The Differential Diagnosis of Antisocial Behavior


CHAPTER 11




The Differential Diagnosis of Antisocial Behavior


A Clinical Approach


 


 


 


 


 


 


The Spectrum of Antisocial Behavior


What follows is a clinical approach to the differential diagnosis of antisocial behavior as a significant symptom in a patient’s psychopathology. Antisocial behavior may be defined as actively damaging or aggressive behavior directed against other individuals or society at large, typically expressed without guilt feelings and classifiable as either passive-parasitic type (e.g., lying, stealing, irresponsibility regarding money, exploitation of others) or aggressive type (e.g., destruction of objects, physical assault, armed robbery, sadistic sexual behavior, murder). While both types of antisocial behavior may be combined, most frequently patients are involved mainly in one or the other. The practical importance of making this differential diagnosis resides first in the assessment of the dangerousness that the patient represents for his or her immediate psychosocial environment and for society at large, and second in the prognostic implications for treatment that sharply separate different types of pathology in which antisocial behavior is present or dominates. From the viewpoint of antisocial behavior as an aspect of severe personality disorders, it constitutes one of the two most important negative prognostic indicators for psychotherapy, the other one being the degree and type of secondary gain of illness.


In what follows, I describe succinctly the various psychopathological entities that have to be considered in the differential diagnosis of this syndrome, starting with the most severe and prognostically most negative diagnosis, and proceeding along a continuum of character structures in which antisocial behavior dominates, from the most severe to the least severe, the latter having a more positive prognosis. The practical implication of this list resides in the relative ease with which the corresponding differential diagnostic evaluation may be achieved in the context of detailed, extensive, complete mental status examinations.


PSEUDOPSYCHOPATHIC SCHIZOPHRENIA


The diagnostic category of pseudopsychopathic schizophrenia, which was used clinically in the 1950s, has fallen into disuse but deserves renewed attention because of the influence that psychopharmacological treatment of schizophrenia has had on the clinical manifestations of these patients (Bender 1959; Durst et al. 1997; Holmesland and Astrup 1984). This designation originally referred to schizophrenic patients who, in the course of psychotic episodes, carried out violent and often strange destructive behaviors, committing murder with bizarre features in the context of delusional and hallucinatory symptomatology. The extreme severity and bizarre nature of criminal behavior carried out under these circumstances drew attention to this, fortunately rare, type of patients.


What is remarkable is that with the advent of effective psychopharmacological treatment of schizophrenia, these patients might become free of their psychotic symptomatology but persist in antisocial behavior of an aggressive and sometimes a combined aggressive- and passive-parasitic type. Under such nonpsychotic conditions, they appear to have a presentation typical of antisocial personality disorder. These patients are usually treated within a forensic-judicial context in specialized hospital services for the criminally ill. Clinical experience has indicated that even if psychotic symptomatology can be controlled by medication, once discharged, these patients continue their antisocial behavior, stop using the medication, and eventually become psychotic again. As mentioned before, these are rare cases that usually end up with permanent inpatient reclusion in specialized psychiatric services and may appear as surprisingly well adjusted in such institutions under conditions of clear and consistent environmental control. They represent the most dangerous type of patients with antisocial behavior, and the protection of family and society is the dominant concern in their management.


ANTISOCIAL PERSONALITY DISORDER


The antisocial personality disorder category represents the most frequently seen personality disorder with significant chronic antisocial behavior and the most resistant to any available present-day treatment. Antisocial personality disorder clearly presents in the two main categories mentioned above, the passive-parasitic type and the aggressive type. The corresponding clinical characteristics have been described in classical work, extending from Hervey Cleckley’s (1941) The Mask of Sanity to Michael Stone’s (2009) The Anatomy of Evil, with detailed description of the types and degrees of severity within a broad spectrum of psychopathology of these patients. It remains controversial as to what extent the term psychopathy should be applied to a particular subgroup, such as the most extremely dangerous, aggressive type of this psychopathology (Coid and Ullrich 2010). The negative prognosis for all present treatment approaches, however, covers the entire spectrum of antisocial personality disorder.


