Prof. Joseph Levine, M.D. is an emeritus associate professor in the Division of Psychiatry, Faculty of Health Sciences, Ben Gurion University in Israel. Prof. Levine is a certified psychiatrist with clinical experience in controlled trials of adult psychiatric disorders and in psychotherapy. He was awarded a NRSAD independent investigator grant for the study of Creatine Monohydrate in psychiatric disorders -- mainly Schizophrenia. He resides and treats patients in Tel Aviv and all of central Israel.
Conversation 55: The Antisocial Personality: Does the "Internalized Personality Board Approach" have anything to contribute on the subject?
Antisocial personality disorder (ASPD) is classified under cluster B of personality disorders in the American diagnostic and classification system known as DSM-5. It is diagnosed more in men than in women. This gender difference may be due to a combination of biological, social and cultural factors.
Antisocial personality disorder is characterized by a long-term pattern of manipulating, exploiting, or violating the rights of others. This disorder is often associated with criminal behavior and substance abuse, making it a significant concern in both clinical and legal settings.
ASPD is not a monolithic condition and can manifest in different forms, often overlapping with other personality disorders. Some researchers propose different subtypes based on specific traits and behaviors:
Aggressive/hostile type: characterized by open aggression, irritability and frequent physical confrontations.
Deceptive/Manipulative Type: Exhibits chronic lying, manipulation, and devious behaviors to take advantage of others.
Impulsive/Risk-Taking Type: Exhibits high impulsivity, lack of foresight, and engaging in risky behaviors without considering the consequences.
Tough/unemotional type: characterized by a deep lack of empathy, shallow emotions and a cold and detached demeanor.
Psychological foundations
Early developmental factors: Childhood experiences, including neglect, abuse, and inconsistent discipline, play a crucial role in the development of ASPD. Adverse childhood experiences can disrupt normal psychological development, leading to maladaptive coping mechanisms and antisocial behavior patterns.
Cognitive deficits: People with ASPD often exhibit deficits in executive functions such as planning, decision making, and impulse control. These cognitive deficits contribute to their inability to conform to social norms and anticipate the results of their actions.
Emotional Dysregulation: Difficulty regulating emotions is a central feature of ASPD. This includes increased sensitivity to threats, poor emotional responses, and an inability to experience guilt or remorse, which reinforces antisocial behaviors.
Biological basics
Genetic factors: Twin and family studies indicate a significant genetic component to ASPD. Heritability estimates for antisocial behavior range from 40% to 50%, suggesting that genetic predisposition plays a crucial role in its development.
Neurobiological factors:
Brain structure and function: Structural and functional abnormalities in the prefrontal cortex, amygdala, and other regions involved in emotional regulation and executive functions have been identified in individuals with ASPD. A decrease in gray matter volume in these areas is associated with impaired impulse control and increased aggression.
Neurotransmitter systems: Dysregulation of neurotransmitters such as serotonin, dopamine, and norepinephrine is associated with impulsive and aggressive behaviors seen in ASPD. Low levels of serotonin, in particular, are associated with increased aggression and impulsivity.
Autonomic nervous system activity: People with ASPD often show reduced autonomic reactivity, such as lower heart rate and lower skin conductance responses. This hypoarousal may contribute to their fearlessness and reduced sensitivity to punishment.
Hormonal effects: Abnormalities in levels of stress hormones, especially cortisol, have been observed in people with ASPD. Hypothalamic-pituitary-adrenal (HPA) axis activity may influence stress responses and aggressive behaviors.
As a rule, the development of ASPD depends on complex interrelationships between genetic, neurobiological and environmental factors. Early interventions targeting at-risk children, especially those exposed to adverse childhood experiences, are essential to prevent the emergence of antisocial behaviors.
Therapeutic approaches, such as cognitive-behavioral therapy (CBT), have shown some efficacy in symptom management, although treatment outcomes remain challenging due to the inherent characteristics of the disorder.
Antisocial personality disorder therefore represents a significant challenge in the field of mental health due to its profound impact on individuals and society. Understanding the underlying psychological and biological variants and mechanisms can help develop more effective prevention and intervention strategies.
Future research should focus on longitudinal studies to decipher the developmental trajectories of ASPD and explore novel therapeutic approaches for antisocial personality disorder (ASPD).
