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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/cdn\/css\/http\/css_Xg7z6oCTVgud_Q0huYz9x9iiD5H_2YPSJ5z2ZViSWdY.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n\u003Cp id=\u0022p-1\u0022\u003EAlthough the DSM-IV clearly outlines the seven criteria used to diagnose antisocial personality disorder, it is often a categorical diagnosis. In order to truly understand and effectively treat an individual presenting with antisocial personality disorder, clinicians must use the DSM-IV criteria in conjunction with a multi-dimensional view of the disorder.\u003C\/p\u003E\n\u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EPersonality Disorders\u003C\/li\u003E\u003C\/ul\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n\u003Ch2 class=\u0022\u0022\u003ETreating Antisocial Personality Disorder: A Multi-Dimensional View\u003C\/h2\u003E\n\u003Cp id=\u0022p-2\u0022\u003EAlthough the DSM-IV clearly outlines the seven criteria used to diagnose antisocial personality disorder, it is a \u201cgross categorical diagnosis\u201d, suggests Reid Meloy, PhD, University of California, San Diego. He emphasizes that to truly understand and effectively treat an individual presenting with antisocial personality disorder, clinicians must use the DSM-IV criteria in conjunction with a multi-dimensional view of the disorder.\u003C\/p\u003E\n\u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/7\/2\/6\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-946770980\u0022 data-figure-caption=\u0022\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure1\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/7\/2\/6\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/7\/2\/6\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure1\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/7\/2\/6\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/11130\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\n\u003Cp id=\u0022p-3\u0022\u003EOne dimension of antisocial personality disorder that will significantly impact treatability is psychopathy. Although only 20\u201325% of individuals with this particular personality disorder display primary or severe psychopathy, its presence may actually hinder any effort to treat the patient. There is a negative correlation between psychopathy and treatability of antisocial personality disorder, with a greater degree of psychopathy resulting in poorer outcomes post-treatment. Furthermore, efforts to treat psychopathy, as a primary disorder, may actually yield results opposite to what would be expected, with psychopathic behaviors becoming worse as treatment progresses (Hare. \u003Cem\u003EPsychiatr Clin North Am\u003C\/em\u003E 2006;29: 709\u201324).\u003C\/p\u003E\n\u003Cp id=\u0022p-4\u0022\u003EWhile there are few or no treatment options for the psychopath, assessing psychopathy in the antisocial personality disorder patient has become easier. There are now a number of empirically-based assessment devices available for psychopathy evaluation. The \u201cHare\u201d risk assessment instruments, including the Psychopathy Checklist (along with its Screening and Youth versions), the Antisocial Personality Disorder Screening Device and the P-SCAN (used primarily in non-clinical law enforcement settings) all provide refined, dimensional snapshots of individuals with antisocial histories. These tools may be useful when planning a course of treatment for a patient who presents with antisocial personality disorder.\u003C\/p\u003E\n\u003Cp id=\u0022p-5\u0022\u003EClinicians should consider, what Dr. Meloy has labeled, the \u201cABCs\u201d of antisocial personality disorder. Does the patient present with \u003Cem\u003EAnxiety\u003C\/em\u003E? Can the patient \u003Cem\u003EBond\u003C\/em\u003E in a genuine manner? When meeting with the patient, does it appear that he or she has a \u003Cem\u003EConscience\u003C\/em\u003E? If any or all of these constructs are apparent, it would suggest that psychopathy is not present, thus increasing the likelihood that the patient would benefit from a clinical intervention.\u003C\/p\u003E\n\u003Cp id=\u0022p-6\u0022\u003EIf a patient scores low for psychopathy, what treatment would be available for antisocial personality disorder? Many of these patients do respond positively to anti-anxiety medications, but only if there is an aspect of anxiety related to their pathology. Many clinicians also employ cognitive behavioral and social learning techniques to treat these patients. Although these treatments display some efficacy, clinicians should be cautious, given the effect sizes are often described as modest compared to their utility with other pathologies.\u003C\/p\u003E\n\u003Cp id=\u0022p-7\u0022\u003EIndependent of the treatment ultimately deemed appropriate for the patient, a clinician must also consider the nature of violence, given its intimate relationship with antisocial personality disorder and psychopathy. \u201cViolence is not homogenous\u201d, states Dr. Meloy. There are two distinct, biologically dissociable forms of violence. One form, affective violence, is a reactive, unplanned form of aggression, most often a response to an imminent threat. When the threat is removed, the violence ceases. The second form of violence, predatory (or instrumental) violence, is a planned, purposeful, emotionless act of violence. Predatory violence is not reactive. In the context of antisocial personality disorder, the higher the degree of psychopathy, the greater the frequency of both affective and predatory violence.