From a clinical perspective, there are two predominant characteristics of this syndrome. One is the severe narcissistic personality structure, which more than 90% of patients with antisocial personality disorder display as a dominant feature (Hare et al. 1990). A small percentage, however, present with personality features that are predominantly characterized by paranoid and schizoid traits, in the context of generally introverted habitual behavior patterns that contrast sharply with the expansive extroverted characteristics of most antisocial personalities. On the other hand, in addition to these characterological features, they evince the typical antisocial behavior of the aggressive or the passive-parasitic type. The second characteristic in patients with antisocial personality disorder, in addition to the predominant characteristics of the narcissistic personality in terms of grandiosity, entitlement, and incapacity for emotional empathy (despite sharp awareness and evaluation of other people’s behavior and intentions), is a history of antisocial behavior beginning in childhood. These patients were usually given the diagnosis of conduct disorder if the early contacts with psychiatric professionals dated from childhood years. These patients typically manifest an absence of feelings of guilt and concern for the antisocial behavior in which they engage, although they may pretend to feel guilty during clinical examinations, particularly once a particular antisocial behavior has been discovered by the examining psychiatrist.


Their relationships with family members, friends, and acquaintances are clearly exploitive, and they show no capacity for an authentic emotional investment in a relationship with others from which they would obtain no benefits. Typically, this emotional indifference and callousness may even show in their behavior toward pets. Sometimes the exploitive nature of these patients’ relationships may be masked by a surface pretense of interest and concern that, on further exploration, proves to be false. They show a remarkable inability to tolerate anxiety, and, indeed, situations that ordinarily would provoke anxiety may trigger antisocial or hostile behavior. These patients lack a genuine capacity for experiencing sadness and mourning. Under conditions of serious threats to their sense of well-being or autonomy they may develop strong paranoid features and engage in aggressive efforts to escape from any situation they cannot control.


Patients with antisocial personality disorder may show a potential for suicide if they feel pushed into a corner, which also relates to a general absence of fear of illness or death. Here, narcissistic grandiosity and omnipotence may combine with a total lack of concern for self once all sources of pleasure are judged to be unavailable. These patients may get involved in objectively dangerous situations, and although such dangers have an exciting effect on them, they also reveal a deep sense of invincibility.


Given these descriptions, it is not surprising that these personalities show no capacity for falling in love and an absence of tenderness in their sexual relations. Those aggressive types of antisocial personalities who are expressing their pathology mostly in sexual behavior may carry out dangerous forms of sadistic sexual attacks.


Remarkably, these personalities do not learn from experience despite grievous negative consequences and may repeat failing behavior again and again. By the same token, they can be very effective in planning criminal actions, without concern about the long-term effects of their present behavior that, unavoidably, will lead to their discovery or failure. They convey the impression that they have no sense of time, of future, or of long-range planning beyond the immediate action in which they are engaged. This peculiarity is what brings about the surprising failure of social survival in individuals who often appear as extremely savvy in planning for antisocial actions. Patients with passive-parasitic features who carry out major fraudulent operations should have been able to predict, one assumes, their eventual exposure, but they cannot think ahead over that time span.


These patients also show a characteristic incapacity to identify with the moral values of other human beings. They do not have the capacity for an emotional investment in a therapeutic relationship. When they get involved in a psychotherapeutic endeavor, manipulativeness, pathological lying, and flimsy rationalizations of irresponsibility typically characterize their behavior. They have an impressive capacity to present themselves in very different ways according to what they perceive to be the expectations of the other person with whom they interact. They have been called “holographic” because of surprising and, for the diagnostician, confusing shifts in their presentation and behavior.


Because of the lack of capacity to respond to psychotherapeutic treatment in patients with antisocial personality disorder, it is extremely important to carry out a careful differential diagnostic assessment with the following syndromes, all of which have better prognosis with psychotherapeutic interventions. I shall stress the relevant differentiating features in brief descriptions of these various syndromes.


SYNDROME OF MALIGNANT NARCISSISM


I have described this syndrome in earlier work (Kernberg 1984, 1992), and it is now quite generally accepted (Bender 2014; M.H. Stone, “The Dark Side of Narcissism: Antisocial Personality Psychopathy and Malignant Narcissism,” unpublished manuscript, 2016) to represent an intermediate area between antisocial personality proper and narcissistic personality disorder with antisocial behavior. The syndrome of malignant narcissism is characterized by the typical narcissistic personality structure in addition to significant paranoid characterological features, ego-syntonic aggression against others and/or self, and antisocial behavior. These patients present the characteristics of severe identity diffusion and usually have significant failure in their capacity for work or profession, for intimacy in their sexual life, and for maintaining ordinary social relations. They often tend to be confused with regressed patients presenting a borderline personality disorder, but the combination of the dominant features of a narcissistic personality, the paranoid tendencies, and marked aggression in combination with antisocial behavior permits the specific diagnosis of the syndrome.


