had been perpetrated against me while i was in custody, and i struck out in a very violent way. another factor in the development of antisocial personality disorders may be childhood trauma and broken families. dr. profit tells of a patient who was molested as a child by a family member and went to the local police for help. the police officer laughed and made a joke about the kind of molestation he was involved in and returned him to the home. he repeatedly ran away, and that made the authorities consider him a stubborn child and put him into reform school. because we tend to take people from their families but don't pay attention to the situations we put them in, he was abused in the reform school, and as a response to that, he started using drugs to get away from the feelings

that he had about the abuse he had undergone. when i said, "how can we help you get a better life?" his response was, "where were you when i was getting abused, "and where was society "when the rules were being violated around me, "and how is it that you expect me now "to pay attention to the rules, "when no one was ying attention to them when i was the object of the rule-breaking?" that's a convenient excuse in some ways whenand no excuseject of tin another wayng?" because he's responsible for his behavior. he's not going to make a better situation for himself by blaming it on other people. it's not unusual to find in antisocial people that they've had experiences which suggest that the rules didn't work for them, so they've made up rules that give them what they think is a better chance at what they want.

unfortunately, these rules disregard responsibilities and rights of otr people. the moral value system that the antisocial personality has is, , in a way, the exact opposite of what we would call morality-- in other words, the socially accepted, the judeo-christian moral tradition, which is also incorporated into our legal code and so forth to varying degrees. that's the standard moral code. certainly, it's true that antisocial personalities don't display that. they have not internalized that. they have, in a sense, taken that value system and rned it inside out, so that what is a positive value for our moral code, such as compassion for other people, can be negatively valued, may be seen as weak by an antisocial personality. things we would value negatively, such as beating somebody up, can be seen as a positive value

in the antisocial moral value code. that's a sign of being strong and manly. some antisocial personalities exhibit especially impulsive behavior. i'm a violent guy. i was a violent guy, i should say... d i brought it everywhere with me. tell m about that violence. explain what you mean by being violent. reactive, impulsive, lashing out, you know, one-punch type of things. people would do something that would offenme. i recall people riding around in harvard square peopleon bicycles,mething and for whatever reason, i dug into tm. it became a thing where i'd catch some poor bugger on a bicycle and taunt him and taunt him and enup pulling him over with my car and puhing him in the face. and enuwith such people,r psychologists are researching possible biological factors in their impulsivity.

dr. rex cowdry is the c executiveicer of the national institute of mtal health neuropsychiatric ar hpil. one of t interesti issue in personality disorders is whether there are traits that are exaggerated or particularly abnormal that contribute to personality disorders. one of t theories is that serotonin, which is a brain metabolite that appears to molate a variety of drives such as aggression or appetitive behavior, uh, may be abnormal in individuals who are prone to loss of behavioral control. interestingly, this is a finding that seems to cut across a variety of diagnostic groups. it's been found in depression in relation to suicidal ac. we found it in our patients with borderline personality disorder. that is, that the individuals who had genuine suicide attempts had lower levels of the serotonin metabolite.

it's been found in another study of borderline personality disorder. it's been found in antisocial personality disorder. in short, it seems to be associated with a behavioral abnormality that cuts across personality disorders. dr. gilligan discusses the possibility of heredity playing a role in the development of the antisocial personality. with respect to the hereditary component, there is a good deal of evidence from number of family studies, adoptive studies, and twin studies that there is at least an hereditary predisposition toward, um, some types of antisocial behavior, specifically property crimes. somewhat surprisingly, there has not been any good evidence yet, to my knowledge-- and i do know of some of the best studies which really specifically don't confirm the hypothesis--

that there's an hereditary predisposition toward violent crime. this is somewhat surprising because almost everything in human life is at least influenced by heredity. but so far, this has not shown up as a specific causal factor for violence. what has been found in one study is that if the father has a history of chronic criminal behavior with a lot of recidivism and the mother is an alcoholic or drug addict or has a major personality disorder, and you have that combination of disturbances, then there is a three-fold increase in the likelihood of violent crime on the part of the child. i've gotten angry enough to where i've tually impulsively hit people, you know, not meaning to at all, you know, or i'd punch a wall or something.

