Antisocial personality disorder in prisoners

(I’ve been sitting on the raw material for this post for almost two years and finally wrote it up.)

When I worked in the jail, I asked myself fairly often whether my clients had anti-social personality disorder.  Supposedly almost half of male prisoners have it, and in that setting you do have to constantly ask yourself whether someone is trying to take advantage of you in some way.

“Anti-social” almost seems redundant in a jail, but it’s not clear what the term should mean. It’s also been called sociopathy and psychopathy, and people don’t agree about whether those are actually different things. The seminal work on the topic is Hervey Cleckley’s The Mask of Sanitywhich describes psychopaths as not truly experiencing emotions, especially love. Lots of other books give advice on how to avoid such people.

The DSM IV-TR, which we were mostly using at the time, required three or more from this list for a diagnosis of antisocial personality disorder:

  1. failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest;
  2. deception, as indicated by repeatedly lying, use of aliases, or conning others for personal profit or pleasure;
  3. impulsivity or failure to plan ahead;
  4. irritability and aggressiveness, as indicated by repeated physical fights or assaults;
  5. reckless disregard for safety of self or others;
  6. consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations;
  7. lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another.

Jails obviously have a lot of people with these characteristics. But they are also full of people with addiction and trauma histories, which can explain almost all the symptoms:

  1. Everyone in jail has been arrested, so that’s a given.
  2. Lying and conning for personal benefit are probably adaptive behaviors in harsh environments like the foster system, abusive relationships, and homelessness. (As my supervisor told me the first time I had my feelings hurt by a client who successfully conned me into making a phone call for her, “This is how she’s survived.”)
  3. Impulsivity and failure to plan ahead: A ton of people are in jail because of this. Executive function is not the strong suit of prisoners. You see a lot of ADHD, a lot of traumatic brain injury, and a lot of substance use (which is both cause and effect of impulsivity).
  4. Irritability and aggressiveness: again, aggression can be adaptive in a dangerous environment. A lot of young men learn this as a way to avoid being victimized. The irritability could also be substance use or withdrawal.
  5. Disregard for safety: A common response to trauma.
  6. Irresponsibility: I read this as “often unemployed,” which isn’t surprising in someone coming out of an unstable family and/or a broken school system. Also would be pretty predictable as a consequence of substance abuse.
  7. Which leaves us with lack of remorse: the only one I can’t explain away even in this population.

I met very few clients who obviously met the “no conscience” model. They were particularly likely to be pimps, I guess because that’s a career particularly well-suited to remorselessness.

The most obviously low-on-conscience guy I worked with got offended once when I asked why he did the right thing in one case when it didn’t seem to benefit him, which made me think he had occasional moments of decency and maybe thought of himself as a decent person. But there were so many other examples of him doing the non-decent thing whenever convenient that this might have just been a front.

Another client was terminally ill and decided during his last weeks that he’d like to discuss his life history with someone. He told me about a variety of horrible things he had done (starting with arson) with no apparent remorse. But he appeared to have genuine love for his dog and spoke fondly of how he hoped to be released in time to go visit it.

At one point I went over my client list and picked the last 60 clients that I had talked with enough and remembered well enough to have an idea of whether they seemed to have a lack of empathy or remorse. 11 (18%) had said something that indicated this (though again, not consistently so—everyone in the sample at least appeared empathetic in certain situations). Another 10% were maybes in that they seemed to maybe have done really callous things but I wasn’t sure. And the remaining 72% didn’t seem to be deficient in empathy. They were mostly locked up for things in the “poor impulse control” department.

I came away from this feeling that:

  • a lot of the diagnostic criteria only make sense for someone coming from a basically ok background where you wouldn’t normally expect to see survival-type lying, violence, etc. The DSM 5 criteria seem much better in this regard, since they now ask you to rule out socio-cultural environment, substance use, and head trauma as causes.
  • this thing seemed a lot more like a spectrum than like a separate category of people.
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