Be wary when sociopaths turn on the charm
Persons with antisocial personality disorder display a disregard for the rights of others that can put them at odds with the legal system (Table). Those charged with or convicted of domestic battery, child abuse, or sexual assault often are referred for psychiatric evaluation pretrial, post-conviction, or during incarceration. Courts also may require psychotherapy in lieu of incarceration or after release.
Antisocial personality disorder differs from psychopathy, which indicates a more severe form of sociopathy. The “psychopath” is almost entirely bereft of superego or conscience and often displays sadistic traits. Antisocial personality disorder and psychopathy often are used interchangeably, however, and the pitfalls I describe apply to both.
DSM-IV-TR criteria for antisocial personality disorder
Antisocial individuals display a pervasive pattern of disregard for and violation of the rights of others as indicated by ≥3 of the following:
Source: Diagnostic and statistical manual of mental disorders. 4th ed, text revision. Washington, DC: American Psychiatric Association; 2000
When evaluating patients with antisocial characteristics, be aware of the hazards specific to this diagnosis. Antisocial patients’ considerable “charm” and ability to appear ingenuous and sincere helps solicit sympathy, allowing them to convince victims to drop their guard, prosecutors to reduce charges, and judges to mitigate sentences. These manipulative patients are skilled at persuading clinicians that we are “working miracles”—which, unfortunately, can take very little effort—hoping to win a favorable evaluation for the judge, probation officer, or parole board.
Evaluating clinical progress in antisocial patients is difficult because improvement can be determined only by a continued lack of antisocial behavior. It might not be possible to know whether antisocial behavior is:
- continuing undetected
- has been temporarily checked (“laying low”)
- or if the patient’s personality truly has been transformed.
The last is least likely because personality characteristics are deeply ingrained. Such a transformation would require the patient’s honest acknowledgement of a need to change and take many years of treatment to achieve. Antisocial patients’ strong secondary gain—to mitigate the consequences of criminal behavior—demands skepticism of reported clinical progress.1
5 treatment caveats
When treating antisocial patients, remaining vigilant to the inherent challenges of working with them, stay within strict boundaries, and keep therapy from going adrift.
- Avoid allowing the patient to engage you with fascinating stories. Such tales may be exaggerated, fabricated, or designed to manipulate, charm, or enthrall to distract you from your treatment goals. Antisocial patients might exhibit pseudologia fantastica, a form of pathological lying in which the individual—although not frankly delusional—believes his embellished claims2 and is so convinced that he can easily persuade and distract the therapist.
- Neither accept nor reject the patient’s claim of innocence. Emphasize that you cannot determine innocence. Instead, point out that you will help the patient identify choices and actions that caused his present predicament. If your patient insists on blaming others, refocus the discussion on his actions and choices that created or facilitated the problem.
- Do not accept your patient’s apologies, claims of remorse, or promises to change. Point out that only victims can accept apologies. Likewise, emphasize that promises to change can only be made to oneself.
- Direct the patient’s attention away from you—your brilliance, talent, and empathy—and focus on the patient, his past poor choices, and how he can improve his choices going forward.
- Treat only the symptoms that can be treated, such as disordered mood, hallucinations, grandiose delusions, and substance abuse, without allowing them to become excuses for criminal behavior. Point out that most patients with depression, schizophrenia, alcoholism, or other mental illnesses do not commit crimes.3
1. Delain SL, Stafford KP, Ben-Porath YS. Use of the TOMM in a criminal court forensic assessment setting. Assessment 2003;10(4):370-81
2. Feldman MD. Munchausen by Internet: detecting factitious illness and crisis on the Internet. South Med J 2000;93(7):669-72
3. Eisenberg L. Violence and the mentally ill: victims, not perpetrators. Arch Gen Psychiatry 2005;62(8):825-6
Dr. Roth is assistant professor of psychiatry, Rosalind Franklin University of Medicine and Science and attending psychiatrist, Department of Veterans Affairs Medical Center, North Chicago, IL.