The exact causes of antisocial personality disorder (ASPD) are not fully understood, but studies indicate a combination of structural and functional brain disorders, genetic, environmental, developmental and gender factors. Here is a further breakdown of some of the main reasons:
Deficits in the prefrontal cortex: People with ASPD often have reduced gray matter in the prefrontal cortex, which is the part of the brain responsible for making decisions, controlling impulses and regulating social behavior. This deficiency can lead to impulsive and aggressive behaviors.
Dysfunction of the cerebral amygdala: The amygdala, a brain nucleus that plays a crucial role in processing emotions and especially fear, is often smaller or functions differently in people with ASPD. This can cause a lack of empathy and difficulty recognizing fear or distress in others.
Brain connectivity problem: There is evidence that communication between different areas of the brain, especially between the prefrontal cortex and the amygdala, is impaired in people with ASPD. This disrupted connectivity can contribute to the characteristic behaviors of the disorder, such as impulsivity and emotional dysregulation.
Biochemical factors: There are also biochemical changes associated with ASPD. For example, changes in neurotransmitter systems, such as serotonin and dopamine, have been observed. These neurotransmitters play a role in regulating mood and behavior.
Genetic factors: There is evidence that genetics play a significant role in the development of ASPD. People with a family history of personality disorders or other mental conditions are at higher risk.
Environmental influences: Early life experiences, such as childhood abuse, neglect, or an unstable family environment, can contribute to the development of ASPD. These negative experiences can affect brain development and lead to behavioral problems.
Developmental factors: Changes in brain function and structure, particularly in areas related to impulse control and emotional regulation, are often observed in people with ASPD. These changes can be influenced by both genetic and environmental factors.
Understanding these factors can help identify individuals at risk and develop early interventions to prevent ASPD progression.
In an article by Pujol and his friends from 2019, see the abstract :
[Jesus Pujol et al.. The contribution of brain imaging to the understanding of psychopathy. Psychol Med. 2019 Jan;49(1):20-31].
Psychopathy is a type of personality disorder characterized by both harsh emotional functioning and deviant behavior that affects society in the form of actions that harm others. Historically, researchers have been searching for data and arguments to support a neurobiological basis for psychopathy. In recent years, a growing body of research has begun to uncover brain changes that seem to underlie the enigmatic psychopathic personality.
In their review, the authors describe the anatomical and functional features of the brain that characterize psychopathy from a synthesis of available brain imaging studies, and discuss how such brain anomalies may explain psychopathic behavior. Consistent results show anatomical changes involving mainly the ventral cerebellar system connecting the anterior temporal lobe to the frontal and ventral regions, and the dorsal cerebellar system that connects the middle frontal lobe to the posterior cingulate gyrus / precuneus complex, and in turn, to medial cerebral structures of the temporal lobe. Functional imaging data indicate that a tendency toward relevant collapse of emotional flow may occur in both of these brain systems and suggest specific mechanisms by which emotion is abnormally integrated into cognition in psychopathic individuals during moral challenges.
Directions for future research describe and emphasize, for example, the relevance of further establishing the contributions of environmental stress at a young age to inhibit the learning of emotional self-disclosure, and the potential role of androgenic hormones in the development of cortical anomalies.
Below we present a case report that examines the life of Henry Lee Lucas, a well-known American criminal, through the lens of antisocial personality disorder (ASPD). The report discusses his early life, his criminal behaviors, psychological evaluation, and the biological and environmental factors that contributed to the development of ASPD.
This case highlights the complexity of ASPD and the interplay between genetic predispositions and environmental influences.
Henry Lee Lucas is one of the most notorious criminals in American history, often cited as the prototype of a person with ASPD. His life story provides a compelling case study for examining the psychological and biological underpinnings of the disorder. This report will detail his background, his criminal activities and the findings of the psychological evaluations conducted during his imprisonment.
Henry Lee Lucas was born on August 23, 1936 in Blacksburg, Virginia. His childhood was characterized by severe abuse and neglect:
Family environment: Lucas grew up in a dysfunctional family. His mother, Viola Lucas, was a violent alcoholic who often physically and emotionally abused him. His father, Anderson Lucas, was an amputee who was also an alcoholic and largely absent from Lucas's life.
Early Abuse: From a young age, Lucas was subjected to extreme physical abuse by his mother, including beatings and forced cross-dressing. He also witnessed the abuse of his brother.
Education and Socialization: Lucas had minimal education, dropped out of school early and had difficulty with social interactions. He was known to show cruelty to animals and other children, early signs of antisocial behavior.
