Rob Kall: So I'm curious about, particularly, borderline disorder and narcissism. Where do they tie in with this?
Donald Black: That's an excellent question. It gets at the larger question of what you mentioned as "co-morbidity." Listeners may not know that term; it just means, "other conditions or disorders that a person has in addition to the anti-social personality disorder." Now, as a psychologist I can tell you: most people I see because of one disorder - let's say obsessive compulsive disorder - also meets criteria for other disorders as well. Maybe substance abuse, or depression, or a gambling problem; and this is true with anti-socials.
They often have a whole host of problems, and I know speaking as a Psychiatrist, they don't come to our clinic specifically for the anti-social personality disorder. They don't come in and say, "Doc, I've got ASPD, I've got Sociopathy. I need help for this." They don't come in for that reason. They'll say, "I'm depressed," or "I'm suicidal," or "I'm drug-addicted, and I need help for that." And then as we evaluate them we see what their personality pattern has been long-term, and then we make that other diagnosis. But anti-socials as a group have a high level of co-morbidity with substance use disorders, alcoholism, drug addiction, they're often addicted to gambling, they often suffer depression or other anxiety disorders; so those are all fairly common.
Now there's a group of them that also seem to have this Borderline Personality Disorder, which is a disorder that tends to be more common in women. Basically, in a nutshell, for those who are not familiar with it, it's a disorder of emotional intensity. People get overly emotional reactions when things happen to them, and what that produces is rapidly shifting moods, difficult relationships, suicidal behaviors, self-harm by cutting or burning or other methods. I think one way you could look at it is, these women (because it's mostly women) are in distress, and they're taking it out on themselves, where[as] the men with anti-social personality disorder, they're kind of taking it out on the world around them. So they're externalizing their problem; the women are internalizing their problem.
But there are a lot of women with borderline personality who also have anti-social traits or features, as you might refer to it. For example, shoplifting, minor crimes, lying, some domestic abuse, neglect of their children. And we see that in male anti-socials, that they may have some borderline features, maybe they hurt themselves repeatedly by cutting, or they have fears of being abandoned by some girlfriend or other person they're in a relationship with. So there's this overlap in some people. I certainly see that in the prison system.
Rob Kall: Now I've had a lot of contact with psychologists over the years - by running conferences, presenting at meetings, and what have you - and I've met a number of psychologists who say that they refuse to see borderline patients, because they tend to let you get close to them, and then bite your face off.
Donald Black: Well, there all also a group of psychiatrists and psychologists who say they're not going to treat anti-socials. They don't want anything to do with them. But in terms of the borderline patients, I think that's unfortunate. I see and treat a lot of borderlines. I write about it, we've developed a treatment program for borderline patients called "The Steps Program," and I can tell you: most of them tend to improve, and if we follow them up years later after we first see them, many of them no longer even fit the definition of borderline personality because they've improved so much.
Rob Kall: That's very hopeful.
Donald Black: It is. So I think it's unfair, and in fact wrong, for a group of mental health professionals to just write off a group of patients. Now, I see this far more commonly with anti-social personality disorder patients, where the doctor or therapist says, "I'm not going to have anything to do with these people because they're dangerous. Maybe they'll become stalkers or they'll hurt me in some way. And besides, we have no treatments anyway!"
But as I point out in my book, we just haven't studied the treatments well enough, so we don't know that it's untreatable. In fact, the same phenomenon of improvement occurs in anti-socials as it does in borderline patients. If you follow anti-socials long enough, many of them will improve and no longer meet the definition for anti-social personality disorder.
Rob Kall: All right. We're going to come back to that. This is the Rob Kall Bottom Up Radio Show, WNJC 1360 AM out of Washington Township, reaching metro Philly and South Jersey, sponsored by Opednews.com . I'm speaking with Donald W. Black, MD. He's a Professor of Psychiatry at the University of Iowa, and he's the author of Bad Boys, Bad men: Confronting Anti-social Personality Disorder, also known as Sociopathy. Now, where does Psychopathy come in - and psychopaths - to this conversation?
Donald Black: Well I'm glad you asked that question because there is overlap between psychopathy and sociopathy or anti-social personality. Sociopathy and anti-social personality are really synonymous, and both terms are commonly used, although "Anti-social Personality Disorder" is the official term. Psychopathy is a variation, and I look at it as "The severe end of the anti-social spectrum." Now what do I mean by that? Any disorder that Psychiatrists treat lies along a continuum of severity from very mild to very severe. That's just how it is.
That's true with anti-social personality disorder too. At one end are those who we might call sociopaths; these are the ones who have a callous disregard for others, lack a conscience, and so forth. It's a popular concept among many mental health professionals to write about that and to study psychopathy; so it's worth saying that, while most all psychopaths are anti-social, maybe a third of anti-socials meet the definition of psychopathy. But psychopathy is not an official diagnosis.
Rob Kall: OK. Next: you mention in your books on a couple occasions use of marijuana as a sign, potentially, of anti-social personality; yet several states have now made it legal, and it's available for use as a medicine in a growing number of states. Where does marijuana fit in with this?
Part two of the transcript will be up tomorrow.