In recent literature, researchers underline that multiple and antisocial personality disorder is real but that it rarely occurs spontaneously, without prompting, and therefore does not deserve to be a primary-level diagnosis. Special attention is given to gender differences and behavior patterns of patients and possible treatment methods. There is a small but well-recognized group of adults with a mild learning disability, predominantly but not exclusively male, who come within this rubric and who pose major problems of management, containment, and public safety, in whatever residential milieu they live. Their behavior is characterized by a callous lack of concern for the feelings of others, gross irresponsibility and disregard for social norms and obligations, inability to maintain close relationships, a very low tolerance of frustration violence, and aggression, an inability to experience guilt or to profit from experience or punishment, and a tendency to blame others for their errant behavior.
Ang and Hughes (2002) examine the differences in antisocial personality disorder in adults. They found that the psychometric properties are weak for women in contrast to the male sample group. In interviewing these patients the lack of any sense of right or wrong, and moral responsibility, can be deep-rooted, obvious, and pervasive. This inability to empathize with the feelings of others, and a lack of imagination as to the consequences of their behavior, can lead to serious considerations of public safety for which treatment efforts are of uncertain efficacy and have to be secondary to considerations of security and containment. Some of these psychopathic adults with learning disability are to be found among the population of persistent fire-raisers and sex offenders (particularly offenders with children).
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Bryan and Stallings (2002) and Crawford (2004) found that aggressive and violent behavior is not typical. Also, these criteria were not included in the DSM-III or RDC classification. Personality and personality disorders are elusive concepts that have not been well-researched by psychiatrists. All too often the term 'personality disorder' becomes a pejorative label with no implications for treatment or services. If it is no more than that it would be better abandoned. That is not an option because, however imperfect our knowledge, we know that personality is one of the key issues in determining the success or otherwise of community living for adults with learning disability, and is equally important as physical dependency needs and frank psychiatric illness. Researchers admit that it is important to revise diagnostic criteria for male and female patients and apply new criteria to antisocial personality disorder. Psychiatry needs to extend and consolidate our knowledge in this area, to formulate practical treatment and management programs. Personality probably consists of characteristics that have been present since adolescence, are stable over time despite fluctuations in mood, are manifest in different environments, and are recognizable to friends and acquaintances.
Woodward et al (2002) examine gender differences in romantic relations and sexual relations in people with antisocial personality disorders. The study found that “Females reported higher rates of partnership formation than males” (p. 231). Most of these personality assessment schedules do, however, involve a component of self-report and subject participation and this is beyond the competence of people with any significant degree of learning disability. Hence, personality disorder has been one of the least researched areas of learning disability psychiatry, and the few studies there tend to be idiosyncratic and unscientific. A multitrait—multimethod approach would utilize diverse measurements for a broad range of traits to establish construct validity for the underlying constellation of behaviors being measured. Many of the behaviors rated will likely be found across different genetic conditions. It is the group of behaviors occurring most frequently in each syndrome that will constitute the behavioral phenotype for that particular genetic disorder.
Windle (1999) and Mueser et al (1999) examine a correlation between antisocial personality disorder and substance abuse among women and men. It was found that men are more inclined to substance abuse than women. Thus, alcoholism is typical for both men and women subjects. Within-syndrome variation and inter-syndrome overlap of behaviors are commonly observed. Many of these behaviors are also reported in people with idiopathic learning disability. Most studies are riddled with methodological flaws, and the data presented here should be interpreted with caution. Although the mechanism by which a genetic disorder could cause the manifestation of a set of specific behaviors is largely unknown, the ultimate pathway must be the structure and function of the brain. Most of these behaviors are not curable but could be remedied with appropriate educational and management programs. Maladaptive behaviors could be managed by using behavioral programs along with the judicious use of pharmacotherapy. If an individual has not learned particular skills by 'ordinary' means he or she can be taught by using highly efficient teaching methods. Unfortunately, once an individual's learning difficulties have attracted a label of 'mental handicap' (or when behavior modification was first introduced, 'subnormality'), the expectations of that person are lowered. The result of lowered expectations is usually reduced opportunity to learn (because less effort is made to teach everyday skills). In addition, the individual may be allowed to 'get away with' behaviors that would be seen as undesirable in an 'average' child.
