Playing the Psychologist: Diagnosing Antisocial Personality Disorder

posted by Dr. James G. Hood
Friday, May 28, 2010


 Diagnosing Antisocial Personality Disorder in Girl, Interrupted

Kyler Hood


After watching the Virginia Tech incident unfold, society must face the disconcerting reality that mental disorders exist and must be dealt with in a positive, straightforward matter in order to promote a smoothly functioning society and to prevent future atrocities. Unfortunately, however, people often cannot personally interact with people suffering from mental disorders in order to learn the symptoms and how these disorders can best be treated and prevented. The movie, Girl, Interrupted, provides the next best alternative by providing a nearly accurate depiction of a woman afflicted with Antisocial Personality Disorder.


In order for an individual to meet the criteria outlined in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders for Antisocial Personality Disorder, several determining factors must be met. A continual pattern of disrespect and violation of others’ rights must have been occurring since the age of 15, and the individual must currently be at least 18 years of age. Three or more of following disruptive behaviors must be characteristic of the individual: “1. Failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest. 2. Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure. 3. Impulsivity or failure to plan ahead. 4. Irritability and aggressiveness, as indicated by repeated physical fights or assaults. 5. Reckless disregard for safety of self or others. 6. Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations. 7. Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another” (Diagnostic and Statistical Manual of Mental Disorders, 4th edition, American Psychiatric Association, 2000). Furthermore, an individual is likely to have had Conduct Disorder before becoming 15 years old and the DSM-IV-TR states explicitly: “The occurrence of antisocial behavior is not exclusively during the course of Schizophrenia or a Manic Episode” (APA, 2000). These criteria provide a framework for the diagnosis of ASPD, however, some experts feel that further distinction is necessary: ‘“Rogers and colleagues had this to say about the situation: As noted by Hare (1998), DSM- IV does considerable disservice to diagnostic clarity in its equating of ASPD to psychopathy”’ (Hare, 2006).


            Antisocial Personality Disorder (ASPD) is found in approximately 1% of women in the general public (APA, 2000) Lewis (2006) notes that “prevalence increases 12-fold among samples of alcohol-dependent women in the general population”; therefore, ASPD prevalence is increased in female offenders. For men, the disorder is found in approximately 3% of the population, and population approximations in clinical settings range from 3%-30% (APA, 2000). The disorder is often considered a “man’s disease” because “Research shows that men are two to eight times more likely to have antisocial personality disorder than women” (Black, Men’s Mental Health).

Clinical Picture

            A sociopath has significant personality traits and associated emotional characteristics that differentiate individuals from the general population. Defining personality traits include being: “grandiose, arrogant, callous, dominant, superficial, and manipulative”, and emotional characteristics include being: “short-tempered, unable to form strong emotional bonds with others, and lack, empathy guilt, or remorse (Hare, 2006). Hare also points out that individuals with ASPD also exhibit a “proneness to boredom, shallow affect, lack of empathy, irresponsibility” and “…promiscuous sexual behavior” (Hare, 2006). All of these sociopathic traits make individuals with APSD extremely likely to be placed in the criminal justice system, although not all individuals get incarcerated. The high rate criminal activity committed by psychopaths makes understanding the disorder’s etiology a prime priority for treating it (Hare, 2006; Black, Textbook of Men’s Mental Health).

            In addition to the personal predisposition that a person exhibits, environmental and social variables contribute to the development of APSD.  Environmental factors include several elements including, but not limited to the way the future psychopath was raised (enforced or not strictly enforced respect for authority, the level of exposure to violence, punishments for misbehavior). Social factors include, but are not limited to the number of family levels, the number and levels of social support, and the associated positive or negative impacts of those social supports (Black, Textbook of Men’s Mental Health). Since these environmental and social factors contributing to ASPD are qualitative and not easily measured, they are not discussed in great depth. Instead, a more overarching, empirically-supported theme becomes apparent. According to the DSM-IV-TR, a strong correlation exists between a low socioeconomic status coupled with urban setting and the development of ASPD.

            Genetic and familial origin also play important roles as precursors to the development of ASPD. The DSM points out that “Antisocial Personality Disorder is more common among the first-degree biological relatives of those with the disorder than among the general population” (APA, 2000). Adoption studies also indicate that the disorder took place more often in individuals that were related to ASPD afflicted individuals than unrelated subjects (Black, Men’s Textbook of Mental Health; Crowe, 1974). Hare acknowledges the importance of genetic and familial factors for the development of ASPD, but he stresses that the combination of all factors—genetic, familial social, and environmental—are all important for the development of ASPD.