you know, it's just, i get that-- you get this sudden rush, d you've just got to release it somehow. like dean lindstrom, lynda has impulsively hit people, but she does not have an antisocial personality disorder, shexperiences pain and remorse from her actions. she engages in self-destructive behavior and other traits of the borderline personality disorder. the term borderline originally reflected the belief that these people fltuated between neurosis and psychosis. today, it's a distinct disorder with its o constellation of chacter features. up to 4% of the population has borderline personality disorder, with women outnumbering men three to one. common character traits in the bordeine personality are extreme instability and unpredictability in behavior, a fe of being alone, manipulativeness in relatnships,

impulsiveness, which we can see in promiscuous behavior or alcohol and drug abuse, d self-destructive, often self-mutilating behaviors. borderlines have a defective sense of identity and are ridden with angry feelings. lynda and kelly are in therapy with three other women who have also been diagnod they've all been in therapy bordefor a minimum of five years and have made enormous progress. spi of all been in therapy the dramatic impromes five years they've made in their lis, thr pain is still evident. it just feels so bad, and it feels so painful, but you don't really know what you're feeling because everything's all jumbled up. there's a ping-pong game in your head wh emotions. this group was started almost four years ago at theapital distric psychiatric center in albany.

dr. marilyn gewacke was the director of the borderline outpatientrogram then. she is currently a psychologis private practice. she talks about the first me she encounred borderlines. they acted out likeo hegrp we ever w. eyaused more turmoil she talks about the first me than any other patient group. lots oself-abusivebehavio. eyaused more turmoil i've seen patients swallacksme thanfr bletin ards,ent group. brearrors inhe batoom to cut themselves, eyaused more turmoil i'verow furniturethh our window, thanfr bletin ards,ent group. d th fnd raer ingenioays of sneaking alhol andrs on thenit. we had our hands full. of snalthough their behavior s extreme, and although tir affects of schopand moods at times suggested depreson that ty didn't fated a major depres dorde sometimes it'sotten to theoint where i get so angry, i don't realize what i have done

until after i've done it, you know. i have got this tremendous fear of getting angry now because i'm always afraid-- i'm sorry-- because i'm always afraid that i'm actually going to hurt somebody, whether i mean to or whether i don't. it just really scares me to get angry at times. individuals with this disorder are very prone to a state that we call dysphoria. it's very hard to describe. it's, in some sense, an overwhelming sense of feeling bad, and it may include elements of depreion, of rage, of anxiety, but mostly it's just a state of terrible distress. one of the intriguing things about the disorder ishat this state distress is usually triggered by specific kinds of events-- a real, or perhaps even an imagined loss,

or a rejecti. what then happens is equally intriguing and disturbing because these dysphoric states are so upsetng th t individual has to do something totop them, becaand they take a numberates of different avenues to try to end this dysphoric state. sotimes they can find a person, and the person can somehow coort them and modula and end this state. another approach that's us is either taking an overdose wrist-cutting or cigarette burns-- or other forms selinju. i was feeling scared. i was feeling nelyurns-- um...i was feeling a lot of things that i just neededa lease from. but i waselin also feeling ueal, like i couldn't touch reality. my one way of touching reality was to cut myself and to see the blood.

that always made me feel better. a lot of times,i can bey that i just want to hurt someone else, and i don't do it, so i'll cut myself or... h? that's true. that's basically usuallywha. i...cut myself as a way of releasing it for that moment. they do someing we call splitting, the splitting defense. they see the world in black and white. everything is all good or all bad. usually if it's them th're all bad. if there is anything noto remember good,d. there's no room for that because you get so overwhelmed with feeling so bad... thernothing helps.r that i don't think i could remember anything good, because i don't. the only good i can remember is my childr,

raising them, you know. but if i'mo that point, i can't focus ont'go or bad. thisontradiction in their own selimages and in the imas ont'of others. is what contributes the borderlines' difficulty in establishing a consistent sense of self. this is why they're so unstable anwhy their behavior changes so frequently. they're constantly shifng between images of feeling great to images of feeling terrible, images of seeing you someonehey love, or images of you as someone who's horrible th can'ttand. they have relationship problems, a lot of chaot, innse relationship, a lot of rage. cally the rage is connected tm innse relationship, for instance, incest, physical abuse, and on. in fact, dr. gewacke says that a majority of the females in h borderline program reported a history of inst.

