of antisocial personality disords, believe covers over, um... deep-seated doubts about one's own adequacy as a man. when i left the juvenile justice system, in particular, the institute for juvenile guidance here at bridgewater, i had a big chip on my shoulder. i was determined that ias going to get even with, uh, society for the injustices that i felt had been perpetrated against me while i was in custody, and i struck out in a very violent way. another fact 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 hool, 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 paying attention to them when i was the object of the rule-breaking?"

that's a convenient excuse in some ways and no excuse in another way 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 other 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 varyingegrees. 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 vient guy. i was a violent guy, i should say... d i brought it everywhere with me. tell me 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 wouffend . i recall people riding around in harvard square on bicycles, and for whatever reason, i dug into them. it became a thing where i'd catch some poor bugger on a bicycle and taunt him and taunt him and end up pulling him over with my car and punching him in the face. and endwith such people,ver psychologists are researching possible biological factors in their impulsivity. drrex cowd is thehi executiveicer of the national institute of mtal health neuropsychiatric sech hpil. one of the interesting issue in personality disorders is whether there are traits that are exaggerated or particularly abnormal that contribute to personality disorders. one of the theories is that serotonin, which is a brain metabolite at apprs to modulate 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 acts. 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 antisocialersonality 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 rpect to the hereditary component, there is a good deal of evidence

from a 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 ia three-fold increase in the likelihood of violent crime on the part of the child. i've gotten angry enough to where i've actually impulsively hit pele, 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, and 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, for unlike dean, she experiences 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 fluctuated between neurosis and psychosis. today, it's a distinct disorder with its own constellation of character features. up to 4% of the population has borderline personality disorder, with women outnumbering men three tone. common character traits in the bordeine personality are extreme instability and unpredictability in behavior, a fear of being alone, manilativeness in relationships, impulsiveness, which we can see in promiscuous behavior or alcohol and drug abuse, and 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. spite of the dramatic impromes it just feels so bad, lis, and it feels so painful, but you don't really know what you're feeling beuse everything's all jumbled up. there's a ping-pong game in your ad with emotions. this group was started almost four years ago at the capital district psychiatric center in albany. dr. marilyn gewacke was the director of the borderline outpatientrogram then. she is currently a psychologist private practice. she talks about the first time she encountered borderlines. they acted out like no hegroup we ever ey caused more turmo than a other pie group. lots obusive behavior. i've seen patients swallowks thanfr o bletin boards, break mirrors inheatoom cut themsels,r. w furniturethrough our wind,

d th f raer ingenious ways of sneaking alhol andrugs on the unit. although their behavior we hwas exeme,ds full. they didn't the category of schophrenia, and although tir affects and moods at timessuggested depression, that ty didn't fited a major depressive dorder. somemeit'sotte to theoint i don't realize what i have donengry, 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 eve an imagined loss, what then happens is equally intriguing and disturbing because these dysphoric stat are so upsetting that the individual has to do something totop them, becaand they take a numberat 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 d this state.

another approach that's us is either taking an overdose wrist-cutting or cigarette burns-- orther forms selinjury. i was feeling ar. i was feeling nelyurns-- um...i was feeling a lot of things that i just needed a release from. but i waselg also feeng ueal, like i couldn't touch ality. my one way of touching realy 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 usually what i do, you know. i...cut myself as a way of releasing it for that moment. they do something we call splitting,

the spliing defense. theyeverything is all good in bor all bad.ite. usually if it's them they're all bad. there's no room for any good. if there is anything to remember good, there's no room for that because you get so overwlmed with feeling so bad... nothing helps. i don't think i could remember anything good, because i don't. the only good i can remember is mchildr, raising them, you know. but if i'mo that point, i can't focus onhat's go or bad. th contradiction in their own selimages and in the images onhaof others bad. is what contributes to the borderlines' difficulty in estlishing a consistent sense of self. thisand why their behavior so uchanges so frequently. they're constantly shifting