Criminal behaviors: Lucas' criminal activity spanned several decades and included a variety of violent offenses:
Early criminal activity: His criminal behavior began in his teens with petty thefts and escalated to more serious crimes. In 1960 he was convicted of murdering his mother and sentenced to prison.
Murders and confessions: Upon his release, Lucas' criminal activity increased. He has accepted responsibility for hundreds of murders across the United States, although the veracity of many of these confessions is disputed. However, he was convicted of several murders based on evidence.
Pattern of Operation: Lucas often targeted vulnerable people, using manipulation and deception to gain their trust before committing violent acts. His crimes were characterized by a lack of remorse and a calculated approach to avoid detection.
Psychological assessment: Lucas underwent several psychological evaluations during his imprisonment:
ASPD Diagnosis: Psychologists diagnosed Lucas with ASPD, noting his common pattern of disregarding the rights of others, cheating, impulsivity, irritability, and lack of remorse.
Cognitive and emotional deficits: Assessments revealed significant deficits in Lucas's cognitive functioning, especially in areas related to executive functions, impulse control and emotional regulation. He exhibited shallow emotions, a lack of empathy, and an inability to form genuine interpersonal relationships.
Personality Traits: Lucas displayed traits consistent with the rigid/unemotional subtype of ASPD, including a profound lack of guilt or remorse for his actions and a cold, detached demeanor during interviews and assessments.
Biological and environmental factors: The development of ASPD by Lucas can be attributed to a combination of genetic, neurobiological and environmental factors:
Genetic predisposition: While specific genetic factors in Lucas' case are not well documented, his family history of alcoholism and antisocial behaviors points to a potential genetic component.
Neurobiological factors: Brain imaging studies of similar cases indicate structural abnormalities in the prefrontal cortex and amygdala, areas involved in emotional regulation and impulse control. Although specific studies on Lucas are lacking, such abnormalities are consistent with his behavioral profile.
Environmental Influences: The severe abuse and neglect that Lucas experienced during his formative years likely played a crucial role in shaping his antisocial behaviors. Chronic exposure to violence and instability disrupted his psychological development, fostered maladaptive coping mechanisms and strengthened his antisocial tendencies.
The life and criminal career of Henry Lee Lucas exemplifies the complex interplay of biological and environmental factors in the development of ASPD. His case highlights the importance of early intervention in children at risk and the need for comprehensive approaches to understanding and treating personality disorders.
The discrepancies in his confessions also highlight the challenges in assessing and managing people with ASPD, who often have manipulation and deception as part of their behavioral repertoire.
The case of Henry Lee Lucas thus provides important insights into the manifestations of ASPD and the contributing factors. It emphasizes the need for a multidisciplinary approach in both research and clinical practice to deal with the complexity of this disorder. Future studies should strive to integrate genetic, neurobiological and psychological data to develop more effective prevention and intervention strategies.
As mentioned, antisocial personality disorder (ASPD) is mainly associated with negative social outcomes due to the inherent characteristics of deception, manipulation and lack of remorse. However, you'd be surprised people with ASPD can also indirectly contribute to society in various ways.
Although antisocial personality disorder (ASPD) is a mental condition characterized by a common pattern of disregard for the rights of others, which is usually associated with criminal behavior, poor social functioning, and significant personal and social costs, however, the question arises as to whether individuals with ASPD may indirectly contribute to society through their unique traits and behaviors.
Traits associated with ASPD: People with ASPD often exhibit certain traits that, while problematic in many contexts, can be advantageous in specific situations:
Fearlessness: Reduced sensitivity to fear and punishment, which can be beneficial in high-risk environments.
Decisiveness: the ability to make quick decisions without excessive judgment.
Charisma and manipulation: skills of persuasion and influence, which can be leveraged in leadership roles.
Resilience and tolerance to stress: high tolerance to stress and negative situations, which allows them to function effectively in challenging situations.
Potential indirect contributions:
Entrepreneurship and business leadership
Risk-taking and innovation: People with ASPD may excel in entrepreneurial ventures due to their willingness to take risks and their innovative thinking. Their fearlessness can drive bold business decisions that others might shy away from, which can lead to breakthrough innovations and economic growth.
Decisive leadership: Their ability to make quick and solid decisions can be an asset in fast-paced business environments, enabling dynamic leadership and effective crisis management.