            Environmental, social, genetic, and familial factors are not the only contributors to the development of ASPD; growing evidence supports the fact that individuals with the disorder have a predisposed disposition towards antisocial behavior. Osumi, Shimazaki, Imai, Sugiura, & Ohira (2007) tested psychopathic individual’s cardiovascular responses to movies that typically arouse heightened physiological response as a result of the unpleasant stimulus. The results indicated that individuals with ASPD showed a decreased physiological response to unpleasant stimuli depending on the type of stimuli (Osumi et al., 2007). In a magnetic resonance imaging study, Kiehl et al. found drastically less affective related activity in the amygdala/hippocampal regions of the brain (Kiehl et al. 2001; Black, Men’s Textbook of Mental Health).

Course and Prognosis

            The signs and symptoms of the ASPD typically begin in adolescence when the individual demonstrates little or no respect for authority, which often causes trouble with parents and peers and at school. Furthermore, the individual may experience contact with law enforcement as lower level crimes such as theft are committed. Since violent, and/or sexually aggressive tendencies often bring the individual in conflict with the law, symptoms of Conduct Disorder are prerequisites for the development for Antisocial Personality Disorder (Black, Textbook of Men’s Mental Health). If the individual demonstrated some of the symptoms for Conduct Disorder before the age of 15 and continues to exhibit remorseless, impulsive, and/or negative behaviors, at the age of 18 the individual is diagnosed with ASPD (APA, 2000).

            After the ASPD diagnosis, the condition continues throughout the afflicted individual’s life, although research indicates that symptoms lessen through the natural aging process. In the Textbook of Men’s Mental Health, Black reports “One estimate is that antisocial personality disorder remits at the rate of about 2% per year”. Even if individuals progress and exhibit more socially acceptable forms of behavior, individuals may have to deal with symptoms of the disorder that return.

            Given the nature of ASPD, the outcome for the afflicted appears especially bleak. The heart of the disorder involves a lack of guilt, which means that individuals will not actively seek and gain any sort of benefit from the usual methods of treatment for individuals with psychological disorders (Hare, 2006). Without treatment the disorder will continue indefinitely with only slight lessening of symptoms (Black, Textbook of Men’s Mental Health).

Diagnostic Considerations

            A wide variety of the different disorders or negative behavior patterns could cause antisocial behavior patterns; however, persistent patterns of antisocial behavior set the diagnosis of ASPD apart from most other disorders. The first consideration should be the individual’s history of substance use. If the individual severely abuses substances, the effects of the drugs could be the causal factor instead of a habitual cycle of antisocial behaviors that started in adolescence. Furthermore, if the detrimental behaviors only take place during Schizophrenia or a Manic episode, and symptoms are not correlated with Conduct Disorder than the individual cannot be diagnosed with ASPD. Manipulation and the appearance of carelessness are also features of Narcissistic Personality Disorder; therefore, a diagnosis of ASPD requires that these symptoms also involve being rash and contentious coupled with a past symptoms or a diagnosis of Conduct Disorder. People suffering from Histrionic Personality Disorder are also careless, shallow, thrill seeking, scheming, and seductive; however, individuals with HPD usually do not engage in antisocial activities, they typically embellish expressed emotions (APA, 2000).

            In order to differentiate ASPD from Borderline Personality Disorder and Paranoid Personality Disorder, the motivations for the individual’s actions must be assessed. People with BPD manipulate others in order to receive affection or some type of physical reward. They also alternate more between emotions and are less antagonistic than people with ASPD. Furthermore, unlike ASPD, individuals with Paranoid Personality Disorder are antisocial in order to gain revenge on someone. Individuals with ASPD, however, engage in antisocial behavior in order to take advantage of people or benefit themselves in some way (APA, 2000).

            Criminal behavior and ASPD share the characteristics of aggression, antisocial behavior, and manipulation, but characteristics associated with ASPD are more chronic and engrained in an individual. Unlike someone involved in criminal behavior, someone with ASPD will not change their ways, and the continuing antisocial behavior results in pronounced impediments in functional tasks of everyday life. Furthermore, individuals with ASPD usually are significantly concerned about their disorder.

            ASPD often co-occurs with other disorders including Anxiety Disorders, Depressive Disorders, Substance-Related Disorders, Somatization Disorder, and Attention-Deficit/Hyperactivity Disorder. Any disorders involving the harnessing of impulses are possibilities for individuals with ASPD. Furthermore, the likelihood of developing ASPD also increases if psychological professionals previously diagnosed the individual with Conduct Disorder (APA, 2000).


            The nature of ASPD makes treatment extraordinarily difficult. Individuals with ASPD will likely not even seek initial treatment because they do not feel remorse for their behaviors, and the “unneeded” treatment will likely prove ineffective. Furthermore, afflicted individuals are manipulative, so they can use a therapist as a mere pawn in order to gain a decreased prison sentence or some other type of reward for themselves (Hare, 2006; Thornton & Blud, 2007).

