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Joseph H. Baskin M.D.


Corrections Psychiatry: Antisocial Personality Disorder

A difficult personality disorder and other challenges to treatment

Many prison inmates carry, in psychiatric terminology, the diagnosis of antisocial personality disorder (ASPD). This is a conglomeration of attributes that includes the disregard for the rights of others, patterns of law-breaking behavior, impulsivity/failure to plan ahead, irritability/aggression, and a lack of remorse. A subset of those with antisocial personality disorder will also meet criteria for psychopathy. The psychopath blends a profound lack of empathy with charm, boldness, and a propensity to exploit others.

It stands to reason that antisocial behavior will continue to occur to various degrees within the prison walls. In some instances, it is amplified due to the restrictive environment. Struggles over dominance lead to conflict. The most potent tool a corrections facility employs is restriction of movement. There were no visible weapons in the facility where I worked. As a shrewd corrections officer explained, if guns were carried, they could fall into the wrong hands—but more fundamentally, if all order broke down and an officer was forced to fire on inmates, what would he then do once he’d expended all the rounds in his clip?

Aggression associated with ASPD is distinguishable from that driven by a psychotic mind. Both perpetrate violence, but the inmate without major mental illness will have a distinct purpose for his actions—intimidation, revenge, or some tangible result. The psychotic’s motives are murkier, the reasoning difficult to ascertain. The behavior itself carries a randomness that reflects the chaos occurring in the mentally ill brain.

Treatment of the acute mental illness can reduce the violence risk of some inmates. Of course, there are inmates who carry both the tendencies of one who is psychotic and criminal. In those instances, it can prove difficult to determine the root of violence. Ensuring the reasonable treatment of psychosis through medication helps elucidate behavioral causes.

Within the prison population, there are two additional diagnoses that are highly co-morbid with antisocial personality disorder: substance abuse and attention-deficit/hyperactivity disorder (ADHD). Both involve the frontal lobe of the brain, the most evolved component of our nervous system. It is where reasoning occurs and the source for suppression of impulses that are not socially acceptable. The combination of the criminal personality and ADHD is a formidable one as impulsivity and aggression synergize.

Within prison, there remains significant use of both illicit drugs and diverted prescription medications. The most effective medical treatments for ADHD are stimulants and are not formulary in prison. The most effective medical treatments for heroin dependence are methadone and Suboxone, also unavailable inside. We are forced to use other methods for helping inmates maintain sobriety when incarcerated. As for many other aspects of treatment, it is highly contingent on the inmate’s mindset and openness for treatment.

In addition to medications, I employed psychotherapeutic interventions for ASPD and ADHD. Cognitive-behavioral and supportive therapies helped the inmate develop improved impulse control and coping strategies. In a way, I served as a surrogate frontal lobe. The older the inmate, as a general rule, the more effective the process. Inmates over 40 were generally more susceptible to feedback as they felt “burnt out” from the life. They appreciated the toll of impulsivity and were tired of consequence. Periodically younger men shared similar insight, but often their realizations were more intellectual, rather than experienced, and thus not fated for real change.