Emergency services and high-risk professions
Courage under fire: The fearlessness associated with ASPD can be an asset in professions that require regular exposure to danger, such as firefighting, law enforcement, and military service. Their ability to remain calm and focused in life-threatening situations can save lives and contribute to public peace.
Effective crisis response: Their resilience and resistance to stress allows them to function well in emergency and disaster response roles, where quick thinking and composure are critical.
Contributions to the social sciences
Insight into criminal behavior: The study of people with ASPD provides valuable insights into criminal behavior, helping to develop better prevention measures, interventions, and rehabilitation programs. Researchers and clinicians can learn from their patterns of thinking and behavior to improve the methods of forensic psychology and criminology.
Improving psychological and sociological theories: Understanding the cognitive and emotional processes of people with ASPD can refine theories related to morality, empathy and social behavior, and contribute to a deeper understanding of human psychology.
Ethical considerations
While recognizing the potential contributions of people with ASPD, it is essential to address the ethical implications:
Risks of Exploitation: Leveraging the qualities of people with ASPD in high-risk occupations or leadership roles must be done ethically to prevent exploitation of others and ensure that the welfare of others is preserved.
Balancing benefits and harms: Society must balance the potential benefits of their contributions with the risks of harming others. Policies and practices should be in place to mitigate the negative effects of their behavior.
Rehabilitation and support: Providing appropriate support and rehabilitation opportunities for people with ASPD is essential. This includes treatment, social integration programs and continuous monitoring to ensure that their actions conform to social norms.
The potential indirect contributions of individuals with ASPD to society thus highlight the complexity of human behavior and the possibility of positively leveraging certain traits. However, this should be approached with caution and ethical considerations. By understanding and managing the risks associated with ASPD, society can potentially harness the unique strengths of these individuals while minimizing negative outcomes.
In 2024, Emilie Flaaten and her colleagues published an interesting article entitled: Antisocial Personality Disorder and Therapeutic Pessimism – How can mentalization-based therapy contribute to increased therapeutic optimism among healthcare professionals?
[Emilie Flaaten, Maria Langfeldt, and Katharina T. E. Morken. Antisocial personality disorder and therapeutic pessimism – how can mentalization-based treatment contribute to an increased therapeutic optimism among health professionals? Front Psychol. 2024, 15. [1320405:
The following is the summary of the article, followed by a translation of parts that will add to the discussion we are dealing with:
"Antisocial personality disorder (ASPD) is associated with treatment pessimism among health care professionals. Several variables are associated with obstacles to therapist willingness to treat ASPD. Relevant variables are: (i) confusion related to the term ASPD, (ii) characteristics of the disorder, (iii) ) attitudes, experiences and knowledge that clinicians have, and (iv) insufficient management of counter-transference.
We hypothesize that therapeutic pessimism is related to the lack of effective evidence-based treatment for people with ASPD. This is problematic because ASPD is associated with socio- Great savings and great suffering for the individual and society.Mentalization-based therapy (MBT) was developed as a treatment for borderline personality disorder (BPD) and is currently considered an effective treatment for this group.
Mentalization is defined as the process by which people understand themselves and others in terms of subjective states and mental processes. This ability affects his psychological functioning, his mental health, his self-organization and his interpersonal relationships.
The overall goal of MBT is to strengthen the individual's mentalizing abilities and facilitate a more adaptive treatment of problematic internal situations. A version of MBT adapted for people with ASPD (MBT-ASPD) has recently been developed. The authors reviewed how MBT-ASPD addresses the main obstacles that contribute to therapeutic pessimism towards this group. Despite a limited evidence base, preliminary studies indicate promising results for MBT-ASPD. Further studies are still needed, this review suggests that MBT-ASPD can contribute to increased therapeutic optimism and demonstrate specific characteristics of MBT-ASPD that contribute to the management of therapeutic pessimism."
In the introduction to their article, the authors claim that "in their clinical guidelines, the National Institute for Health Care and Excellence (NICE) notes how the 'therapeutic pessimism' among health professionals towards antisocial personality disorder (ASPD) is repeatedly highlighted in the literature (National Institute for Health Care and Excellence in treatment, 2010). Stereotypical perception of ASPD is widespread … and the negative attitudes towards people with ASPD have been characterized by the idea that this group is not treatable or may even get worse from treatment (Rice et al., 1992)."
In recent years, this view appears to have changed somewhat in accordance with increased focus and research on the potential treatment opportunities for ASPD. However, today there is still no evidence-based treatment for this group (National Institute for Health and Care Excellence, 2010; Gibbon et al., 2020). Understandably, with the lack of effective treatment options for ASPD, treatment pessimism among health care professionals is likely to continue.
