Sociopathy. I think I would trust a Psychiatrist-cum-researcher who Ted Bundy said was the first person he ever trusted enough to tell the truth to. It really pays to find out why people do the things they do, including mass murder. As far as ASP, in general, have you ever thought that there are rules in society that really need to be changed? I believe there are and I have experienced a myriad events in my life (all involving some sort of abuse and now the legal system working against me even though I’m the one who is currently bringing up a case against 30 individuals who abused me in Rhode Island Hospital over a 36 hour period straight causing me two PTSD meltdowns in less than 24 hours, and weakening my already deformed heart, possibly causing my heart now to be sensitive to its own protective enzyme, Troponin, because of the PTSD I have caused by all the abuse I suffered which was allowed by all the powers that be, mainly because the abusers were the powers that be, were supported by the powers that be because they agreed with the powers that be while I was very vocal about the wrongs of the powers that be or those who are stupid enough to support the powers that be because the powers that be have extremely high EQ, causing them to appeal to those in the lowest common denominator despite what is behind their glittering exteriors; I have enough perspicuity most of the time to be able to see behind the facade and when I call them on it I get abused for that alone…Anyway, the legal system is working against me even though I am the victim. Why? Becuase the Disability Law Center refuses to even broach the abuse I suffered and am still suffering from today (heightened PTSD, heart weakening, etc.)because it says it is a non-profit and does not have enough funding. Well, if I was an African-American who went through what I did as a disabled individual (I have a profound hearing disorder because of which the abuse began), the whole NAACP and its affiliates would come down on those individuals and the hospital itself and the victim would get a trial no questions asked. Why does the NAACP have such power and the Disability Law Center doesn’t? Money. The NAACP has more money. But, it’s money deserved because the African-Americans have always gone the distance for one another since Harriet Tubman and beyond. Disabled people almost never go the distance for another disabled individual. It’s pretty obvious that our legal representatives won’t even take one step. Well, let me tell you, I almost died of hypothermia fighting for an individual’s God-given rights to be treated like a human being by her abusive caretakers the first week of January, those caretakers abused me as well. I have had hypothermia three times already in my life and almost died twice from it. I didn’t care. I went the distance. A little over 20 years ago I was forced to work in a sweatshop run by the Office of Rehabilitative Services, a government run agency, full time for less than minimum wage while big companies like Disney were making money off of all of us (these sweatshops of disabled individuals run by such government organizations like ORS were going on throughout the country). I was one of the first to pipe up about it and a lot of people, including my fellow disabled, said I was crazy. I went to a therapist at a time (around 1991) who was not treating me for what I really had (I had and still have Asperger’s and as I said PTSD which was never treated or taken seriously until this year) who said I was a caped crusader for trying to do something to stop the unfair treatment we were receiving. What I have mentioned is just the microscopic tip of the tip of the needle of all that I experienced, alone, that needs to be fixed in society. So, could you think that a non-violent individual who is just against society as a whole may not have ASP but just is perspicacious enough to perceive what is wrong with everything and is very sensitive to it all but has been able to keep his heart and soul in tact? Because, believe me, all the abuse, for example I have suffered from in the past 31 years has indeed been caused by a society whose system and mores and the like need desperate changing. I really do believe that a lot of the violent ASP’s go into law-enforcement and the legal system because they, by working in those systems, can legally work violently, either physically or emotionally against society, let me tell you. They’ve done it to me on more than four occassions as part of the all the abuse I suffered since I was 11. I am going to be 43 on March 26. I’m a Mensan, by the way. Will the fun ever stop?
I would think that part of the resistance of clinicians to work with such clients stems also from the likelihood that people with this diagnosis are going to resist acknowledging there’s a problem to which they contribute (as you said) and, therefore, would be more likely to miss appointments; be less open to challenge their beliefs, not make efforts to change; resist accepting guidance; may even be violent or disruptive; and/or be challenging to get payment from and/or not cooperate with what might be required to get insurance reimbursement. I realize there are approaches to working with resistant and/or mandated clients, but that doesn’t mean that they aren’t more challenging, possibly less likely to show positive outcomes, and less affirming of the clinician’s sense of competence (though, hopefully, the clinician would not let that last issue affect their practice, would be be mindful of that concern and keep it in check somehow). Anyway, I’m only commenting as an amateur with some very basic training, but I didn’t believe I saw this fleshed out sufficiently in the blog post to which I’m referring. It may very well be something addressed in the book and known by the other but omitted above only due to space or other editorial limitations. By the way, the admittedly nondescript link above (http://bit.ly/14kn9Bo) goes to my SugarSync archive of social work-related materials, primarily focused on child welfare and protection (my profession), sexual orientation and gender identity. Thank you for the interesting read and, more so for the important and, in many ways, unrewarding and under-appreciated work you are doing.
Oh, and one more thing I would add, or request actually, is more detailed distinguishing between antisocial personality disorder and, what I refer to as being, not antisocial, but ‘asocial,’ maybe what you referred to as shy, though I think even there there’s a difference in motivation or causation. ‘Homebody’ might be another way of describing what I mean as asocial; someone who simply prefers fewer social interactions but not out of any conscious or subconscious avoidance, fear, anxiety. Just a thought that might be worth exploring or considering at some point. Thanks again.
Hello, I am wondering if we are not getting into a scale where ASP as whole started to shape the society to abuse it more efficiently ? For example it seems extremely common to sell extremely bad products and get away with that, further on companies selling bad products tend to sell more of them because cheaper and less durable! Considering also lobbying to push the businesses of bad products and you have a full scale of commercial abuse at work! Health concern activities naturally included, causing sometimes great bodily or psychological harm (nasty drugs, surgical mishaps (think about the Pip breast implants etc.) etc.). And if you are an ASP you won’t mind much working in these conditions, in fact you may thrive and achieve great legal wealth, making sometimes ASP an asset for success. From there you have a context that tend to minimize the shocking effect of many little ASP actions by habituation and then a society that become ASP tolerant and even ASP oblivious!
So obviously society must change (*1) before it’s too late! I wonder if parasitic ASP can become common enough to end our modern technical society, or if the parasitic side stop the ASP growth before it’s too late, because the ratio of possible victims is not high enough ?
(*1) : we need to develop empathy and to reward it accordingly, for th people and the structures, toward the people and the environment.
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