antisocial 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.

nursing diagnosis violence, risk for, directed at others

risk factors may include: contempt for authority/rights of others (antisocial
character)
inability to tolerate frustration; need for immediate
gratification; easy agitation
vulnerable self-esteem; inability to verbalize feelings
use of maladjusted coping mechanisms including
substance use
negative role modeling; suspiciousness of others
[possible indicators:] body language (muscle tension, facial expression, rigid
posture); increased motor activity, irritability,
agitation
hostile, threatening verbalizations (boasting of prior
abuse of others); possession of destructive means
becoming assaultive when angry; choice of aggression
to meet needs; overt and aggressive acts
substance abuse
desired outcomes/evaluation criteria— verbalize understanding of why behavior occurs,
client will: its consequences, and how it affects outcome(s).
 develop and use assertive/nonaggressive, socially
acceptable behaviors to gratify needs and interact
with others.
demonstrate self-control as evidenced by relaxed
posture and manner.

ACTIONS/INTERVENTIONS RATIONALE

independent
convey accepting attitude toward client. work on feelings of rejection are undoubtedly familiar to
development of trust. be honest, keep all promises, client. an attitude of acceptance promotes feelings
and convey message that the behavior, not the client, of self-worth. trust is the basis of a therapeutic
is unacceptable. relationship. note: major obstacles in working
with this client lie in an inherent inability to form a
trusting, open relationship with a therapist.
maintain low level of stimuli in client’s environment a stimulating environment may increase agitation
(low lighting, few people, simple decor, low noise and promote aggressive behavior.
level).
provide structured environment, set firm limits individuals with antisocial personality disorder
(e.g., consistent schedule, ward rules, expectations often function better in a controlled setting.
of the client for cooperating. involve client in structure discourages escalation of aggressive
process and follow through with consequences). behaviors and facilitates therapeutic intervention by
reducing the anxiety caused by ambiguity.
encourage verbalization of feelings and provide increases client’s self-awareness of feelings and
outlet for expression. stressors.
help client identify the true object of his or her because of weak ego development, client may be
hostility (e.g., “you seem to be upset with . . .”). misusing the defense mechanism of displacement.
helping client recognize this in a nonthreatening
manner may reveal unresolved issues so that they
may be confronted.
note distortions of the truth, manipulation. confronting unacceptable behaviors helps to
confront client with these behaviors in a calm but increase client’s awareness of own feelings and the
firm manner, pointing out discrepancies in effect these feelings and behaviors have on others.
statements and behaviors.
monitor escalating behaviors (e.g., increased client can become dangerous very quickly with or
psychomotor activity, threats, attempts to without provocation. early detection provides
intimidate). isolate if observed to be losing control. opportunity to alter behavior before violence
occurs.
be aware of prior history of violent behavior, therapist needs to be aware of client’s style of
seriousness of homicidal tendency, gestures, threats. acting and behaviors to provide a safe
(use scale 1–10 and prioritize according to severity environment and protect client and others.
of threat, availability of means.)
remove all dangerous objects from client’s decreases availability of “means” that can
environment, as appropriate. compromise safety of client/others.
remain calm and nonaggressive in communicating anger is released through others. not responding
with client. avoid responding to client’s verbal to client’s anger breaks cycle, providing
hostility with anger. opportunity for change.
assist client to identify when feelings of loss of recognition of these events provides an
control began and to identify events that led to this opportunity for resolution/adaptation of more
situation. effective behaviors. note: these individuals have
often been victims of child abuse and need to deal
with these feelings.
explore with client how aggressive, destructive needs to realize own role and responsibility in
behaviors have affected interpersonal relationships personal interactions.
(e.g., with children, spouse, parents, peers).
discuss ways to detect potentially provocative/ these clients tend to tune out aversive stimuli and
volatile situations before becoming involved. help need to increase awareness of environment to
client learn to anticipate situations that usually avoid becoming involved in volatile situations.
result in anger, and develop a plan to handle anger restructuring helps to eliminate old behavioral
before losing control. patterns that result in acting out. a plan of action
provides client with a feeling of control.
review with client the benefits of using assertive consequences serve as the best motivation for
behaviors and the consequences of aggression. ask changing behavior. client needs a rehearsed plan
client to identify situations when aggression was of action to aid in handling situations differently.
used and discuss/role-play alternate methods for
handling those situations.
encourage client to engage in healthy outlets for developing new ways of reacting is essential to
anger (e.g., telling other person in an assertive breaking the maladaptive pattern of responding.
manner, use of large motor skill activities/relaxation
techniques).