"Several attempts have been made to ensure that ASPD is no longer a diagnosis of exclusion (Pickersgill, 2009). NICE has developed clinical guidelines covering general and ASPD-specific treatment principles, as well as suggestions for potential preventative measures and early intervention. Two Cochrane reviews with a 10-year gap between them (2010, 2020) studied several psychological interventions for ASPD, the latest review summarizing the findings from 19 randomized controlled trials (RCTs) comparing 18 different psychotherapies to treatment as usual (TAU). Some RCTs suggest that specialized psychotherapy may be more effective than TAU for People with ASPD However, both Cochrane reviews concluded that there is a lack of good quality evidence on how to effectively treat people diagnosed with ASPD (Gibbon et al., 2010: 2020).
In a recently published RCT, researchers compared ST to TAU among offenders with personality and aggression disorders. They found that ST produced faster improvements than TAU (Bernstein et al., 2023). Although the findings need replication, the study contradicts the belief that people with ASPD are untreatable. In conclusion, the NICE guidelines summarize several therapeutic principles that may be useful when treating people with ASPD and findings from several RCTs suggest that specialized psychotherapy may be more effective than TAU. However, there is still insufficient treatment provision for this patient group (National Institute for Health and Care Excellence, 2010)."
This article therefore supports that certain types of psychotherapy can be effective. The article continues and discusses the pessimism of ASPD treatment.
“ASPD has been treated for years, in forensic and regular mental health settings (Gibbon et al., 2020). There are treatment options offered to people with ASPD, but they seem to be insufficient to effectively treat the disorder.
The unmet needs of many people with ASPD reflect a need for change In health care provided today (National Institute of Health and Care Excellence, 2010), treatment pessimism among health care professionals appears to be a particularly important reason for the lack of effective treatment options for ASPD.
Four main themes related to therapeutic pessimism recur in particular. These are: (i) confusion related to psychopathy and ASPD (ii) treatment-defying behavior, (iii) refusal to accept treatment and (iv) poor management of countertransference.
Investigating these obstacles could be an important step toward finding effective treatments for people with ASPD."
ASPD and psychopathy are terms that have been discussed and understood differently throughout history. Different debates about what ASPD and psychopathy are, and a growing interest in more clinical psychological perspectives, have shaped the development of the diagnosis and its nosology. Originally in the context of DSM II and DSM III, researchers argued for the existence of two different personality types: a tougher one with low anxiety, the so-called psychopathic subtype, and a more aggressive personality that is unstable and emotionally driven, the sociopathic or antisocial subtype (Pickersgill, 2012).
Today there is some confusion about what everyone means when discussing this diagnosis. The DSM-IV and 5 version of ASPD contain more behavioral traits such as impulsivity, cheating, recklessness, aggression, illegal behaviors, irresponsibility and less psychopathic personality traits.
Hence, the DSM ASPD is more inclusive than, for example, the psychopathic personality as defined by the PCL-R (Hare, 2003), covering more of the intrapsychic aspects of the disorder such as rigidity, grandiosity, shallow emotionality, laxity, and manipulativeness along with overlapping behavioral traits similar to the ASPD diagnosis in the DSM. Therefore, although ASPD and psychopathy share some characteristics, there are differences between these two disorders. ASPD is a broader and more inclusive term based largely on behavioral traits such as antisocial behavior and crime."
So it seems to recognize a more severe type of personality disorder that combines both narcissistic traits and ASPD traits in addition to severe personality defects and is characterized by fearlessness and boldness. Apparently this type will be more difficult to treat than the usual antisocial personality.
In the model we are developing for understanding the self, we assume that the individual's "social self" consists of the internalization of influential figures in his life, arranged in a hierarchical order [the group of these internalizations we metaphorically called "the board of internal figures"], where one or more internalized figures have the greatest influence, especially about the attitudes, feelings and behavior of the individual, whom we called "the leader(s) – self (selves)" [a figure that was also called before "the dictator – self": see previous conversations].
It is possible that, similar to short-term memory, parts of which are transferred to long-term memory, it’s valid even with regard to the internalization of characters. In other words, there is a short-term internalization that, depending on the circumstances, the importance and duration of the character's influence, will be transferred to long-term internalization in the internalized directorate of characters.