between images of feeling great to images of feeling terrible, images of seeingou someone they love, or images you as someone who's horrib d th can'ttand. they have relationship problems, tycally the rage is connected into childod trauma, for instance, incest, physical abuse, and on. in fact, dr. gewacke says that a majority of the females in her 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 with cor. 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 done-- 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 would anybody want to do thato me?" but when i do acknowledge it, i now say, "oh, no. that d happen to me. what did i do wrong?" can't understand it. recent research suggests that probably... at least intient dividual, th borderline rsonality dirder have h severphysical or early on.use that figurmay be high, but it suggests that there is a role of, um, trauma in the development of this disorder in some dividuals. t not everybody who exriences this trauma delops borderline personality disord, so you havto go ck and ask the eson

why are some individuals particularly vulnerable to develop this sorder when subjected to trauma, whereas other individuals make-- how shali say? a better adjustment to a terrible situation. dr. cowdry and his colleagues nimh have been le to re-cree the dysphoria that in our case,experienc we tried tuse procaine--ug. administered procaine, which seems to activate areas of the limbic system-- and found that borderline personality disorder patients were particularly prone to experience dysphoria when they're given procaine. 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, particularly, including aggression, is different in these individuals.

it may be that borderline patients with a biological factor,itional factor, th a genetic predispotion and you put them i a certain environmen and the whole picture into what lar becomes a border patient most peoplet tbe with personality disorders don't experience their character traits as distressful. they often don'seek help. when they do, treatment can behallenging, 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 pele 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 talk 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 federal 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 work with thipopulation. 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, e suchverwhelmgly important cial problems that it is a tragedy that in this country, and in most countries, we have devoted soittle attention

ta great dealhat kinds ohas to be learnedork. about the treatment of the antisocial personality, but the outlook for other personality disorders appears to be more hopeful. dr. knafo talks about thprogress made by her obsessive-compulsive pat. last week, john came into a session and in the middle of the session looked up and said, "you know, i am a difficult person." now, this seemingly simple statement was a long time coming and reflted years of work he recalled thatas he woule that led up to it. during the summer months, he would automatically turn up the air conditioning-- never bothering to ask me, never bothering to consider whether i wacomfortable the way things were. suddenly he realized that he had been inconsiderate, that this was his personality, that he didn't take others' feelings into consideration,

that he would have to work to thinkbout these thing in order to change his behavior. revealing his new-fod understanding, he claimed, "my time is consumed little obsessivities. "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 see of trust in the therapist and in the therapeutic situation in general. tactfully and considerately, the therist bringsconsistenn to the incongruities and the inconsistencies in the patient's behavior. the maladaptive character trait is lifted, as it were,

out of the level of pernality so that the person can look at it 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-dystonic, foreign, a symptom to be 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 personality disorders mo 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 is the opportunity r the personality disorder patient to display the problematic behavior

right within the group. you have an in 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 psychotherapy th the personality disorder tient, you have much more restricted opportunity for testing new behaviors. you have much more restricte opportunity for seeing the personality disorder behavior right in front of you. if two narcissistic men are in the same group, 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 members may say to him,

"that's exacy what youo." for many thepists, it's not auestion of either individual or group work. both can be us gether. one of my patients summed it up well when she said, "in individual therapy, "i learn to understand mylf, "but in group, "iave to practice that understanding "over and over again, "and everything happens in group 1oo times quicker because i'm doing so many things at once." because borderline paties often have substance abuse problems they neeto have that treated concurrently. being involved in a.a. or n.a. provid a social support system which can be very helpful. um...borderline patients tentimes can profit from medications which will diminish some of the more acute distrs which they feel and help them with crises. in a sense, the al with medication therapy

is to try to lessen the symptoms the degree of distress or the degree of chaos to...enough so that psychotherapy is possible, enough so that gradually over time, some of these controls can be intnalized through psychotherapy. so medication becomes a useful adjunct in a sense, in mancases, to make psychotherapy more possible or more productive. there's a lot workstil. 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 new perspecte we have to be willing ts and not be so afraid to talk about our successes. and most importantly, we have to continue to listen to the people

who have these disorders. through eir sties, we'll begin to unravel this puzzle. "who am i? "what is to be? "finding my identity. "yes, longing for ceptance, "understanding. "i want to know what love is "without experiencing horrible pain, "trusting that a hug willot hurt, "a touch will not be pain, "crying will not burn. "oh, this ttle girltrapped y "itroubled d very scared, "do i dare reveal myself, "or should i stay hidden in this prison which protects me like a knight in armor?" captioning performed by the national captioning institute, inc. captions copyright 1991 alvin h. perlmutter

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