These patients also differ from individuals with antisocial personality proper in that they still have the capacity for some nonexploitive investment in others—in maintaining a nonexploitive sexual relationship, for example—and they still may show a capability for some idealization of a more normal way of living to which they aspire and the capacity for guilt feelings under circumstances when they become aware of their responsibility in hurting a person who is important to them. In other words, they still possess an “island” of a potentially ideal, good relationship that has appeal to them. This makes a psychotherapeutic relationship possible, and if the treatment provides an adequate, firm frame that protects the patient, the environment, and the treatment itself from destructive acting out, these patients may prove to be psychotherapeutically treatable. A history of significant relationships, a capacity for love, the ability to take good care of a pet, and the willingness to be honest with another about their violent, chaotic, aggressive behavior provides an element of authentic humanity. These favorable prognostic indicators stand in sharp contrast to the permanent distance and emotional unavailability of the antisocial personality proper and signify a much better outcome.


These patients differ from patients with antisocial personality disorder in their capacity to tolerate severe anxiety and depressive reactions. Ego-syntonic aggression may be directed against others in the form of provocative violent behavior, destruction of property, arrogant and controlling interactions, or angry temper tantrums, but these patients do not show the dangerousness of the aggressive behavior of antisocial personality disorder nor the pervasive conscious exploitation of significant others.


The severity of the pathology of these patients is reflected in the high frequency of inpatient treatments they require. Malignant narcissists constitute the outer limit of patients who respond to psychodynamic psychotherapies, particularly transference-focused psychotherapy (TFP). Their treatments usually require strict limits on their activities, and patients with overwhelming antisocial features, deceptiveness, and/or grave chronic self-mutilations may require supportive technical approaches.


NARCISSISTIC PERSONALITY DISORDER WITH ANTISOCIAL FEATURES


Narcissistic personality disorder with antisocial features has a better prognosis and is open to the general psychotherapeutic treatment approaches for pathological narcissism (Kernberg 2014). Antisocial behavior is a prognostically negative factor, but treatment is not necessarily impossible. These are usually patients with passive-parasitic antisocial behavior, often geared to gratifying a specific narcissistic need such as stealing objects that they need for their professional endeavors without having the funds to acquire them in a legal way. Others may engage in aggressive antisocial behavior as leaders or members of criminal groups but with a definite capacity for loyalty and commitment to some ideal. These patients are able to be involved in nonexploitive behavior with significant others despite their typical narcissistic difficulty in establishing love relations in depth. They may evince authentic interests and ideals beyond their own survival. Antisocial behavior has a specific function in sustaining these patients’ narcissistic grandiosity but is typically restricted to a particular area rather than involving all their social interactions. One university professor in the arts would steal rare books with reproductions of paintings as his only antisocial behavior. Their treatment, in short, is psychotherapeutic, which also corresponds to all the less severe modalities of antisocial behavior that follow, with increasingly positive prognosis as we go down the list. Depending on various individual features, some of these patients may obtain maximal benefit with unmodified, standard psychoanalysis.


OTHER BORDERLINE PERSONALITY ORGANIZATION DISORDERS WITH ANTISOCIAL FEATURES


Here, I am referring to antisocial behavior in patients with severe personality disorders, all of which are characterized by the syndrome of identity diffusion—that is, they evince a lack of integration of the concept of self and lack of integration of the concept of significant others, but without the dominance of a narcissistic personality structure. This group includes, among others, antisocial behavior in a borderline, schizoid, paranoid, or an infantile or histrionic personality disorder. From a psychodynamic viewpoint, the antisocial behavior usually is closely connected to a dynamic feature of their personality.


For example, in the case of paranoid personality disorders, dishonest behaviors may be intended to damage a perceived enemy or to manipulate social situations in order to take revenge, and the antisocial behavior may be rationalized to the extent of “fitting” into a generally preserved ethical orientation. In infantile or histrionic personality disorders, chronic lying (including pseudologia fantastica) may serve to create an embellishment of one’s life in an attempt to generate unusual interest on the part of others. In this connection, however, the tendency toward chronic lying may by itself constitute a severe limitation to the engagement in a psychotherapeutic relationship and may, in the end, defeat the therapeutic efforts.


In general, all the patients of this group have the potential, once their major splitting operations and projective identifications can be explored and resolved in the treatment situation, to experience authentic guilt and concern over their aggression and reach the depressive position in working through their antisocial behavior. Although at this point there are no specific empirical research findings indicating which patients of this group may benefit more from a psychodynamic or from a cognitive-behavioral approach, it seems reasonable to conclude that the more the symptoms are specific to antisocial behaviors and/or other circumscribed symptoms, cognitive-behavioral approaches would be a first priority. If, however, the severe personality disorder affects patients’ functioning in the major areas of life tasks—that is, in work and profession, in love and sex, or in their general social functioning—a psychoanalytic psychotherapy such as TFP is the first choice.