The social self consists of "secondary selves" which include the following types:
1) The variety of "self-representations" that originate from attitudes and feelings towards the self and its representations in different periods of life.
2] Representations of internalized characters that originate from the significant characters that the person was exposed to during his life, but as mentioned, there may also be imaginary characters represented in books, movies, etc. that greatly influenced the person.
3] internalized representations of "subculture" [subculture refers to social influences in the environment in which a person lives and are not necessarily related to a specific person].
This model is at the base of the therapeutic method focused on reference groups [valid both for characters internalized within the individual's mind and for external characters or groups surrounding a person] (REFERENCE GROUP FOCUSED THERAPY or RGFT).
AI-assisted illustration: The Board of Internalized Characters. The size of the figures expresses the hierarchy headed by the internalized inner leader
From the point of view of REFERENCE GROUP FOCUSED THERAPY (RGFT) it seems useful to distinguish between two extreme situations: one with a heavy biological load and the other with a heavy psychosocial load, although it is possible to have combinations of these two.
The reason for this is the fact that RGFT is particularly effective in cases where the pathological condition is caused by "disorders associated to social influence" – due to psychosociological effects.
In fact, RGFT coined a new term: SIRD (SOCIAL INFLUENCE RELATED DISORDER) to characterize such a condition.
In cases where the antisocial phenomenology can be characterized as SIRD, it can be assumed that this condition is closely related to a certain type of inner leader and/or subculture within the management of the person's internalized characters that activates antisocial behavior and attitudes.
When talking about the inner leader, it can be one or more people in the person's life who have deeply influenced them and therefore have the highest rank in the inner hierarchy of the individual's internalized board of directors. It can be assumed that these characters exhibited blatant anti-social behavior and that their emotional tone, attitudes and behavior were internalized.
A similar thing can be said about the individual's internalized subculture. If the external subculture in which the individual lived during his growth and development was mainly associated with the enforcement of aggressive, exploitative and criminal behavior along with frequent use of illicit drugs and excessive alcohol consumption, it can be expected that its internalized counterpart in the board of figures in the psyche of the child and adolescent will be characterized by similar attitudes and behavior.
It is also important to mention that apart from the internalized characters that can negatively affect a person with ASPD, there are often real and active reference groups (such as close friends or exploitative criminal partners and criminals dependent on drugs or alcohol, etc.) that may inspire or enforce antisocial behavior.
Here is the place to point out that such people are not expected to seek help on their own and that it is more likely that they will end up in therapeutic settings within penal systems.
By the way, as the research data shows, one of the brain disorders found in ASPD is dysfunction of the amygdala, which can cause, among other things, difficulty in recognizing fear or distress in others and perceiving or feeling the emotion of fear in yourself.
We will add here that we hypothesize that the internalization of social norms is closely related to the emotion of fear [fear of punishment or the reaction of the group in which the individual lives] and that this internalization is based on interactions that convey the desired behavior (norms) to the individual while communicating about expected punishment measures in the event that the norms are not implemented.
This is usually related to causing a feeling of fear in the individual involved as part of the emotional repertoire and internalization of the corresponding attitudes (norms) of a significant person [for example, the figure of the father or the educator] and/or the relevant subculture. This internalization may prevent violation of the associated norm in the future.
In ASPD associated with dysfunction of the amygdala [this seems to be more relevant in the psychopathic type] there may be a failure to internalize the emotion of fear as part of the necessary pair (fear + declarative formulation of the relevant norm) that determines compliance with this norm in the future.
Thus, there is a chance that only the declarative part about the norm will be internalized without the necessary complementary emotional component (fear).
This may explain common behavior in people with ASPD who have no difficulty citing the norms and even use this knowledge to manipulate others while disobeying the norm themselves.
We will now elaborate more on the analysis of the antisocial personality disorder (ASPD) using the model "directorate or board of internalized characters" that was briefly presented above.
Key characters and influences:
Negative role models: People with ASPD may internalize negative role models in their internalized role models from early life, such as abusive or neglectful parents, delinquent peers, or other influential figures who modeled antisocial behavior.
Cultural and subcultural influences: These people may have internalized characters from a subculture that glorifie antisocial behavior, crime, or rebellion against social norms.
The internalization process:
The internalization of these negative characters occurs through repeated exposure, learning and reinforcements. These characters influence an individual's beliefs, values and behaviors, and shape an anti-social worldview.
