NCP Anti Social Personality Disorder

DSM-IV

301.7 Antisocial personality disorder

“Sociopath” and “psychopath” are terms often used to describe the individual with antisocial personality. As deceit and manipulation are central features of the disorder, it is extremely difficult to treat. Imprisonment has been society’s major method for controlling the most dangerous behaviors.

ETIOLOGICAL THEORIES

Psychodynamics

Psychodynamically, this individual remains fixed in an earlier level of development. Because of parental rejection or indifference, needs for satisfaction and security remain unmet, and the ego is underdeveloped. Because of a lack of ego strength, behavior is id directed and results in the need for immediate gratification. An immature supergo allows this individual to pursue gratification, regardless of means and without experiencing feelings of guilt.

Biological

Genetic involvement has been implicated in studies that showed that individuals with antisocial personality, and their parents, showed excessive EEG abnormalities when these examinations were conducted on both groups. Some research suggests that a variant of the D4 dopamine receptor gene (D4DR) appears more frequently in individuals who report high levels of “novelty seeking.” People scoring high on this characteristic are often judged to be excitable, quick-tempered, and seek out thrilling sensations/situations—features associated with antisocial personality disorder. However, no clear effect on personality has been demonstrated at this time. (Despite genetic or environmental factors, sociopaths choose their lifestyle; therefore, it is up to them to choose to change it.)

Family Dynamics

Family functioning has been implicated as an important factor in determining whether or not an individual develops this disorder. The following circumstances may predispose to the disorder: absence of parental discipline (teaching/guidance), extreme poverty, removal from the home, growing up without parental figures of both sexes, erratic and inconsistent limit-setting, being “rescued” each time the person is in trouble (never having to suffer the consequences of own behavior), and maternal deprivation.

CLIENT ASSESSMENT DATA BASE

Circulation

Heart Rate: Slight increase may be demonstrated when anticipating stress (correlates with electrodermal responses indicating minimal anxiety)

Ego Integrity

Lacks motivation for change, often not seeking therapy voluntarily (unless client can no longer tolerate the mess he or she has made of own life or is facing long-term imprisonment)

Absence of feelings of guilt/shame

Use of aliases

Neurosensory

Mental Status: Personality appears charming, engaging, and is usually intelligent; demeanor is often a pretense intended to deceive or facilitate exploitation of others; manipulation is style of operating (e.g., needs and demands immediate gratification); low tolerance level results in feelings of frustration when desires are not immediately gratified

Mood: Adaptive to individual’s intended goal, mood may range from charming and pleasant to intensely angry

Affect: Emotional reactions may be erratic and extreme, with lack of concern for other people’s feelings

Thought Processes: Client is preoccupied with own interests and has grandiose expressions of own importance, poor insight/judgment, and impulsivity or failure to plan ahead

Signs of personal distress possibly evident (e.g., tension and poor tolerance for boredom)

Lacks emotional attachment to others—even parents

Displays preference for stimulation rather than isolation

Safety

Experiences low level of autonomic arousal and responds to dangerous or painful stimuli with minimal anxiety

Reckless disregard for safety of self/others

May be homeless—living on the streets or from others’ charity

Sexuality

Early, aggressive, sexual acting-out behaviors

Social Interactions

Occurs most frequently in lower socioeconomic populations

Family may be dysfunctional with little positive interaction; may be history of violence in the home

Displays chronic antisocial behavior incompatible with the value system of general society (e.g., lying, stealing, fighting, frequent conflicts with the law, conning others for personal profit or pleasure)

Repeatedly violates the rights of others without remorse (i.e., is indifferent to or rationalizes behavior [is thought to be without a conscience])

Rejects authority, has contempt for morality, does not learn from the past, and does not care about the future

Significant impairment in social, marital, and occupational/military functioning (generally has poor employment history, fails to honor financial obligations)

Teaching/Learning

More prevalent in males (with onset in childhood) than females (with onset at puberty)

History/evidence of conduct disorder with onset before age 15 with antisocial behaviors occurring since age 15 and usually diminishing after age 30, when the individual seems to “mellow out”/get tired of situation

Alcohol/substance abuse

DIAGNOSTIC STUDIES

EEG: Abnormally higher amounts of slow-wave activity, reflecting a possible deficit in inhibitory mechanisms, which may lessen impact of punishment.

Aversive Stimuli: Tends to be slower in learning to avoid shock, associated with a lower than normal level of physiological arousal; heightened ability to tune out aversive stimuli.

Psychopathy Checklist: Recently developed rating scale identifies 2 sets of characteristics (impulsiveness and instability; callousness, egocentricity, and limitation of capacity for anxiety) that are useful in predicting client outcome and likelihood of future violent crime activity.

Drug Screen: Determines substance use

NURSING PRIORITIES

1. Limit aggressive behavior; promote socially acceptable responses.

2. Develop a trusting relationship.

3. Assist client to learn healthy ways to deal with anxiety.

4. Increase sense of self-worth.

5. Promote development of alternate, constructive methods of interacting with others.

DISCHARGE GOALS

1. Self-control maintained.

2. Assertive behaviors used to gain desired responses.

3. A trusting relationship initiated.

4. Anxiety recognized and diminished/managed.

5. Client/family involved in ongoing therapy/support groups.

6. Plan in place to meet needs after discharge.