NEUROTIC PERSONALITY ORGANIZATION WITH ANTISOCIAL FEATURES


This category is the only one that was specifically clarified by Freud in his concept of “criminals out of unconscious guilt” (Freud 1916/1957). These are, indeed, patients with neurotic personality organization—that is, with normal identity and antisocial behavior. This group would include obsessive-compulsive, depressive-masochistic, and hysterical personality disorders. The antisocial behavior may present a bizarre quality in the sense that it is usually expressed in such ways that it leads to discovery and punishment or self-punishment. For example, a physician with an obsessive-compulsive personality stole chocolates and other sweets in the cafeteria of the hospital where he worked, which led to an embarrassing discovery. In another example, a respected biology researcher falsified data of an experiment and repeated this experiment several times to nullify the false results that she had reported. In the course of psychotherapeutic treatment, the acting out of unconscious guilt feelings over a particular psychological complex may become quite obvious and permits resolution of the syndrome. These patients have very good prognosis with psychoanalysis and psychoanalytic psychotherapies, and the question is whether treatment can be made available before they seriously risk their social, intimate, or work situation.


ANTISOCIAL BEHAVIOR IN ADOLESCENT ADJUSTMENT DISORDERS


I am referring here to antisocial behavior during adolescent development of anxiety and/or depressive disorders, in the context of dominant unconscious conflicts that get acted out in their social behavior, in their intimate relations, at home, or at school. Emotional crises and related impulsive behavior may present with provocative features, as temper tantrums, and, in certain social conditions, with occasional antisocial behavior. These adolescents usually present isolated episodes of dishonesty, physical attack, participation in invasion of property, or stealing, clearly in the context of severe emotional turmoil and generalized conflicts in their social life.


Here, if the diagnostic evaluation of the adolescent reveals an identity crisis (in contrast to a severe personality disorder with identity diffusion), the prognosis is excellent. Identity crises can be differentiated from the severe manifestations of identity diffusion by the persistence, in the middle of the emotional regression, of a clearly differentiated sense of self and realistic assessment in depth of the personality of the significant others in their immediate family and social environment. Timely psychotherapeutic engagement usually clarifies the issues and permits symptom resolution. If, on the other hand, it seems that what is involved is a severe personality disorder, then one must evaluate to what extent the antisocial behavior is more than situational in the context of bad judgment or peer pressure than seemed to be the case initially and whether one of the previously described syndromes is involved. Usually, the combination of adolescent time-limited antisocial behavior in the context of emotional turmoil and impulsivity, anxiety, and depressive reaction provides the elements justifying the inclusion in the present category. It also needs to be taken into consideration that culturally fostered antisocial behavior by social subgroups in school, or a culturally tolerated adolescent behavior, may be involved, such as shoplifting of cosmetics by adolescent girls, which is quite prevalent in American culture.


DISSOCIAL SYNDROME


Dissocial syndrome was originally described in British literature related to the study of antisocial adolescent gang behavior and was included in DSM-I as a subgroup of “sociopathic personality disturbance” (American Psychiatric Association 1952). Patients with this syndrome were described as living in an abnormal moral environment but capable of strong loyalties. They usually are members of adolescent gangs engaging in antisocial activities. Here, one should differentiate the personality features of the various gang members. Frequently, gang leaders may have antisocial personalities or severe narcissistic personalities with antisocial behavior, whereas the followers show a broad spectrum of less severe personality organization or are youngsters in adolescent crises. They include youngsters with infantile or histrionic personality disorders or dependent personality disorders, as well as adolescents with severe conflicts at home who are searching for a supportive social environment that they find in the social life of the gang. Antisocial behavior in this syndrome is typically carried out in a group setting. Sometimes simply separating an adolescent from this social subculture may take care of the problem, whereas severe conflicts at home, including major psychopathology in the family environment, may constitute important factors that motivate the adolescent’s reluctance to abandon the social culture of the gang. The combination of psychotherapeutic interventions with patient, family, and school may be very effective.


ANTISOCIAL BEHAVIOR WITHOUT PSYCHOPATHOLOGY


Some people steal because they are hungry and find themselves in a situation in which they believe they have no other way of obtaining the minimum they need to survive. They may be victims of a social pathology rather than individual psychopathology. It is, of course, essential in all cases to study the psychosocial environment that fosters, supports, encourages, or, to the contrary, strongly and rigidly opposes the antisocial behavior in which any patient is engaged.


