Antisocial Personality Disorder

From: Dave Hamilton
To: Judith Bandsma
Subj: DSM Casebook

Hi, Judith.

Sorry to take so long with this; I've been hoping someone out here in the wilderness will set up my Windows 95 machine so I could scan it in. That *still* hasn't happened - the machine is here all in pieces - so I started early and typed it in. Mistakes are mine.

Note that this is quite different from the single case that was in the DSM-III-R. That one was used because it was a subject personally known to the author and quite current. This is one of four cases presented in the DSM-IV. It nicely illustrates Psychopathy (now called Antisocial Personality Disorder) and demonstrates that not all psychopaths kill people.

Here ya go...

-forward- Hervey Cleckley (1905-1984)

In _The Mask of Sanity_ published in 1955, Cleckley attempted to clarify the confusing and paradoxical nature of Psychopathic Personality. According to him, people with this disorder are "outwardly intact, showing excellent peripheral function, but centrally deficient or disabled in such a way that abilities cannot be utilized consistently for sane purposes or prevented from regularly working self-destructive and other serious pathological results." The following case is adapted from his book.


This young man, 21 years of age, does not look at all like a criminal type or shifty delinquent. Tom looks and is in robust physical health. His manner and appearence are pleasing. There is nothing to suggest that he is putting on a bold front or trying to adopt any attitude or manner that will be misleading. Though he knows the examiner has evidence of his almost incredible career, he gives such an impression that it seems for the moment likely he will be able to explain it all away.

This poised young man's immediate problem was serious, but not monumental. His family and legal authorities were in hope that if some (mental) disorder could be discovered in him, he might escape a jail sentence for stealing.

Evidence of his maladjustment became distinct in childhood. He appeared to be a reliable and manly fellow, but could never be counted upon to keep at any task or to give a straight account of any situation. He was frequently truant from school. Though he was generously provided for, he stole some of his father's chickens from time to time, selling them at stores downtown. Pieces of table silver would be missed. These were sometimes recovered from those to whom he had sold them for a pittance or swapped them for odds and ends that seemed to hold no particular value or interest for him.

Often when truant from high school classes, Tom wandered more or less aimlessly, sometimes shooting at chickens, setting fire to a rural privy on the outskirts of town, or perhaps loitering about a cigar store or a pool room, reading the comics, throwing rocks at squirrels in a park, perpetrating small thefts or swindles. He often charged things in stores to his father, stole cigarettes, candy, cigars etc. He lied so plausibly and with such equanimity, devised such ingenious alibis or simply denied all responsibility with such convincing appearances of candor that for many years his real career was poorly estimated. Though he often fell in with groups or small gangs, he never for long identified himself with others in a common cause.

At 14 or 15, having learned to drive, Tom began to steal automobiles with some regularity. After he had tried to sell a stolen car, his father consulted advisers and, on the theory that he might have some specific craving for automobiles, bought one for him as a theraputic measure. On one occasion while out driving he deliberately parked his own car and, leaving it, stole an inferior model, which he left slightly damaged on the outskirts of a village some miles away. Meanwhile, Tom continued to forge his father's name on small checks and steal change, pocketknives, textbooks, etc., at school. Occasionally, on the pretext of ownership he would sell a dog or a calf belonging to some member of the community.

Tom was sent to a federal institution in a distant state, where a well-organized program of rehabilitation and guidance was available. He soon impressed authorities at this place with his attitude and in the way he discussed his past mistakes and plans for a different future.

He found employment in a drydock at a nearby port and talked modestly, but convincingly, of the course he would now follow, expressing aims and plans few could greatly improve on. His employers found him at first energetic, bright, and apparently enthusiastic about the work. Soon evidence of inexplicable irresponsibility emerged and accumulated. Sometimes he missed several days and brought simple, but convincing excuses of illness. As the occasions multiplied, explanations so detailed and elaborate were made that it seemed only facts could have produced them. Later he sometimes left the job, stayed away for hours, and gave no account of his behavior except to say that he did not feel like working at the time.

Reliable information indicates that he has been arrested and imprisoned approximately 50 or 60 times. It is estimated that he would have been put in jails or police barracks for short or long periods of detention on approximately 150 other occasions if his family had not made good on his small thefts, damages, etc, and paid his fines for him.

Sometimes he was arrested for formenting brawls in low resorts, provoking fights, or for such high-handed and disturbing behavior as to constitute public nuicance. Though not a very regular drinker or one who characteristically drank to sodden confusion or stupification, he exhibited unsociable and unprepossessing manners and conduct after taking even a few beers or highballs. In one juke-joint imbroglio, over the years, he is credited with having stuck a fellow reveler on the head with a piece of iron.

Tom's mother had, over the years, suffered special anxiety and distress because of his unannounced absences. After kissing her goodbye, saying he was going downtown for a Coca-Cola or to a movie, he might not appear for several days or even for a couple of weeks! This young man, has, apparently, never formed any substantial attachment to another person. Sexually he has been desultorily promiscuous under a wide variety of circumstances. A year or 2 earlier, he married a girl who had achieved considerable recognition as a local prostitute whose fee was moderate. He had previously shared her offerings during an evening (on a commercial basis) with friends or with brief acquaintences among whom he found himself. He soon left the bride and never showed signs of shame or chagrin about the character of the woman he had espoused or any responsibility toward her.

Cleckley's Diagnosis: Psychopathic Personality

-Discussion of "Tom"-

Tom illustrates all the features required for a DSM-IV diagnosis of Antisocial Personality Disorder (DSM-IV, p. 649): current age over 18, evidence of Conduct Disorder before age 15 (truancy, stealing, lying, vandalism, delinquency, chronic violations of rules at home), and, since age 18, a pervasive pattern of irresponsible behavior and disregard for and violation of the rights of others (failure to sustain consistent work behavior, abandonment of his wife, stealing, lying, assaulting others), and lack of remorse.

One criticism of the DSM=III criteria for Antisocial Personality Disorder was that they put too much emphasis on overt antisocial acts that might result in legal difficulties and not enough on the psychological features of the disorder, such as absence of guilt feelings, loyalty to others, and empathy. Tom certainly demonstrates these psychological characteristics, which Cleckley believed were central to the concept of Psychopathic Personality.

These features were not included in the DSM-III, -III-R, and -IV criteria for Antisocial Personality Disorder for two reasons. First of all, they require more inferential judgements than do the largely behavioral symptoms listed in this criteria. Second, there is evidence that, for the most part, people who exhibit the behavioral disturbances required for the diagnosis of Antisocial Personality Disorder are, like Tom, undersocialized. Finally, in the DSM-IV field trial comparing alternative criteria sets, the more behavioral DSM-III-R criteria had high correlations with external variables indicating validity (e.g., number of marriages and sexual partners, poor work history, number of arrests and convictions) as did criteria for focusing on the characteristic psychological features of the disorder.

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