nursing diagnosis coping, individual, ineffective

may be related to: very low tolerance for external stress
lack of experience of internal anxiety such as
guilt or shame
personal vulnerability; unmet expectations; conflict;
difficulty delaying gratification
inadequate support systems
multiple life changes
possibly evidenced by: inability to cope, problem-solve; choice of aggression
and manipulation to handle problems and conflicts
inappropriate use of defense mechanisms (e.g., denial,
projection)
chronic worry, anxiety, depression; poor self-esteem
high rate of accidents; destructive behavior toward
self (substance use/abuse) or others
desired outcomes/evaluation criteria— identify maladaptive coping behaviors and
client will: consequences.
 verbalize awareness of own positive coping abilities.
demonstrate increased tolerance for external stress
and meet needs with assertive behaviors.
verbalize feelings congruent with behavior.

ACTIONS/INTERVENTIONS RATIONALE

independent
provide outlet for expression of feelings/concerns. individual needs to get in touch with own feelings,
assist client to recognize anxiety by describing accept ownership of them, and be responsible for
feeling states. them before he or she can begin to change
behavior. identifying sources of fears and anxieties
increases understanding and self-awareness of
feelings, which facilitates appropriate actions.
assist to identify/recognize early warning signs of becoming aware of feelings provides opportunity
increased anxiety. for client to apply new skills that aid in
controlling/reducing anxiety and impulsive
actions.
explore anxiety-producing situations. help to clarifying basis of anxious feelings may help
formulate possible reasons for feelings. eliminate unnecessary worry. establishing a
possible cause-effect relationship provides
opportunity for insight.
discuss present patterns of coping with feelings client needs to become aware that present
and effectiveness of these mechanisms. patterns are self-destructive as well as harmful to
others.
investigate pattern of attempting to control increases client’s awareness of inappropriate mode
environment through anger and intimidation and of interaction and the consequences.
use of denial and projection.
provide information about constructive, effective client has likely not learned effective coping skills
coping strategies (e.g., discussing feelings with staff, and needs information to begin to replace
running or jogging, relaxation techniques). maladaptive skills/modify stressors.
confront client with manipulative and intimidating helps reinforce the need to stop this pattern.
behaviors when they occur.
explore the implications/consequences of continuing needs to be constantly aware of the direction life is
antisocial activities. taking and the effect these behaviors have on
society and self.
discuss the importance of being responsible for individuals with antisocial personality disorder
own actions and not blaming others for own tend to externalize blame onto others and do not
behaviors. accept responsibility for own actions.
give positive feedback when client demonstrates enhances self-esteem and reinforces acceptable
use of constructive alternatives. behaviors.
evaluate with client effectiveness of new behaviors if client’s new methods of coping are not working,
and discuss modifications. assistance will be needed to reassess and develop
 new strategies.

discuss fears or anxieties of others’ responses to gives client a sense of what might be expected
client’s new behaviors, and client’s feelings from others and how to respond, helping to
concerning these responses. role-play anticipated alleviate fears. using role-play provides the
experiences. opportunity for experiencing new ways of
responding.

encourage participation in unit activities, groups, interaction with others provides opportunities for
outdoor education program (e.g., hiking, wall/rock client to begin to experience success, feel good
climbing, caving). about self, get needs met in positive ways. exercise
therapy also expends energy and increases release
of endorphins, enhancing sense of general well-
being.

acknowledge difficulties of therapy and slow difficulty in developing therapeutic relationship,

progress. discuss likelihood of discouragement and degree of impairment, and need for total life
ways to deal with these feelings. restructuring require prolonged intervention.

nursing diagnosis self esteem, chronic low

may be related to: lack of positive feedback; repeated negative
feedback

unmet dependency needs; retarded ego development

dysfunctional family system

possibly evidenced by: acting-out behaviors, such as excessive use
of alcohol and other drugs, sexual
promiscuity

feelings of inadequacy/diminished self-worth;

inability (difficulty) accepting positive reinforcement
nonparticipation in therapy
desired outcomes/evaluation criteria— acknowledge self as an individual who has
client will: responsibility for own actions.

verbalize a sense of worthwhileness.

make healthy choices regarding management of/be

involved in meeting own care needs.

demonstrate prosocial functioning.

recognize and incorporate change into self-concept in
accurate manner without negating self-esteem.