            Even with ASPD’s particularly bleak prognosis, researchers are suggesting new methods for treatment that hopefully will prove successful in the future. All individuals with ASPD possess differing levels of psychopathy; therefore, each individual must receive treatment that is specifically designed to promote the most positive change in that individual. To accomplish this task, mental health practitioners must focus on psychological features (associated with behaviors) that are most malleable in response to treatment. Care providers must also work on eliminating the behaviors of afflicted individuals that are detrimental to the overall treatment of the individual. In addition, treatment methods themselves such as the use of self report must be modified, so that they are not subject to deceit or manipulation by the clients. Since afflicted individuals are particularly conniving, staff must be carefully trained how to deal with clients, and procedures must be clearly outlined in order to prevent patient co-opting. Treatment providers must appeal to the short-term focus of psychopaths, not a long term or other person focus, because otherwise treatment will prove ineffective. Societal approved behavior must receive more benefits than antisocial behavior, and treatment must remain constant (the positive effects of treatment may vary in an individual, but previous behavioral patterns have the possibility of remission). The treatment provided must be adaptive in that it responds to the diverse characteristics of an individual. Furthermore, when individuals make life transitions, they require supervision even if treatment has been lessened or stopped, and cognitive behavioral therapy should be used. If someone must decide who requires the most attention, younger individuals with signs of the disorder should be given treatment first because they are most responsive to treatment (Thornton & Blud, 2007).

Multiaxial Diagnosis of Lisa Rowe

Axis I: None.

Axis II: Antisocial Personality Disorder

Axis III: Nicotine Addiction

Axis IV: Unemployment. Often in trouble with the law. No stable home environment. Inadequate social support. Committed to a psychiatric ward and escapes in a cyclical fashion. Participates in sexual acts for money.

Axis V: GAF= 35 (at the beginning of the movie); GAF= 44 (at the end of the movie)

Summary of Movie

            Girl, Interrupted is a movie that centers on the character, Susanna Kaysen. Susanna has been experiencing severe depressive episodes which significantly impair her functioning and make her unpleasant to be around. As a result, Susanna checks herself into a mental institution where she meets individuals with a wide array of psychological problems. The diverse spectrum of personalities makes every experience interesting, and as Susanna continues treatment she befriends Lisa, a sociopath that pushes Susanna to bend the rules and have a good time (whether it be bowling after hours, hurling insults at past acquaintances, or singing energetically to a locked away companion). Eventually, however, Lisa takes things too far. She berates their friend, Daisy, relentlessly until, pushed to the brink, Daisy kills herself. Afterwards, Susanna witnesses Lisa’s alarming lack of remorse, and she realizes something about herself. She may have problems, but she still cares about other people. From that moment onward, Susanna resolves to get better until by the end of the movie, she is released. Susanna finally realized that unlike the people that will likely remain in the psychiatric ward indefinitely or for most of their lives, her problem was simply a meaningful interruption in the larger scheme of her life.

Movie Evaluation

            In the beginning of Girl, Interrupted, Angelina Jolie’s depiction of Lisa Rowe as an individual with Antisocial Personality Disorder was accurate. Lisa swaggered back into the psychiatric ward as if she owned the place. “It’s good to see you again” she said to one of the occupants. Clearly this was not Lisa’s first act of antisocial behavior, which stays true to the symptoms of the disorder—antisocial behaviors are recurrent.

            As Lisa gets coerced into the psychiatric ward and stumbles upon Susanna, the accurate portrayal of her disorder continues. The first noticeable characteristic is that when she shows up, Lisa appears to be in handcuffs. The viewer must assume that she has had an incident with law enforcement, and now is being forcibly returned for treatment. People with the disorder often are in trouble with the law, and do no actively seek out treatment unless forced or there is some material gain. Finally, Lisa erupts in fiery rage shouting: “Who the fuck are you? Where’s Jamie?” As with most sociopaths, Lisa demonstrates considerable rage and belligerence that rise to the surface quickly.

            The ranting and the escort by the psychological personnel demonstrate another characteristic of psychopaths: they have no respect for authority. Lisa openly mocks the rules of the psychiatric personnel as they escort her to the living quarters. Afterwards, Lisa yells and swears at the doctors, and barricades the doors.