this may play a role in their condition. it's something nobody should have to go through. it's... being...so small and not being able to defend yourself against grownups that are wanting to either hurt you or... molest you, or do whatever they want to do. and...of course, when you're a child, nobodyistens. i agree withorey. it's hard to deal with, especially when you try to tell people and nobody believes you. that just makes you wonder if it's not you, you know, if it's not your fault. or you'd de-- the same thing-- you'd done something to bring it on. um... and then you wonder-- like, i have two sisters, and you wonder why you--

not that i wished it on them or anything-- and not them. you know? um... does that sound bad? i'm not trying to say i wish it on them. no, you're not. but... you know, it really makes you wonder... what you did to deserve some of the things that happened to you. i was afraid to acknowledge it myself. i still am. to this day, i'll say, "that didn't happen to me. why uld anybody want to do that to me?" but when i do acknowledge it, i now say, "oh, no. that did happen to me. wh did i do wrong?" i can't understand it. recent research suggests that probably... 7o% of individuals,

at least inpatient individuals with bderline personality sorder have h severe physical or early on.use that figure may be high, but it suggests that there is a role of, um, trauma in the develnt of this disorder in some individuals. but not everybodywho exriences a develops borderline personality disorder, so you havto go back and ask the estion why are some individuals pae to develop this disorder when subjected ttrauma, whereas other individuals make-- how shali say? a better adjustment to a terrible situation. dr. cowdry and his colleagues at nimh have been able to re-cree the dysphoria that borderles experience by administering a drug. in our case, we tried tuse praine administered procaine,

which seems to activate areas of the limbic system-- and found that borderline personality disorder patients when they're given prone to expeprocaine.sphoria there are a number of biological hypotheses that one could formulate. one of them is that the limbic system, which is a relatively primitive part of the brain that is involved with drive states, particularl including aggression, is different in these individuals. it may be that borderline patients wi a biological factor,ituonal factor, th a genetic predispotion and you put them i a certain environm and the whole picture blms into what later becomes a rdne pie and the whole picture it's got tbe b intertion. most people with personality disorders don't experience their character traits

as distressful. they often don'seek help. when they do, treatment can be challenging, but not impossible. there is a myth that antisocial personalities are not interested in treatment. actually, i would say that that is true in the community. actually, i would say that thatby and large, the people often won voluntarily come to treatment, but if you see a population of antisocial people in a prison setting, and you're there as part of a mental health team, you quickly discover that there is an overwhelming desire on the part of people who have engaged in serious antisocial behavior to have somebody that they can trust, somebody who will lk to them and try to understand them and help them get their lives in order. i suffered four years in solitary confinement and transferred to one of the harshest prisons in the united states, the deral prison at marion, illinois.

it gave me time to think. they come to the therapy no different than they come to any other situation. they're looking to figure out what the therapist wants and what they want out of that situation. unfortunately, many therapists are naive to that idea. if you're going to do therapy with someone who's antisocial, you have to start out by creating a safe place, and you have to say, "listen, i will treat you. "that is, we'll have a place where we can talk about change and the dysfunctional aspects of being you." however, therapy also has to be for itself. frequently what contaminates the therapy and eliminates the possibility of helping these folks is that the therapy's not for itself. you say, "why are you here?" "the parole board said i need treatment to get paroled." that's the end of therapy.