ACTIONS/INTERVENTIONS RATIONALE

independent
encourage verbalization of feelings of inadequacy, client may relate acting-out behaviors to a poor
worthlessness, fear of rejection, and need for self-concept, and acceptance of reality of own
acceptance from others. behaviors in relation to others’ reactions can assist
decision to change.
assist client to identify positive aspects about self helps to build on positive aspects of personality
related to social skills, work abilities, education, and use them to improve self-concept.
talents, and appearance.
provide clear, consistent, verbal/nonverbal client’s perception is keen and can instantly detect
communication. be truthful and honest. insincerity.
explore the relationship between feelings of provides opportunity for client to understand
inadequacy and aggressive behaviors, use of drugs, relationship between low self-esteem and
sexual promiscuity. ineffective measures taken to “feel” better.
discuss how companions are chosen. ask if these helps client see how much peers can influence
people reinforce client’s own antisocial activities/ thinking and thereby reinforce antisocial behavior.
values.
ask client to describe interpersonal relationships, individuals with antisocial personality disorder
their quality and depth. if relationships are have great difficulty forming close relationships.
superficial, discuss how this came about. exploring early relationships with parents or
siblings may provide insight into the problem.
review ways to improve the quality of interaction learning to recognize/respect feelings of others in
with others. relation to own helps client develop more
satisfactory relationships.
help client identify positive aspects of the self and individuals with low self-esteem often have
develop ways to change the characteristics that are difficulty recognizing their positive attributes.
socially unacceptable. they may also lack problem-solving ability and
require assistance to formulate a plan for
implementing the desired changes.
minimize negative feedback to client. enforce limit- negative feedback can be extremely threatening to
setting in a matter-of-fact manner, imposing a person with low self-esteem, possibly
previously established consequences for violations. aggravating the problem. consequences should
convey unacceptability of the behavior but not of
the person.
encourage independence in the performance of positive reinforcement enhances self-esteem and
personal responsibilities and in decision-making encourages repetition of desirable behaviors.
related to own self-care. offer recognition and
praise for accomplishments.
provide instruction about assertiveness techniques, these techniques increase self-esteem while
especially the ability to recognize the differences enhancing the ability to form satisfactory
between passive, assertive, and aggressive behaviors interpersonal relationships.
and the importance of respecting others’ human
rights while protecting one’s own basic human
rights.
identify individual goals for therapy and activities focusing on practical realities helps the client to
to enhance feelings of success and self-esteem. move ahead step by step. journaling can assist
suggest keeping a journal of these activities. client to connect actions with changes that occur,
to promote continuing positive change.
 nursing diagnosis family coping, ineffective: compromised/disabling
may be related to: family disorganization and role changes
client providing little support in turn for the primary
person
prolonged disability progression that exhausts the
supportive capacity of significant people
highly ambivalent family relationships; history of
abuse/neglect in the home
possibly evidenced by: expressions of concern or complaint about significant
other’s response to client’s problem
significant person reporting preoccupation with
personal reactions regarding condition
significant person displaying protective behavior
disproportionate (too little or too much) to client’s
abilities or need for autonomy
desired outcomes/evaluation criteria— identify/verbalize resources within individual
family will: members to deal with the situation.
interact appropriately with the client/each other,
providing support and assistance as indicated.
provide opportunity for client to deal with situation in
own way.
express feelings openly and honestly.