\u003C\/p\u003E\n\u003Cp id=\u0022p-8\u0022\u003EFortunately, pharmacological management seems to be most appropriate when addressing the violent tendencies of antisocial personality disorder patients. In order to pick the most appropriate medication, clinicians should consider which form of violence is most prevalent. Research has indicated that while phenytoin impacts affective violence, it has no effect on predatory violence. In a double-blind, placebo-controlled study, Barratt et al. (1997) demonstrated that phenytoin (200 mg in the morning and 100 mg in the evening) significantly reduced impulsive but not premeditated acts of aggression in a population of prisoners who had difficulty controlling their aggression (p\u0026lt;0.05; \u003Cem\u003EJ Clin Psychopharmacol\u003C\/em\u003E; 17:341\u20139). Serotonin agonists, however, appear to inhibit both forms of violence. Although medication management for violence does show some efficacy, Dr. Meloy cautions that \u201cmotivation [for treatment] is critical\u201d in order for these pharmacological interventions to have true utility in the treatment of antisocial personality disorder.\u003C\/p\u003E\n\u003Cp id=\u0022p-9\u0022\u003EOne final consideration is the therapist\u0027s reaction, be that physical or psychological, to the patient. The notion that clinicians may experience such strong reactions to the antisocial\/psychopathic patient is not without empirical support. Noting his earlier work, Dr. Meloy recalls, \u201cindividuals would experience certain physical, visceral states when they were around a psychopathic individual.\u201d\u003C\/p\u003E\n\u003Cp id=\u0022p-10\u0022\u003ESurveying approximately 1,000 individuals employed in mental health and law enforcement in 12 states, reactions to psychopaths were assessed using two questions: a) \u201cHave you ever interviewed a psychopathic patient based on the psychopathy criteria developed by Robert Hare and his colleagues?\u201d and b) \u201cDid you have a physical reaction, and, if so, can you describe it?\u201d There was a 77.3% positive response for a physical reaction when interviewing a psychopath. The trend of this data also suggested that females had a stronger response than males (p\u0026lt;0.001), and that mental health workers had a stronger reaction than law enforcement agents (p 0.001; Meloy and Meloy. \u003Cem\u003EJ Threat Assess\u003C\/em\u003E 2002;2:21\u201333).\u003C\/p\u003E\n\u003Cp id=\u0022p-11\u0022\u003EPsychologically, strong counter-transference reactions were reported in response to working with antisocial\/psychopathic individuals. Clinicians need to cope with their counter-transference so they do not act out against the patient. The most common counter-transference reactions to the antisocial personality and psychopathic patient include:\u003C\/p\u003E\n\u003Cul class=\u0022list-unord \u0022 id=\u0022list-1\u0022\u003E\u003Cli id=\u0022list-item-1\u0022\u003E\u003Cp id=\u0022p-12\u0022\u003E\u003Cstrong\u003ETherapeutic Nihilism\u003C\/strong\u003E \u2013 the patient is not treatable\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-2\u0022\u003E\u003Cp id=\u0022p-13\u0022\u003E\u003Cstrong\u003EIllusory Treatment Alliance\u003C\/strong\u003E \u2013 an alliance when there is none\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-3\u0022\u003E\u003Cp id=\u0022p-14\u0022\u003E\u003Cstrong\u003EFear of assault or harm\u003C\/strong\u003E \u2013 believing the patient will act out violently\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-4\u0022\u003E\u003Cp id=\u0022p-15\u0022\u003E\u003Cstrong\u003EHatred and wish to destroy\u003C\/strong\u003E \u2013 identifying with the predatory violence of the patient\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-5\u0022\u003E\u003Cp id=\u0022p-16\u0022\u003E\u003Cstrong\u003EAssumption of psychological maturity\u003C\/strong\u003E - believing the patient has insight into their pathology\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-6\u0022\u003E\u003Cp id=\u0022p-17\u0022\u003E\u003Cstrong\u003EFascination, excitement and sexual attraction\u003C\/strong\u003E\u2013arousal in response to the taboo behavior of the patient\u003C\/p\u003E\u003C\/li\u003E\u003C\/ul\u003E\n\u003Cp id=\u0022p-18\u0022\u003EIn summary, a clinician must consider the multiple dimensions of antisocial personality disorder in order to provide the most efficacious treatment for their patient. These factors include the level of psychopathy, personality disorder, the nature of violence and the clinician\u0027s reactions to the patient. Although the treatment effects with this population are modest, Dr. Meloy is optimistic about the direction of research in this area and the new understanding of antisocial personality disorder that it may yield.\u003C\/p\u003E\n\u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2007 MD Conference Express\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/7\/2\/6.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzlzq1\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzlzq1\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}