Treatment Planning For
Antisocial Personality Disorder
The only effective treatment for Antisocial Personality Disorder appears to be the passage of time. Those individuals who do not get killed or kill themselves and survive into their 40s tend to mellow out and become less impulsive and predatory, When Substance Abuse is a prominent part of the clinical picture, it provides an important target for intervention. Individuals with this Personality Disorder often also have episodes of depression that may require treatment and suicide risk prevention, especially given the high suicide rate associated with the disorder.
One major problem is where and how treatment should be provided. Individuals with Antisocial Personality Disorder are usually noncompliant with outpatient intervention.Prison rehabilitation programs have not been very effective, and these individuals become wolves among sheep when hospitalized in psychiatric facilities, as seen in the way Mr. Y behaved during his psychiatric hospitalizations. If this discussion of the treatment of Antisocial Personality Disorder sounds pessimistic, it is meant to.
This was part of the write up for Antisocial Personality Disorder in the DSM-IV-TR Case Studies Guide, published 2001 and written by Alan Frances, MD and Ruth Ross, MA back when the DSM-IV-TR first came out. I was completely caught off guard when I read the last sentence above, “If this discussion of the treatment of Antisocial Personality Disorder sounds pessimistic, it is meant to.” I happened to talk to Dr Frances prior to this Guide published, as the same was said in the DSM-IV Case Studies Guide as well, about something completely unrelated, and I asked him at the end of our conversation about this comment, and was even more surprised to hear the following, as best paraphrased about 15 years later:
ME: So I’m curious, in the part about A P D/O, I read something of the sort about “the discussion of the treatment sounds pessimistic, it was meant to”, did you have any input to who wrote that, because I personally loved it as was so on the mark.
Dr F: Yes, in fact it was me. I wasn’t sure if it was the best thing to write, but in the end, I did it,
ME: Wow, that must have been tough to be rather cynical about a mental health disorder.
Dr F: Well, that’s if it is [a mental health disorder]. It certainly is not amenable to treatment, and aren’t providers at risk anyway to work with these individuals?
He went on to say I was the first person to support, if not applaud what he wrote. Really?! What is it with colleagues that they will expect any and all providers to take on any patient who walks into an office setting. I would even ask why such patients are allowed to stay in inpatient settings as well, once their pathology is overt and disruptive, but, that has not been my domain for years, so I defer to colleagues working that setting to decide who they will continue to treat.
So why I am I writing about this today? Because I am genuinely afraid of what will be the fallout from the Newtown Ct shootings for psychiatry. While there are people who are overtly impaired with Axis 1 mood or thought disorders and exhibit antisocial traits or behaviors, only to have such personality struggles wane and dissipate once treatment interventions take hold, what about those who are primarily axis 2 disordered, and as part of the disorder, have no interest in change or reflection of impact of said behaviors on others, and in fact prey on others’ empathy and caring? Why do we have to exert time and energy and our sincere caring, only to have it used against us, if not put us at full risk for harm and abuse?
Yes, I am cynical and jaded when it comes to treating Antisocial Personality Disordered patients. I did some brief correctional work over 10 years ago and will never forget the experience, obviously not for good nor valued reasons. But, I almost typed “nor educational reasons” and caught myself, as I did in fact learn much from the experience. Antisocial people do not and will not change until proven otherwise, and, should people make the mistake of making treatment even remotely punitive or enforced for antisocial patients, forget any positive endpoints working with said patients.
I really do not think we will find out anything of substance to explain what Adam Lanza did on Friday December 14, 2012. I think we will learn about assumptions and vague innuendos by others, and maybe some will have some validity in the end. But, I think this today, and while I instinctively hope I am wrong, I also hope it might make some sense, painfully but accurately in the end: Mr Lanza probably had a sizeable amount of antisocial traits within him, and while it may have been some random event or the proverbial “straw that broke the back” incident or moment, it more likely wasn’t that hard for him to take his mother’s life, then the lives of 25 others at an elementary school.
What worries me from this incident is this: in this impassioned zeal to “make sure this never happens again”, psychiatry will be burdened with taking on the care, in non correctional settings, to treat what will amount to basic antisocial people who are seen as threats to the community, usually as defined by the legal system first. And I don’t want it, as I see enough antisocial behavior that masquerades as “bipolar” or “depression” or “anxiety”, but mostly as just fallout from comorbid substance abuse/dependency that is equally NOT in our domain to treat primarily. And I really hope I read here in comments, or at other colleague sites in the future, the same thing.
We are a species that kills others within our own. It is probably hard wired now, and won’t change just because politicians and impassioned public figures want things different. I leave you with this line from the “Avengers” movie, after Loki kills the man who had the retina to open the vault and then makes everyone on the street knell to him, except one elderly man, who rises and says “there will always be men like you.”
Yes, there will always be men like Adam Lanza, maybe not with possible autism/aspergers/other subtle developmental disorders, but, they will kill, do it cruelly and viscously, and it won’t make sense to those of us with caring, compassion, and empathy. Oh, and those of us who have boundaries with life.
I hope the Connecticut State Police tell us something of value by the end of the year. Even if it is speculation. Maybe we can use it for some worth.
May one’s grief be comforted by those sympathetic, supportive, and stable, and may such grief be processed to give one strength and resolve. Hopefully the work is not too long, but is considerably sustained once achieved. May we all find a silver lining to one of the darkest moments in our history!