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 The Diagnostic and Statistical Manual
"The Diagnostic and Statistical Manual of the American Psychiatric Association -- is the so called bible of psychiatry, at least in North America. It gives the official diagnostic criteria of all mental illness. The latest revision -- DSM-IV -- was published in 1994."
"Psychopathy has been called a lot of things since the condition was first described by Pinel in 1806 and termed "mania sans delire." Pritchard coined the term "moral imbecility" in 1835. For a time there was an attempt to remove the moral stigma of the term psychopathy with the term sociopath. The current term is APD -- Antisocial Personality Disorder."
301.7 Antisocial Personality Disorder
Diagnostic Features
The essential feature of Antisocial Personality Disorder is a pervasive pattern of disregard for, and violation of, the rights of others that begins in childhood or early adolescence and continues into adulthood.
This pattern has also been referred to as psychopathy, sociopathy, or dyssocial personality disorder. Because deceit and manipulation are central features of Antisocial Personality Disorder, it may be especially helpful to integrate information acquired from systematic clinical assessment with information collected from collateral sources.
For this diagnosis to be given, the individual must be at least age 18 years and must have had a history of some symptoms of Conduct Disorder before age 15 years. Conduct Disorder involves a repetitive and persistent pattern of behaviour in which the basic rights of others or major age-appropriate societal norms or rules are violated. The specific behaviours characteristic of Conduct Disorder fall into one of four categories: aggression to people and animals, destruction of property, deceitfulness or theft, or serious violation of rules.
The pattern of antisocial behaviour continues into adulthood. Individuals with Antisocial Personality Disorder fail to conform to social norms with respect to lawful behaviour. They may repeatedly perform acts that are grounds for arrest (whether they are arrested or not), such as destroying property, harassing others, stealing, or pursuing illegal occupations. Persons with this disorder disregard the wishes, rights, or feelings of others. They are frequently deceitful and manipulative in order to gain personal profit or pleasure,(e.g., to obtain money, sex, or power). They may repeatedly lie, use an alias, con others, or malinger. A pattern of impulsivity may be manifested by a failure to plan ahead. Decisions are made on the spur of the moment, without forethought, and without consideration for the consequences to self or others; this may lead to sudden changes of jobs, residences, or relationships. Individuals with Antisocial Personality Disorder tend to be irritable and aggressive and may repeatedly get into physical fights or commit acts of physical assault (including spouse beating or child beating). Aggressive acts that are required to defend oneself or someone else are not considered to be evidence for this item. These individuals also display a reckless disregard for the safety of themselves or others. This may be evidenced in their driving behaviour (recurrent speeding, driving while intoxicated, multiple accidents). They may engage in sexual behaviour or substance use that has a high risk for harmful consequences. They may neglect or fail to care for a child in a way that puts the child in danger.
Individuals with Antisocial Personality Disorder also tend to be consistently and extremely irresponsible. Irresponsible work behaviour may be indicated by significant periods of unemployment despite available job opportunities, or by abandonment of several jobs without a realistic plan for getting another job. There may also be a pattern of repeated absences from work that are not explained by illness either in themselves or in their family. Financial irresponsibility is indicated by acts such as defaulting on debts, failing to provide child support, or failing to support other dependents on a regular basis. Individuals with Antisocial Personality Disorder show little remorse for the consequences of their acts. They may be indifferent to, or provide a superficial rationalization for, having hurt, mistreated, or stolen from someone (e.g., "life's unfair,' 'losers deserve to lose," or "he had it coming anyway"). These individuals may blame the victims for being foolish, helpless, or deserving their fate; they may minimize the harmful consequences of their actions; or they may simply indicate complete indifference. They generally fail to compensate or make amends for their behaviour. They may believe that everyone is out to "help number one" and that one should stop at nothing to avoid being pushed around.
Associated Features and Disorders
Individuals with Antisocial Personality Disorder frequently lack empathy and tend to be callous, cynical, and contemptuous of the feelings, rights, and sufferings of others. They may have an inflated and arrogant self-appraisal (e.g., feel that ordinary work is beneath them or lack a realistic concern about their current problems or their future) and may be excessively opinionated, self-assured, or cocky. They may display a glib, superficial charm and can be quite voluble and verbally facile (e.g., using technical terms or jargon that might impress someone who is unfamiliar with the topic). Lack of empathy, inflated self-appraisal, and superficial charm are features that have been commonly included in traditional conceptions of psychopathy and may be particularly distinguishing of Antisocial Personality Disorder in prison or forensic settings where criminal, delinquent, or aggressive acts are likely to be nonspecific. These individuals may also be irresponsible and exploitative in their sexual relationships, They may have a history of many sexual partners and may never have sustained a monogamous relationship. They may be irresponsible as parents, as evidenced by malnutrition of a child, an illness in the child resulting from a lack of minimal hygiene, a child's dependence on neighbours or nonresident relatives for food or shelter, a failure to arrange for a caretaker for a young child when the individual is away from home, or repeated squandering of money required for household necessities. These individuals may receive dishonourable discharges from the armed services, may fail to be self-supporting, may become impoverished or even homeless, or may spend many years in penal institutions. Individuals with Antisocial Personality Disorder are more likely than people in the general population to die prematurely by violent means (e.g., suicide, accidents, and homicides).
Individuals with this disorder may also experience dysphoria, including complaints of tension, inability to tolerate boredom, and depressed mood. They may have associated Anxiety Disorders, Depressive Disorders, Substance-Related Disorders, Somatization Disorder, Pathological Gambling, and other disorders of impulse control, Individuals with Antisocial Personality Disorder also often have personality features that meet criteria for other Personality Disorders, particularly Borderline, Histrionic, and Narcissistic Personality Disorders. The likelihood of developing Antisocial Personality Disorder in adult life is increased if the individual experienced an early onset of Conduct Disorder (before age 10 years) and accompanying Attention-Deficit/Hyperactivity Disorder. Child abuse or neglect, unstable or erratic parenting, or inconsistent parental discipline may increase the likelihood that Conduct Disorder will evolve into Antisocial Personality Disorder.
Prevalence
The overall prevalence of Antisocial Personality Disorder in community samples is about 3% in males and about 1% in females. Prevalence estimates within clinical settings have varied from 3% to 30%, depending on the predominant characteristics of the populations being sampled. Even higher prevalence rates are associated with substance abuse treatment settings and prison or forensic settings.
"We have more reason to fear the hollow man than the poor neurotic who is tormented by his own conscience. As long as man is capable of moral conflicts - even if they lead to neurosis - there is hope for him. But what shall we do with a man who has no attachments? Who can breathe humanity into his emptiness?"
Selma Fraiberg
"...Over their lifetimes ... [psychopaths] demand a disproportionate amount of time and money from society in general and from health professionals in particular. Whether that time is spent in managing their incorrigible behaviour as children, dealing in consultation with their criminal offenses as adults, or caring for their damaged or deserted families, antisocial personalities cannot be disregarded by their psychiatrists...
Comprehensivee Textbook of Psychiatry
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