Psychiatry · Year 2 · from Psychiatry
Case 2: Antisocial Personality Disorder
Patient Presentation
Demographics: 32-year-old male
Chief Complaint: Psychiatric evaluation ordered by court following assault charge
History of Present Illness: A 32-year-old man presents for court-ordered psychiatric evaluation after being arrested for assault. He punched a man at a bar after a disagreement over a pool game. He shows no remorse: "He disrespected me. He had it coming." Review of records reveals an extensive history: multiple arrests for assault, theft, and drug possession beginning at age 14, two periods of incarceration, and violation of probation multiple times. He was diagnosed with conduct disorder at age 12 after repeated truancy, fighting, and cruelty to animals. He has never held a job for more than 6 months due to conflicts with supervisors or absenteeism. He has two children from different relationships whom he rarely sees and for whom he pays no support. He has a history of polysubstance use including alcohol, cocaine, and opioids. He presents as charming initially but becomes irritable when questioned about his history. He denies any problems: "Everyone else causes problems, not me."
Mental Status Examination:
- Appearance: Well-groomed, confident demeanor, multiple tattoos
- Behavior: Initially charming, becomes dismissive and irritable; no psychomotor abnormalities
- Speech: Glib, superficial
- Mood: "Fine. I don't have any problems."
- Affect: Shallow, restricted range, no apparent distress
- Thought content: Minimizes antisocial behavior, blames others, no insight into impact on victims
- Cognition: Intact
- Insight: Absent - does not perceive any problems with behavior
- Judgment: Poor - repeated poor decisions with foreseeable consequences
Relevant History:
- Conduct disorder diagnosis at age 12 (required for ASPD diagnosis)
- Juvenile detention at ages 14 and 16
- Adult incarcerations at 22 and 27
- History of domestic violence (prior partner)
- Positive for ADHD symptoms in childhood (untreated)
Workup:
- PCL-R (Psychopathy Checklist-Revised): Score 32 (high - indicates psychopathic traits)
- Urine drug screen: Positive for cocaine
- Records confirm conduct disorder before age 15
Diagnosis: Antisocial Personality Disorder; Stimulant Use Disorder (cocaine), moderate
Treatment/Recommendations:
- Diagnosis confirmed for court documentation
- Treatment recommendations:
- Substance abuse treatment (primary focus - more treatable than ASPD itself)
- Anger management program
- Vocational rehabilitation
- Clear contingencies and consequences for behavior
- Prognosis discussion: Limited evidence for treatments directly targeting ASPD; focus on harm reduction and managing comorbid conditions
- ASPD may improve somewhat with age, particularly impulsive features
- Treatment setting must have clear boundaries and consistent consequences
- Verification of information recommended (tendency toward manipulation and deceit)
- Report provided to court with diagnosis and treatment recommendations
Clinical Pearl: Antisocial personality disorder requires evidence of conduct disorder before age 15 and at least 3 criteria including failure to conform to social norms, deceitfulness, impulsivity, irritability/aggressiveness, reckless disregard for safety, irresponsibility, and lack of remorse. Treatment is challenging due to limited motivation and poor insight. Focus is typically on managing comorbid conditions (especially substance use) and harm reduction rather than expecting personality transformation. The Psychopathy Checklist-Revised (PCL-R) assesses psychopathic traits, which overlap with but are distinct from ASPD. Information should be verified from collateral sources given the tendency toward manipulation.