ACTIONS/INTERVENTIONS RATIONALE

independent
identify behaviors/interactions of family members. provides information about patterns within family
note factors affecting abilities of family members to and whether they are helpful to resolution of
provide needed support. current problems. personality disorder/mental
illness of other family members inhibits coping
abilities.
listen to comments and expressions of concern of provides clues to underlying feelings, unconscious
client/sos, noting nonverbal behaviors and/or motivations/defenses.
responses.
discuss basis for client’s behavior(s). helps family begin to understand and accept/deal
with unacceptable actions.
assist family and client to understand who “owns” when each individual begins to assume
the problem and who is responsible for resolution. responsibility for own actions, each one can begin
to problem-solve without expectation that
someone else will take care of him or her.
encourage free expression of feelings, including expression of feelings can be the beginning of
frustration, anger, hostility, and hopelessness. recognition and resolution of short-/long-term
problems.
set limits on acting-out and impulsive behaviors, and family members need to understand that acting
determine safety of home situation. out angry feelings is not acceptable. identification
of factors/behaviors in the home situation can lead
to alternative actions to prevent harm to
client/family members.
help family members identify coping skills being identification of what is helpful and what is not
used and how these skills are/are not helping them will allow for learning new ways to cope with
to deal with the situation. behaviors/situation.

collaborative
refer to additional resources as needed (e.g., family may need further assistance to help with
therapy, financial counseling, spiritual advisor, resolution of current/long-term problems. may
social services). need to remove client/family members to ensure
safety.

nursing diagnosis social interaction, impaired

may be related to: factors contributing to the absence of satisfying
personal relationships (e.g., inadequate personal
resources [shallow feelings], immature interests,
underdeveloped conscience, unaccepted social values)
possibly evidenced by: difficulty meeting expectations of others; lack of
belief that rules pertain to them
sense of emptiness/inadequacy covered up by
expressions of self-conceit, arrogance, and contempt
use of unsuccessful social interaction behaviors;
behavior unaccepted by dominant cultural group
desired outcomes/evaluation criteria— identify causes and actions to correct isolation.
client will: express increased sense of self-worth.
participate willingly in activities/programs without
use of manipulation.
demonstrate behavior congruent with verbal
expressions.

ACTIONS/INTERVENTIONS RATIONALE

independent
note expressions of hopelessness/worthlessness these may be the only genuine emotions this
(e.g., “i’m a loser,” “it’s fate.”). individual feels and may be expressed in subtle
ways when failures can no longer be denied.
 although these feelings may be dismissed quickly,
this may be the time when the client is most
accessible to change.
listen to expressions of feelings and “insight,” client may be very good at saying what others
pointing out discrepancies between what is said want to hear. however, behavior is the ultimate
versus behaviors. determinant of real change. it is almost impossible
for this person to understand the feelings of
others.
confront expressions of powerlessness, inability to consistent confrontation with reality of how
control situation or make a difference in relationship/ client’s behavior affects interactions with and
trust
commitments. of others may force client to begin to look at own
responsibility for problems in these areas. this
person’s refusal to accept criticism and/or
projection of failure as the fault of others make it
difficult to change behavior.
encourage client to make requests/ask for what is as needs are met by direct action, client may begin
wanted in a clear, straightforward manner and to see the value of this approach.
express feelings clearly to others.
explore client’s need for immediate gratification. client needs to understand own feelings in order
to work on resolution.
ask client to describe feelings when someone says client often experiences pleasure through
“no.” review with client feelings regarding authority antisocial behaviors and needs to gain insight
and violating rights of others. regarding personal motives.
discuss with client thoughts and fantasies present antisocial behavior may lead to involvement in
before committing crimes. ascertain how much criminal activity. fantasizing about crime plays a
planning went into the crimes. did the client large role in eventual commission. in order to
“experience the crime mentally” before commission? restructure cognitive processes, client needs to
break this pattern.
have client discuss thoughts/feelings about family, reinforces positive values or attitudes and exposes
peers, authority figures, opposite sex, violence, and problem areas in thinking process. this is
victims. give feedback on the “correctness” of important for cognitive restructuring.
thinking process.
help client recognize behaviors that do not get these individuals have difficulty interpreting
intended response and discuss possible modifications. others’ feelings and need guidance in this area.

collaborative
involve in group activities (e.g., occupational/ provides opportunity for interaction with others to
vocational therapy, psychotherapy, outdoor learn new behaviors, gain support for change,
education program, codependency meetings). reduce dependence on manipulation of others.