Hierarchy within the directorate of internalized characters:
Dominant internalized characters:
The Leader-Self: In people with ASPD, the Leader-Self may represent a strong, unempathetic, domineering figure who favors self-interest, power, and disregard for social norms.
Suppressed positive influences: Any positive influence through internalized empathic characters is often repressed or overrun by the dominant antisocial characters.
Internal conflicts and power dynamics:
The hierarchy is usually skewed towards the dominance of antisocial characters, which leads to a lack of internal conflict about the morality of their actions. Instead, the conflict may arise in the form of frustration in light of social restrictions or consequences.
We note that in previous conversations we mentioned that "trigger event analysis" (TEA) is an analysis of the type of events that may negatively affect a person. Trigger event analysis divides all triggers that lead to negative mental impact into 6 categories called "sensitivity channels" of the individual.
These are related to: 1] status, 2] norms, 3] attachment 4] threat, 5] routine 6] energy.
These triggers have explicit or implicit social characteristics, i.e. they are related to the reference groups of the patients (the manual of internalized characters and the groups of characters in external reality). As a rule, these are negative triggers, or in other words, events that accelerate deterioration or distress in the mental state.
A negative trigger is defined as an event that precipitates a mental deterioration that stands with the deterioration in a causal relationship and for which the deterioration appears in a temporal context.
As mentioned, we classify such triggers as belonging to one of the following types:
Status within the reference group: Examples of such a trigger could be changes in employment status, deterioration in marital relations, a significant lottery win, and more.
Conflict with norms related to the reference group: examples of such a trigger can be: pressure from the reference group on the person to perform an action that is inconsistent with the person's moral norms, inability to obey the norms of the reference group (for example due to the person's intellectual ability), unwillingness to accept the norms of the reference group, consequences of violating the norms of the reference group (and consequently a certain punitive response of the reference group).
Change (or threat of change) in the communication system with significant figures to the person: the death of a significant other, severance of relations with a lover, interference with physical contact with a significant other (as a result of being drafted into the army, entering a boarding school, etc.). On the other hand, there are events such as the birth of children, marriage, entering a new reference group (for a new job, starting studies), etc. Such a change also includes a change in the personal relationship with a pet (eg a beloved dog) or an object of great value to a person.
Threat to human survival (physical or economic): economic problems, serious life-threatening diseases, etc. belong to this category.
A significant change in lifestyle: Examples such as moving to a new place, vacation, change in work routine, change of role (becoming a parent, retirement, enlistment in the army, etc.) can be mentioned here.
Deterioration of human energy resources: as a result of: overwork, lack of sleep, unbalanced meals or undereating, related diseases and more.
In general, "trigger event analysis" helps us identify the patient's core issues that need to be addressed. The triggers are compared against the relevant reference groups.
If triggers are associated with a limited number of specific external reference groups, it is likely that the problem will be related to those external groups – here it is recommended to use the "Reference Group Focused Treatment" method for external groups (which will be called "RGFT for external reference groups").
If the triggers refer to an internal reference group – the problem is probably in the patient himself. In this case, "Reference Group Focused Therapy for Internalized Groups" (RGFT Internalized Reference Group) is recommended.
In light of this, this personality disorder can also be understood in light of the analysis of trigger events.
Sensitivity channels:
Status sensitivity: People with ASPD may be highly sensitive to perceived threats to their status or power, leading to aggressive or manipulative behaviors.
Sensitivity to norms: These people often reject social norms, and find themselves in conflict with laws and regulations, which can result in antisocial actions.
Attachment sensitivity: Early attachment disorders can lead to a lack of empathy and emotional connection, and contribute to antisocial behaviors.
Trigger events:
Perceived threats: Trigger events can include perceived threats to an individual's autonomy, control, or power.
Social conflicts: situations involving social rejection, authority challenges or legal consequences can act as triggers and reinforce antisocial behavior patterns.
What are the therapeutic options available to treat this personality disorder:
First we suggest that reference group focused therapy (RGFT) can be relevant although there is still a lack of research on the subject:
Goal: to identify and change the influence of negative internalized characters (RGFT for internal groups) and/or actual external reference groups (RGFT for external groups) and strengthen any repressed positive influence.
Application: Therapists work to help people recognize the influence of their internalized characters. Through guided reflection and cognitive restructuring, people can begin to challenge and change these influences. Effective mainly in the psychological type of antisocial personality disorder, with a limited effect regarding the subtype of psychopathy.