Diagnostic Evaluation


The practical implications of this diagnostic spectrum are important. Prognosis and treatment indication depend on the diagnostic assessment and, particularly, the indication or contraindication for a specific psychotherapeutic engagement. As mentioned earlier, pseudopsychopathic schizophrenia is a rare entity that usually must be managed within the forensic field. For these patients, the most important clinical considerations are the extent to which the psychopharmacological treatment of psychosis will reveal a patient able to function with or without antisocial behavior, the corresponding dangerousness, and the indication for possible lifelong hospitalization.


In most cases of antisocial behavior, the most important practical diagnostic question is whether the patient presents an antisocial personality disorder proper or one of the less severe syndromes with antisocial behavior. The differential diagnosis usually is not too difficult to establish in a series of diagnostic interviews, with careful consideration of the past history of the patient, information from all possible sources regarding present and past antisocial behavior, and evaluation of shifting clinical characteristics through a sequence of interviews.



What follows are some examples that illustrate the application of this spectrum of severity of syndromes with antisocial behavior and the differential diagnosis among these various conditions.



A patient was hospitalized after killing his cousin with a shotgun, severing her head, and impaling it in the garden of the house where they lived. He was observed dancing around the impaled head and taken into custody. In the hospital, he was found to be hallucinating and delusional, diagnosed as presenting a schizophrenic illness and treated with atypical antipsychotic medication. After several weeks of treatment, he recovered ordinary reality testing and evinced no delusions, hallucinations, or abnormal behavior, but was remarkable for his total lack of guilt over the crime he had committed. After a further period of observation of several weeks, he brutally assaulted another patient after having been discovered stealing possessions of that patient. The tentative diagnosis of pseudopsychopathic schizophrenia was confirmed after months of neuroleptic treatment in the hospital, when, after a successful escape from the hospital, he stopped all medication and again developed a psychotic condition with manifestations of intense violence that led to his capture and rehospitalization.


Another patient, a young East German adult who was involved with a gang of neo-Nazis that set fire to buildings housing immigrant Turkish workers in a German city, revealed in his psychiatric examination severe narcissistic personality features, including a haughty and paranoid attitude toward personnel (rationalized in terms of his nationalistic ideology), and seemed ready to engage in battle following any minor provocation. He had initially been considered as possibly presenting an aggressive type of antisocial personality structure, but it emerged that he was involved in a yearlong love relation with a young woman, who had become pregnant and delivered a child, and this girlfriend had threatened him with ending their relationship if he did not stop his participation in the attacks on Turkish immigrants. It was this threat that led him to confess his participation in the racial assaults to the investigating authorities and to accept psychotherapeutic treatment offered to him in the context of his forensic evaluation. He was in love with this girlfriend and did not want to lose his relationship with their baby. This case illustrates the syndrome of malignant narcissism—that is, antisocial behavior in the context of a narcissistic personality, paranoid features, and ego-syntonic aggression.


Very different, again is the previously mentioned case of the university professor in the arts, who became an expert in stealing art books over many years while manifesting no other antisocial behavior and was diagnosed as having a narcissistic personality with antisocial behavior.


In contrast, a man who had paid a member of the Mafia an enormous amount to kill his father presented an extremely difficult diagnostic problem. The recipient of that money had been taken into custody for other criminal behaviors, without having carried out that murderous act. He confessed the nature of this financial arrangement, which led to the imprisonment and psychiatric examination of the patient. He revealed a schizoid personality with significant paranoid features, a social withdrawal that conveyed the impression of the possibility of a psychotic process that, however, could not be confirmed. It remained unclear to what extent this was an antisocial personality disorder of the rare paranoid-schizoid personality type or a psychotic illness with antisocial features. The legal system managed his case as that of an aggressive antisocial personality disorder.


Another patient, an accountant, managed over a period of years to appropriate and spend his wife’s inheritance, steal the savings of his children, and accumulate a huge debt of unpaid taxes before all of this was discovered, while proclaiming his profound love for wife and children. His history of stealing and diversion of funds reached back into his childhood. He had never shown any aggressive behavior toward others, self, or objects. He pretended to feel guilty over his behavior only at points where it had been discovered and kept his antisocial behavior secret as long as he was able to sustain his secrets. This patient presented a passive-parasitic type of antisocial personality disorder.


I have referred earlier to the physician with an obsessive-compulsive personality who stole chocolates and candy from the cafeteria of the hospital, practically assuring in the process that he would be observed and found guilty of such behavior. Psychoanalytic treatment of this patient confirmed the hypothesis of criminal behavior motivated by unconscious guilt, and several years of treatment liberated him completely from this psychopathology.

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Mar 29, 2020 | Posted by in PSYCHIATRY | Comments Off on The Differential Diagnosis of Antisocial Behavior
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