            In response to the escalating situation, the mental health authorities quickly whisk Lisa away for treatment, which consists of medications, shock treatments, and what appear to be sedatives. As the viewer finds out later, none of the treatments seem to work in the long term for Lisa, and that is in conjunction with the true nature of the disorder in the real world. Historically, mental health practitioners have tried many methods including cognitive behavioral therapy, shock treatment, and medications. Some populations have shown slight improvements with certain forms of treatment, but the results are inconclusive, so Lisa’s misfortune in the movie is accurate.

            In the days following her first unpleasant introduction, the Lisa continues to display the symptoms of carelessness consistently found in individuals with ASPD. Janet’s statement sums up how Lisa acts: “Lisa thinks she’s hot shit because she’s a sociopath”. Sociopaths characteristically do have feelings of grandiosity and a somewhat cool demeanor about themselves.

            Sociopaths are also controlling and manipulative. In one way or another Lisa seems to always get whatever she wants from people. Sometimes Lisa will get them giving up medication or working together to sneak into the bowling alley or giving her money and a place to stay (even though the benefactor is dead). Even the “friendship” between Lisa seems to be something that lasted only as long as it was beneficial to Lisa.

            In addition to the manipulative wiles of sociopaths, Lisa demonstrates a careless disregard for all social norms. Lisa swears whenever and at anyone (including people that socially would require even greater respect). Lisa also violates the social norms about sex because she recounts being permissive for money, and she talks more explicitly than is considered appropriate. Lisa remarks to a hospital supervisor: “Fuck his brains out”.

            Relishing social taboos seems not to be Lisa’s only vice because she frequently can be seen puffing on a cigarette; psychopathic individuals often possess Substance Disorders. As a result of Lisa’s impulsive behaviors and rebellious attitudes towards social norms for healthy living (not smoking), she suffers from a nicotine addiction.

            Lisa also exhibits the complete lack of remorse that is one of the defining features of the disorder. Every time she lies, steals, or talks about past escapades Lisa never feels guilty. Usually, Lisa will simply make a joke about whatever she is doing because she does not care enough (actually not at all) to take the situation seriously. The most alarming example of Lisa’s complete detachment is when she sees Daisy hanging, a circumstance that she contributed to with her rash, cruel remarks. After Susanna calls for an ambulance (a normal response), Lisa sarcastically remarks: “An ambulance? Better make it a hearse”. Lisa then goes on to tell Susanna that she is stupid for caring, but only after she has stolen the dead women’s money. Afterwards, Lisa takes her things and leaves her “friend” behind without a second thought.

            Although appalling to the viewers and the corresponding characters in the story, Lisa’s actions in the story have been consistent with the diagnosis of ASPD; however, her response to Susanna’s confrontation was not something a person with the disorder would likely do. In response to Lisa’s thoughtless reading of her personal diary and constant carelessness, Susanna explodes: “No one cares if you die, Lisa, because you’re dead already. Your heart is cold…It’s pathetic”. As a result of Susanna’s tirade, Lisa responds with similar anger that would be expected of someone with ASPD. Then, however, Lisa quickly turns into a sobbing mess, and is sorry for her promiscuity and cruelness to others. Although such a response is touching and constitutes a heart warming end for a great movie, Lisa’s sudden guilt and regrets are not true to life. People suffering from ASPD will get better with age, but only through an incredibly gradual process. Even if individuals do recover substantially, individuals often relapse.

            Despite the movie’s one inaccurate depiction, the movie, Girl, Interrupted, accurately depicted ASPD, and it managed to be entertaining the whole time. Therefore, anyone looking for a crazily enjoyable movie should sit down and watch it.


American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000

Black, D. W. Antisocial Personality Disorder, Conduct Disorder, and Psychopathy. Textbook of Men’s Mental Health. 143-170.

Crowe RR: An adoption study of antisocial personality. Arch Gen Psychiatry, 31: 785-791, 1974.

Hare, D. R. (2006). Psychopathy: A Clinical and Forensic Overview. Psychiatric Clinics, 709-721.

Kiehl, K. A., Smith, A. M., Hare, R. D., Mendrek, A., Forster, B. B. et al. (2001). Limbic abnormalities in affective processing by criminal psychopaths as revealed by functional magnetic resonance imaging. Biological Psychiatry, 50,

Lewis, C. (2006). Treating Incarcerated Women: Gender Matters. Psychiatric Clinics, 29, 773-789.

Osumi, T., Shimzaki, H., Imai, A., Sugiura, Y., & Ohira, H. (2007). Psychopathic traits and cardiovascular responses to emotional stimuli. Science Direct, 42, 1391-1402.

Thornton, D., & Blud, L. (2007). The Influence of Psychopathic Traits on Response to Treatment. In Herve, H., & Yuille, J.C. (Ed.), The Psychopath: Theory, Research, and Practice. (pp. 505-539). Mahwah, NJ: London.

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