You can also use the following treatments:
Cognitive behavioral therapy (CBT):
Purpose: to treat distorted thinking patterns and behaviors related to ASPD. Basically, the treatment works to change the attitudes of the internalized dominant characters that reflect antisocial content.
Application: CBT techniques can help people with ASPD identify and change negative thought patterns.
Therapists can work on building empathy and prosocial behaviors through role playing, perspective taking, and reinforcing positive behaviors. This treatment has a limited effect and can be combined with RGFT.
Narrative therapy:
Goal: to reshape the individual's personal narrative and his internalized characters.
Application: Therapists encourage people to externalize their problems and rewrite their stories, emphasizing positive change and developing a more pro-social identity. This treatment has a limited effect and can be combined with RGFT. It can be combined with RGFT
Attachment-based interventions:
Goal: treat early attachment disorders with introverted characters and build healthier relational patterns.
Application: Therapists focus on developing safe attachment relationships, both within the therapeutic framework and in the individual's personal life, while cultivating empathy and emotional regulation. This treatment has a limited effect and can be combined with RGFT.
We note that there is evidence that dialectical behavior therapy (DBT) and mentalization-based therapy (MBT) are therapeutic approaches that can be successfully used to treat various personality disorders, including antisocial personality disorder (ASPD).
Dialectical Behavior Therapy (DBT):
Initiator: Marsha Linehan in the late eighties.
Original Purpose: Originally developed to treat borderline personality disorder (BPD).
Core components:
Individual therapy: focuses on personal issues and application of skills.
Group skills training: teaches behavioral skills in a group setting.
Telephone training: offers support between sessions.
Caregiver Advisory Team: Provides support and guidance to caregivers.
Relevance of DBT to ASPD:
Emotional regulation: Helps people with ASPD manage strong emotions, which can reduce impulsive and aggressive behaviors.
Distress Tolerance: Teaches skills to tolerate distressing situations without resorting to harmful behaviors.
Interpersonal Effectiveness: Improves interactions and social relationships, and addresses the interpersonal deficits seen in ASPD.
Mindfulness: encourages non-judgmental awareness of the present moment, assists in self-reflection and behavioral regulation.
Efficiency:
This treatment has shown promise in reducing destructive behaviors, improving emotional regulation, and improving interpersonal functioning. Its structured approach and focus on practical skills make it applicable to ASPD, although more research is needed to establish its effectiveness specifically for ASPD.
Mentalization Based Therapy (MBT):
Developers: Peter Fonagy and Anthony Bateman in the early 2000s.
Original purpose: developed to treat borderline personality disorder (BPD).
Core components:
Mentalization: the ability to understand oneself and others in terms of mental states (thoughts, feelings, intentions).
Therapeutic Relationship: Utilizes the therapist-patient relationship to explore and improve mentalizing ability.
Group and individual therapy: combines the two formats to strengthen mentalization skills.
Enhanced Empathy: Improves the ability to understand the feelings and perspectives of others, which is often impaired in ASPD.
Impulse control: A better understanding of one's mental states can lead to improved impulse control and reduced antisocial behaviors.
Interpersonal Relationships: Helps develop healthier relationships by improving communication and emotional understanding.
Comparison and complements:
DBT focus: primarily skill-based, focusing on practical techniques for managing emotions, tolerance for distress, and improving relationships.
MBT Focus: Emphasizes understanding one's own and others' mental states, cultivating deeper self-awareness and empathy.
Application:
Both treatments require skilled therapists and can be delivered in individual and group formats. The choice between DBT and MBT, or a combination of both, depends on the specific needs and characteristics of the person with ASPD.
DBT and MBT offer valuable approaches to treating antisocial personality disorder by addressing key areas such as emotional regulation, impulse control, empathy, and interpersonal relationships. Further research and clinical experience will continue to refine their application and effectiveness for ASPD.
We suggest that understanding antisocial personality disorder through the "Reference Group Focused Therapy" model especially in the psychological type of personality disorder that involves the individual's upbringing environment [and does not involve genetic characteristics] that assumes a deep influence of negative internalizations, especially that of the dominant role of the leader-self [besides the activating events that reinforce antisocial behaviors] allows the integration of this approach in the variety of treatments suggested above, especially in combination with DBT and MBT.
It is also recommended to consider in the treatment the information arising from the analysis of trigger events for the specific patient.
That's it for now,
yours
Dr. Igor Salganik and Prof. Joseph Levine
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