Personality Disorder

28 03 2011

Al Pacino - Scarface

I’ve seen a lot of drug dealers lately. I’ve never met one in my personal life, but I have met plenty as a doctor. I must be on some list somewhere, because in the last week, I’ve seen three of them. In the process of doing my assessments I have seen an interesting trend.

3 out of three were diagnosed with anti-social personality disorder with narcissistic traits.

I’ve always been a bit of a skeptic when it comes to personality disorders. It always seems to me like a bit of a diagnostic cop-out.

It just so happens that in psychiatric circles, it’s pretty much a known fact that there is no treatment for personality disorders. That’s very handy.  If we don’t like you, and there is no treatment, then we have no duty to care for you. It’s the perfect ‘out’. So, if we don’t know what is wrong with you and we don’t like you, and we’d just as soon wash our hands of you, guess what… You have a personality disorder.

That’s why it struck me as odd that three of the last three patients I saw last week who had been diagnosed with personality disorders had recently had a psychiatric assessment on their way out of jail.

I know, you’re probably thinking… ‘They are the scum of the earth, let’s be done with them’! OK, I get that. It’s hard to have empathy for someone who has no empathy.

But what struck me was that each of these fellows was actually relatively likeable. I don’t mean ‘take them home for dinner’, likeable, but not as bad as you would think. They have a number of things in common that might explain why they are often tagged with the diagnosis, “personality disorder”

  1. They all grew up with mother’s who were either not around, or were pre-occupied, or just didn’t ‘get’ them. They did not have strong attachment to their primary caregiver. In fact, many were bullied, neglected or abused as children, so they often have little attachment to anyone.
  2. They are reward deficient. Meaning they have a tendency to be easily bored, are risk takers, defiant, irritable and sensitive to criticism.
    The first trait, ‘attachment disorder’ means they do not feel the misfortune of others. This allows them to lie, cheat, steal, manipulate, defraud, assault or even kill people, without losing sleep. If no one ever cared about you, why should you care about anyone else.
The second trait, ‘reward deficiency’ means that earning a living the legal way is too boring. It means you don’t sweat it too much when you are on a ‘most wanted’ list, because risk is part of the allure. It means you are oppositional; you don’t bow down to authority (because that’s no fun). It also means that you are quick to anger and you’d just as soon kill someone who disrespects you, than look at them. Remember Pacino in Scarface or Brando in The Godfather?
    Reward deficiency also ties into narcissism. Narcissism is a moral not a biological construct. In the animal kingdom you don’t call the alpha male a narcissist. He’s just looking out for number one, that’s how he got to be the alpha male. In our society we consider that being selfish. When I get to know these guys, I don’t see selfish. I see self preservation. I see a person who feels so bad, that he can’t tolerate things getting any worse. That manifests as not liking: being told what to do; being criticized; or not having things your way.
    In other words, he’s reward deficient. That pretty much explains it. If your like that, and you have attachment disorder, people consider you a narcissistic asshole. But is it really their fault? It’s not their fault that they inherited genes that disrupted their dopaminergic reward circuit. And, it’s not their fault that their mother and other’s did not teach them the language of empathy. That’s why when you talk to them, even though they just got out of jail for some pretty nasty business, they seem a lot less horrible than you would think, relatively likeable actually.
    However, I’m not saying it’s OK to be a drug dealer. But if you hear the whole story, like I do, you are less likely to ascribe blame. As one of my psyche teachers said. It’s maybe not their fault, but it is there responsibility and as such, even though I get where they are coming from, I still think they should pay for their crimes. However, while they are in jail, paying for their crimes, maybe they can get some therapy to help them understand themselves, or maybe they might get some medication to increased the voltage in their dopamine circuits. Maybe that might help them turn around more than just being in jail and then being diagnosed with an untreatable personality disorder.
Anthony Ocana MD
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What is evil?

29 12 2009

Umar Farouk Abdulmutallab

Looking through the paper today, I could not miss the article about the Nigerian guy who tried to blow up the Northwest flight from Amsterdam to Detroit on Christmas morning.

According to an article in the Globe and Mail, December 28, 2009. This baby-faced 23 year old was the quiet and studious son of a wealthy Nigerian banker, who resembles, at first glance any other young man from the northern Nigerian city of Kaduna. He wore designer clothes, sunglasses and fashionable suits. However, there was something  different about him.  His neighbour noticed that he stayed at the mosque far longer than anyone else after prayers. He rarely talked, and when he did it was mainly about Islam. According to the neighbour, “There is a serious and growing problem of Islamic fundamentalism in this part of Nigeria. He is a product of this type of hatred and intolerance.”

