Antisocial Personality - Outside the DSM

The first personality disorder in psychiatry was psychopathy¹, which means it has an extremely long, convoluted history that I can’t fully go into for this blog. I do think it’s necessary to clear up some terminology because it’s super confusing. First, the DSM-5-TR (psychiatry diagnostic model mainly used in the United States) uses antisocial personality disorder², while the ICD-11 (global diagnostic model) captures antisocial personality using the construct of dissociality. Then there are former names for antisocial personality including, psychopath(y), psychopathic personality³, sociopath(y), sociopathic personality [DSM 1], and dyssocial personality³. However, we currently and complacently use the term psychopath(y) to describe the “worst” of people who violate laws, like serial killers, majorly influenced by Hare’s Psychopathy Checklist.

Further, we have the confusing concept of describing behaviors versus actual personalities¹. This is akin to describing symptoms versus the disease. For example, a headache could be a symptom of hypertension, diabetes, or a brain tumor, all of which are very different. In the same way, vandalism is an antisocial behavior that could be acted out by multiple personalities such as narcissistic, paranoid, or antisocial (PS: Antisocial behavior used to be called dyssocial behavior or sociopathic behavior). This is a major criticism of the DSM-5-TR’s portrayal of antisocial personality disorder² - that the criteria are mostly behaviors, not necessarily capturing the underlying personality dynamics^{4 5 6 7}. So what is underneath the exterior behaviors of the antisocial personality? 🤔

*Please also note that antisocial (against social) does NOT mean asocial (not social).

The Makings of Antisocial Personalities

The genetic research on antisocial personalities is tricky because it’s hard to separate antisocial behaviors from the actual antisocial personality, and genetics from environment. Robins (1966)⁴ found that having a sociopathic or alcoholic father contributed to antisocial personality, even if the father wasn’t present…but what if the impactful variable was actually the absence of the father (physically or neglect from substance abuse)? It’s a chicken or egg conundrum.

In childhood, they did not have adequate attachments, were “unloved⁴,” and suffered traumatic injustices. They likely felt helpless and powerless, not having confidence in their own power or in the power of others to help/protect them. So power becomes very important to them, and they seek confirmation of their own omnipotence or power. Let’s paint a picture. Envision a child that is neglected, traumatized, abused, etc, and inherently helpless due to age. Teachers, cops, Child Protective Services were in their life, but didn’t save them. The systems and law failed them. They are left to save the self, to not rely or trust others, to reject their helplessness and weakness, and embody the power that they need. They learn that emotions and vulnerability are weak. Action is learned, not emotions and not caring for others. They need to act. To have personal power. To save the self. Invest in the self. Be self-focused. Survive.

The Workings of Antisocial Personalities

Because survival is a big part of childhood for antisocials, their automatic nervous system operates at high levels and eventually stays there as a baseline. This is also paired with low serotonin levels, depression, and emptiness. Then, they need more sensory and emotional input to get above that baseline for pleasurable excitement and to just feel alive. So not only do they struggle to regulate their emotions, vacillating between anger/rage and “manic exhilaration,⁷” they need intensity, like sky diving, drag racing, etc. I also suspect this is influenced by primitive envy⁵, as antisocials likely feel there’s something others have that they lack (e.g., love, connection). They “wish to destroy that which they most desire⁵.” They reject and devalue the vulnerable, squishy things in life, but they unconsciously want it. It’s hard to communicate this, but it comes out in their behaviors, like a baby can both smile and then bite mom. A pathological example of this is how Ted Bundy destroyed young women that looked like his mother, noting he needed to “own” them⁵. I think it’s really important to look on the inside of antisocials because we get so distracted by their fierce behaviors.

The Defenses of Antisocial Personalities^{8 5}

All personalities defend against anxieties and difficulties to adapt to the world. The main defenses that antisocial personalities use are primitive, including omnipotent control, projective identification, acting out, and dissociation.

Omnipotent Control involves the need to exert and confirm one’s power to defend against weakness/shame. It is a defense learned in the first 6 months of life when there isn’t any understanding of separateness between infant and mother. If an infant is hungry, the infant gets milk, and the infant believes it is all-powerful. This is also an extension of primary narcissism. In an adult relationship, this could look like inconsideration: “I am not cold, so you must not be cold.” Pathologically, this could be consciously manipulating to have someone under their thumb. Omnipotent control is found in many areas where there are power dynamics (e.g., politics, business, law, religious hierarchies, military).

Projective Identification involves putting an unacceptable quality characteristic on another person, then the other person identifies with it. For example, if the antisocial person feels weak in any way (which is definitely not acceptable to them), they might act dominant/powerful with you, making you feel and identify as weak. Or if they don’t trust you, they elicit mistrust of them…or if they’re angry, they lash out and now you are angry…or if they can’t feel empathy for you, you now find yourself not able to be empathetic toward them…etc. The antisocial’s struggle to verbally express emotion can easily result in evoking their feelings in others so that others can understand. This is paired with the next defense.

Acting Out is essentially behaving on emotions to relieve them, but usually in an oblique manner (e.g., fighting, threatening, stealing). Antisocials act, but they also need more to get to their threshold of feeling. For example, their startle response is lower and their tolerance for darkness is high. They may be stuck in their fight response, always being on guard for threats. But do they actually feel anxiety? Do they lack anxiety or just hide it? We would never see their anxiety because they act so fast due to hypervigilance and past trauma. Healthier antisocials can experience anxiety, and they either hide it or it comes out as anger or irritability.

Dissociation is separating impulses, thoughts, or emotions that are too “threatening” to the ego. This can be anything from minimizing personal experience to complete amnesia. To assess this in an antisocial is tough because they can lie and manipulate, so they may not actually be utilizing this defense. However, dissociation and abuse are linked, and antisocials have experienced abuse. Additionally, when raging, the memory part of the brain can shut down, leading to decreased ability to recall what actually happened.

Can Antisocial Personalities “Get Better”?

Theorists, researchers, and clinicians have been in conflict about this for over 200 years, yet there is a strong stereotype that antisocial personalities are untreatable^{4 6 7 1}. This is where moral judgment infringes on professional assessment. Antisocials reject society, so society rejects them⁵. However, there is evidence that some antisocial individuals can make progress^{5 1}.

Summing all of this up, the DSM doesn’t capture the personality underlying the external behaviors. Most antisocial personalities aren’t even engaging in criminal behaviors^{6 7}, which goes against a lot of what we think when we hear the term “antisocial.” To look inside the antisocial personality is to see the expanse of darkness inside all humanity, and if you dig deep enough, you’ll find the seed of pain every individual has buried within. I’ll leave you with this quote from Danish psychiatrist Georg Sturup 19518:
“Don’t forget these people. They have no one, yet they are people. They are desperately lacking and in terrible pain. Those who understand this are so rare; you must not turn your back on them.”

Antisocial personality dynamics are complex!!! If you want to better understand an antisocial individual in your life, or if you are an antisocial personality and want to explore it, feel free to reach out! If you’re in Virginia (or a PsyPact state), check out our private practice, Quest Psychological and Counseling Services for available services. If you’re a provider stuck on a case, we also offer consultations for mental health professionals!

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