A CASE OF ANTISOCIAL PERSONALITY DISORDER
By: THEODORE MILLON
et al.
Notes:
(1) Numbers mark aspects of the case most consistent with DSM
criteria as follow, and
do not necessarily indicate that the
case “meets” diagnostic criteria in this respect.
(2) Patient's name has been changed in respect to
confidentiality, and name mentioned is not of a real existent person.
Case of Oscar
Employed
as a maintenance supervisor, Oscar was referred to the university’s employee
assistance program (EAP) because of a harsh, dictatorial interpersonal style. He missed two previous appointments and
was 20 minutes late today. His history is marked by a long series of arguments with coworkers, which appear to be increasing in
frequency. Although he is rarely at work on time, (6)
he has somehow managed to collect overtime pay from the university for the past
three pay periods, and his time sheets are being examined for evidence of
fraud. (1) He is belligerent with both his supervisor and the crew he
manages. (4) On several occasions, staff has complained that they
smelled alcohol on his breath.
Oscar
is 33 years of age, (B) about 6 feet tall, with an average build and dark
good looks. Edgy and irritable, he remains seated only with difficulty. He
simmers as he discusses the details that have brought him here. He immediately
takes the position of one who has been wronged and launches into a
heart-wrenching story of how life has mistreated him cruelly. He regales an
elaborate tale of how his mother is sick in the hospital, and there is no one
but him, the dutiful son, to take care of her. He has been late or absent from
work to take care of her, and he needed the extra money to pay her medical
bills and her rent as well as take care of his alcoholic brother and his eight
shoeless children. These are interesting claims in light of the fact that his
mother died six years ago and he hasn’t seen his bachelor brother in more than
two years. (2)
Eventually,
pieces of Oscar’s history unravel. He came to the United States illegally at
age 4. The family subsisted as seasonal pickers on farms throughout the
Southwest. He speaks condescendingly about his parents, noting that they
pretended to be what they were not, never had a home, had too many kids, were
usually without running water, and were never home. Verbally, they insisted he
keep clean, show respect, and study the books they carried from farm to farm. Nevertheless,
any chance for learning was apparently undermined by Oscar’s aversion to
authority. Occasionally, his parents would rise up to assert their authority,
but these episodes were short-lived. During his teenage years, he was in and
out of juvenile detention centers mostly for truancy and assault. (C)
Trust
is the theme of this first meeting. Married at 18, Oscar refers to his wife
simply as “the bitch.” Apparently, her cooking is inadequate, she puts the kids
and her job before him, and worse, she gets angry if he does not come home
after work. Furthermore, he draws an angry comparison between “the bitch” and
his coworkers, both supervisors and subordinates alike. Like her, they fail to appreciate him and would “fall flat on their faces” if he suddenly disappeared.
“They have it easy,” he says with obvious resentment. “I carry all the
responsibility.” Oscar is angry, viewing therapy as a disciplinary action and
punishment. He makes it clear that the actions of his supervisors and
subordinates will not soon be forgotten. Oscar speaks with a cool calculation.
Not ruled by anger, his actions are instead planful, but punctuated by an
underlying rage. He believes the world to be a hostile place requiring
deliberate defensive and offensive actions. When asked about his plans of
revenge, he replies with cold and unblinking eyes, “They brought it on
themselves.” (7)
DSM-IV Criteria
A. There is a pervasive pattern of
disregard for and violation of the
rights of others occurring since
age 15 years, as indicated by
three (or more) of the following:
(1) failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest
(2) deceitfulness, as indicated by repeated 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
B. The individual is at least age 18 years.
C. There is evidence of Conduct Disorder with onset before age 15 years.
D. The occurrence of antisocial behavior is not exclusively during the course of Schizophrenia or a Manic Episode.
(1) failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest
(2) deceitfulness, as indicated by repeated 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
B. The individual is at least age 18 years.
C. There is evidence of Conduct Disorder with onset before age 15 years.
D. The occurrence of antisocial behavior is not exclusively during the course of Schizophrenia or a Manic Episode.
References
(1) Personality Disorders in Modern Life, second edition,
2000, 2004 by John Wiley & Sons, Inc.
(2)Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition. Copyright
1994 American Psychiatric Association.
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Antisocial Personality
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