His father, a prominent banker, was so worried by the radicalization he saw in his son that he contacted the U.S. embassy in Nigeria to report his concerns.

According to the current world-view, this young man is the epitome of evil. But what is evil?

If we look at Mr. Abdulmutallab through the lens of mental health, there are a couple of things that we can say: He is angry, intolerant, obsessed. He lacks empathy for others, remorse for his actions. He may have even been psychotic at the time. What we can say for sure is that he meets the criteria for what we call anti-social personality disorder. This does not mean that he did not like to socialize, although that may be true. It means he is capable to committing acts that are against the most basic social norms.

Again, the Western media is happy to moralize these traits as “bad”. But it might be more appropriate to view these traits under the umbrella of “sick”. In fact whenever the veneer is stripped back on people who commit these types of acts, they often come across more as “troubled” rather than evil. In many other aspects of their lives they seem either very normal, or often, subject to real or perceived trauma.

Take the young men at the centre of the Columbine massacre. They were the victims of relentless bullying….

We don’t know why Mr. Abdulmutallab saw fit to try to blow up an airplane full of people, but it seems to me this is more the domain of forensic psychiatry than morality.

This is neither to condone, nor to justify, terrorism. The taking of innocent lives for any reason is always a tragedy. It is an act for which we must hold people accountable. However, if we can understand why people commit acts of terrorism, maybe we might be more successful at fighting it. On the face of it, we have spent billions of dollars and sacrificed thousand of lives and we seem no further ahead in the fight against terrorism. A terrorist can be anybody. A suicide bomber will be effective in any small crowd. It seems to me, this is not the sort of thing you can fight using conventional warfare.

The person who commits terrorism, especially through suicide, obviously feels deeply wronged on some level. Real or perceived, that sense of injustice is so great, that the person feels it is worth dying for. We ignore these underlying causes at our peril.

That’s what bullies do. They are neither attentive to, nor do they take responsibility for the wrongs that they perpetrate on their weak or innocent victims; Then they are surprised that their victims lash out using what seem like cowardly methods; Finally, they retaliate with the fury of righteousness on their feeble attackers.

Again, this is not to blame the US, nor any other country or target of terrorism, it is merely an attempt to make sense of this seemingly senseless act and perhaps to cast it in less moralistic terms in the hopes that we might avert some of the negative consequences.

A healthy person who is wronged and then invalidated might feel helpless. An angry, intolerant, anti-social person is more likely, in a final act of defiance, to lash out in the most extreme way possible, by sacrificing his/her life to harm his tormentor .

In the mental health business, we have a name for the disorder that allows someone to harm others with no remorse. We call it “attachment disorder”.

It is often the case that bullies have at one time been traumatized themselves. As mentioned earlier, this may may be real or perceived. It doesn’t really matter. People who suffer from attachment disorder, feel no attachment to others and are therefore insensitive to the hurt that they may cause. As opposed to a psychopath who chops off someone’s head in a mad impulse, the person with attachment disorder has pre-meditated the consequences of his/her actions in gruesome detail, but without a whiff of remorse.

The theory goes like this: The person with attachment disorder was never properly nurtured by his/her primary caregiver. On the contrary, he/she was likely verbally, emotionally, physically and/or sexually abused, neglected, shamed and/ or abandoned. Often this type of abuse is repeated, ritualized and/ or relentless. For the record, this is not rare.

There are millions of people in our society who have endured tis kind of trauma, somewhere in their lives. According to the theory, if the people who are supposed to care for you, don’t, then why would/should you care about anybody else. And when you don’t care about anybody and you are or feel wronged and invalidated you become the kind of person that can blow up an airplane full of innocent people Christmas Day.

Now, I don’t know Mr. Abdulmutallab, nor is there any suggestion that he had this kind of background, so for the moment this is purely speculation, but anyone who is capable of such an act, despite their outward appearance, is usually someone who is acting from a place of extreme hurt. So, if this is the case, what is evil and how should we best deal with it?

Dr. Anthony Ocana
MSc, MD, CCFP, ABAM

Addiction Specialist
Co-founder NorthShore ADHD Clinic
http://www.northshoreadhd.com