Rowe et al (2006) and Pfiffner et al (2001) examine the impact of family on antisocial personality disorders among children of both sexes. The researchers found that there is a danger in reinforcing 'desired' behaviors if the assumption is made that the environment the person functions in is fine and it is the person who is antisocial, ill, deviant, unacceptable, and so forth. They underline that psychiatrists must be careful to exercise behavioral approaches for the benefit of the client, not simply to encourage compliance. Very often it is the environment that is odd rather than the person: odd environments produce odd behavior. Behavior modifiers have utilized this process to teach new skills, by reinforcing successive approximations to the desired behavior. For example, if a therapist is teaching an individual to use a sign to indicate that something is wanted, at first any rough approximation to the sign is reinforced. Gradually, in a series of small steps, the criterion for reinforcement is raised so that the sign has to become more and more like the correct sign to gain reinforcement. Shaping is a very useful technique when used in conjunction with suitable reinforcers (see comments in the previous section) and other procedures derived from research into the effects of antecedents on behavior.
Kjelsberg (2004) found that although faulty child-rearing, dysfunctional parental relationships, psychosocial deprivation, and maladaptive social learning are undoubtedly key factors underlying antisocial sexual behavior in some learning-disabled sex offenders many come from warm, stable, and caring families and show little evidence of significant psychopathology. The key predisposing factor in the genesis of their sex offending is the restrictive and protective attitudes of society, family which limits opportunities for normal sexual expression, restricts access to socio-sexual information, and often results in inconsistent responses to sexual behavior or misdemeanors, with resultant sexual frustration and confused concepts. Socialization programs are the bedrock of most treatment programs and the major intervention when sex offending is part of a generalized antisocial behavior disorder. They aim to instill a sense of personal responsibility, improve self-control, and assist the internalization of behavioral standards by utilizing approaches based on token economy principles. Tokens or points, which can be exchanged for a range of benefits, are issued on a systematic basis to reinforce socially desirable behavior, sometimes coupled with specific penalties for undesirable behavior. Several programs have been developed that differ only in such details as whether all or only specific aspects of behavior are targeted or points/tokens are awarded immediately, daily, or weekly.
Hodges (2003) discusses the correlation between posttraumatic stress disorder and antisocial personality disorder among women and men. He underlines that “symptoms of female inpatients with BPD overlapped frequently with symptoms of mood disorders and, to a lesser degree, with those of eating disorders and anxiety disorders” (419). A smaller group but highly significant in terms of management and treatment needs. These are markedly damaged individuals who show a high prevalence of sociopathic personality disorder, psychosocial deprivation, brain damage, and other maladaptive behaviors including non-sex offenses. Their sex offending is the consequence of a deep-seated antisocial behavior disorder and they are more likely to commit serious offences and to become persistent offenders. They require intensive treatment and care in a structured and controlled environment. These individuals are typically shy and immature with limited sexual knowledge and little or no sexual experience. They usually come from warm and caring, if somewhat overprotective, families and have a low prevalence of psychosocial pathology and other antisocial behavior. Their sex offending is essentially a developmental problem - crude attempts to fulfill normal sexual impulses in the context of a lack of normal outlets, poor adaptive behavior skills, sexual naivety, poor impulse control, and social ineptness. They tend to commit less serious offenses and are less likely to become recidivists, but if they do they tend to commit a broader range of sex offenses than the other groups, reflecting the opportunistic and undifferentiated nature of their sexual responses. Treatment measures should focus on sex education and counseling, training in relationships and other skills, and improving self-confidence and social awareness.
In sum, the studies under analysis mark that women show weaker signs and symptoms of antisocial personal disorder than men. Thus, this situation is caused by inadequate diagnostic criteria and current classifications. Changing behavior usually involves altering consequences so that natural reinforces are rearranged to follow different behaviors: for example, staff may pay attention to a client's positive behaviors rather than to the problem behaviors they had previously attended to, and this will increase the rate of positive behavior (provided that attention is reinforced). A second major problem with how behavior modification has been implemented is that new research findings have not always found their way into clinical practice. Many practitioners have continued to use techniques derived from early research when more recent work suggests more effective ways of understanding and overcoming a problem. This is largely because most behavior modification practitioners have still not been taught the principles underlying the approach, and many behavioral interventions are attempted without reference to clinical psychologists who are more likely to have kept pace with developments in understanding behavior (including non-behavioral methods). The syndrome to be tested among women and men should then be rated by the same raters and informants for each group who are familiar with their client's behaviors. The rating should be blind to the genetic conditions and vice versa. The behavioral rating scale should be properly validated for the study group and tested for inter-rater, inter-informant, and test—retest reliability. In a cross-sectional study behavior should be rated for a reasonable time as behaviors tend to vary among these individuals over time. Internationally accepted commonly used definitions should be used for each condition. After such rigorous hypothesis testing one should be able to establish an association (if it exists) between a genetic condition and antisocial personality disorder.
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