there have been amazingly few psychiatrists or psychologists who've been willing to work with this population. well, maybe it's not amazing. you know, it's, uh... these are potentially dangerous people. um...but i do think that antisocial pernality disorder, and crime and violence in general, are su overwhelmgly important social problems that iis a tragedy that in this count, and in most counies, we have devoted so little attention to learning what kinds of treatment can work. a great deal has to be learned about the trtment of the antisocial rsonality, but the outlook for other personality disorders appears to be more hopeful. dr. knafo talks about the progress made by her obsessive-compulsive patient, john. last week, john came into a session and in the middle of the sessiod "you know, i am a dficult person." now, thiseemingly simple statement

s a long time coming and flted years of work he recalled that as he would enter my office during the summer months, he would automatically turn up the air conditioning-- never bothering to ask me, never bothering to consider whher i was comfortable suddenly he realized that he had been inconsiderate, that this washis personality, that he didn take others' feelings into consideration, that he would have to work to thinkbout these thing in order to change his behavior. revealing his new-found understanding, he claimed, "my time is consumedby litte "i don't enjoy my free time. "i can't allow myself to let go. "i've been this way for a long time. "this has become a pattern and will be difficult to change." the way around this is to create a very supportive,

well-structured environment for the patient, one in which he is encouraged to gradually develop a sense of trust in the therapist d in the therapeutic situation gener. tactfully and considerately, the therapist brings consistent attention to the incongruities aand the inconsistencies in the patient's behavior. the maladaptive character trait is lifted, as it were, so tt the personevel can look at itty as an isolated behavior, rather than as something that all of him is invested in he can look at it objectively and experience it as painful, ego-dyston, foreign, a symptom to b gotten rid of. some therapists think that group therapy can be extremely effective in the treatment of some personality disorders. groups are the treatment of choice.

the reason they are, i think, is because personalityisorders most often manifest themselves in terms of interpersonal behavior, in terms of how people interact with one another and interact with other people. i think that what you have in a group therapy situation and interact is the opportunity for the personality disorder patient to display the problematic behavior right within the group. you have ann vivo situation where the patient can pretty much produce that behavior right there in front of you and in front of the other patients in the group. everybody can see what's going on, and they also have an opportunity in that group therapy situation to try out new behaviors. i think that in a, um, individual psychotherapy, in a one-to-one psychothapy

with the personality disorder tient, you have much more restricted opportunity for testing new behaviors. you have much more restric opportunity for seeing the personality disorder behavior right in front of you. if two narcissistic nare i, one narcissistic man seeing another narcissistic man may able to say, "that guy is so self-centered. he never thinks about anybody but himself." and the other membs may say to him, "that's exacy what you do." for many thepists, it's not a question of either individual or group work. bothan be usedgether. one of my patients sued it up well when she said, "in individual therapy, "i learn to understand myself, "but in group, "i have practic that understanding "over and over again, "and everything happens in group 1oo times icker because m doing so many things at once."

because borderline patients often ve substance abuse problems, they need to have that treated concurrently. being involved in a.a. or n.a. provides a social support system which can be very helul. um...borderline patients oftentimes can profit from medications which will diminish so of the more acute distress which they feel and help them with crises. in a sense, the al with medication therapy is to try to lessen the symptoms or the degree of distress or the degree of chaos to...enough so that psychotherapy is possible, enou so that gradually over tim some of these controls can be intnalized through psychotherapy. so medication becomes a useful adjunct in a sense, in many cases, to make psychotherapy more possible or more productive.

there's a lot of work still to be done. mainly, that's on our shoulders as mental health care givers. we have to continue to educate ourselves and our patients. we have to be open to n perspecte have to be willing to learn from our mistakes and not be so afraid to talk about our successes. and most importantly, we he to continue to listen to the people who have these disorders. through their sties, we'll begin to unravel this puzzle. "who ai? "what is to be? "finding my identy. "yeslonging for ceptance, "i want to know what love isng. "without experiencing horrible pain, "trusting that a hug will not hurt, "a touch will not be pain, "crying will not burn.

"oh,"is troubledirl trapd very scared,ody "do i dare reveal myself, "or should i stay hidden in this prison which protects me like a knight armor captioning performed by the nationalaptioninginsti. captions cyright 1991 alvin h. perlmutter

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