Is antisocial personality disorder really NPD on crack?

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I have to admit I’ve been confused by the distinctions between the Cluster B personality disorders, especially those of NPD and ASPD. There seems to be little distinction in most literature between NPD and ASPD (antisocial personality disorder) with most experts saying the difference is just a matter of degree, with ASPD (psychopathy or sociopathy) being higher on the spectrum than NPD.

Let’s turn to the Bible of mental disorders for some clarification. These are from the DSM IV-TR, but have apparently been updated, because these descriptions are all labeled obsolete. But for our purposes, I’ll stick with these criteria.

Diagnostic criteria for 301.81 Narcissistic Personality Disorder

Handsome narcissistic young man looking in a mirror

A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

(1) has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements)

(2) is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love

(3) believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or high-status people (or institutions)

(4) requires excessive admiration

(5) has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations

(6) is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends

(7) lacks empathy: is unwilling to recognize or identify with the feelings and needs of others

(8) is often envious of others or believes that others are envious of him or her

(9) shows arrogant, haughty behaviors or attitudes

Diagnostic criteria for 301.7 Antisocial Personality Disorder

antisocial_personality

A. There is a pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years, as indicated by three (or more) of the following:

(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

B. The individual is at least age 18 years.

C. There is evidence of Conduct Disorder with onset before age 15 years.

D. The occurrence of antisocial behavior is not exclusively during the course ofSchizophrenia or a Manic Episode.

Just for comparison’s sake, let’s include the (obsolete) criteria for the other two Cluster B disorders: BPD (Borderline Personality Disorder) and HPD (Histrionic Personality Disorder):

Diagnostic criteria for 301.83 Borderline Personality Disorder

borderline

A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

(1) frantic efforts to avoid real or imagined abandonment.
Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.

(2) a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation

(3) identity disturbance: markedly and persistently unstable self-image or sense of self

(4) impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, Substance Abuse, reckless driving, binge eating).
Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.

(5) recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior

(6) affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days)

(7) chronic feelings of emptiness

(8) inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)

(9) transient, stress-related paranoid ideation or severe dissociative symptoms

Diagnostic criteria for 301.50 Histrionic Personality Disorder

histrionic_personality

A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

(1) is uncomfortable in situations in which he or she is not the center of attention

(2) interaction with others is often characterized by inappropriate sexually seductive or provocative behavior

(3) displays rapidly shifting and shallow expression of emotions

(4) consistently uses physical appearance to draw attention to self

(5) has a style of speech that is excessively impressionistic and lacking in detail

(6) shows self-dramatization, theatricality, and exaggerated expression of emotion

(7) is suggestible, i.e., easily influenced by others or circumstances

(8) considers relationships to be more intimate than they actually are

It does seem that ASPD is more linked to criminality than NPD, most likely due to poor impulse control, which isn’t a problem in people with NPD. People with ASPD are more willing to break the law and are more likely to be in prison. They are less likely to be concerned with image or consequences of their actions (most people with NPD want to maintain their sqeaky clean image which means staying out of prison). Antisocials also seem more prone to violent behavior.

The DSM criteria for ASPD seem to describe psychopathy/sociopathy. Most narcissists are probably not psychopaths, but are on the same spectrum. Does this mean that ASPD and NPD should really be considered the same disorder, with ASPD higher on the psychopathy spectrum?

BPD is more clearly distinguishable from ASPD and NPD because a person suffering from this disorder does have a conscience and can feel empathy and remorse, but like someone with ASPD they have problems with impulse control. Also, their motives for doing what they do are different: they fear abandonment, while people with ASPD and NPD fear their true self being exposed.

HPD seems very similar to the somatic form of narcissism and includes many narcissistic traits. However, it seems that someone with HPD would be more prone to drama, neediness and tantrum throwing (although these traits aren’t unknown in narcissists). Like BPD, the motives for the sufferer’s behavior seem based on insecurity and fear of abandonment rather than the need to maintain a false front.

NPD and ASPD are more common in males than females, and HPD and BPD are more common in females than males. Does gender determine what disorder a child is more likely to develop later in life? Are BPD and HPD really the “female” forms of the other two disorders?

ASPD almost seems like an exaggeration of typically male traits–aggressiveness, lack of emotion (except rage), and risk taking; whilst HPD seems like an exaggeration of typically female traits — excessive emotionality, preoccupation with beauty/sexiness, and excessive neediness. BPD and NPD are somewhere in between these two and can include elements of both: ASPD –> NPD –> BPD –> HPD

The fact that the American Psychiatric Association keeps changing their criteria just makes things even more confusing.

27 thoughts on “Is antisocial personality disorder really NPD on crack?”

  1. My answer is No. I see antisocial as the reckless rebel, the juvenile deliquent. The Narcissist also makes their own set of rules, but tends to “win” more with society and tends to be more manipulative. The person with BPD has some narcissistic traits in that they are always trying to “suck” love out of others from their fear of abandoment, but they are able to actually feel love and empathy for others. The Histrionic I see like the Black-Widow spider: attractive, seductive, and very vain.

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    • These seem like pretty accurate descriptions. So NPD is dangerous because of the manipulation and the fact they are “wolves in sheeps clothing” who may give a good impression….ASPD is just in your face dangerous, these people are usually violent or even criminals.

      I’m thinking of Joan Crawford as a good example of someone with a lot of histrionic traits, but she was actually diagnosed with BPD. She seemed more narcissistic to me though. Whatever she was, she definitely had that black widow spider thing going, lol.

      I know there are women who have ASPD, but I wonder how common it is for men to have HPD? I can only think of one that I know.

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    • I think they are dealing with the same subtleties too. the Antisocial is your prison inmate while narc is the high achiever businessman. I do think all the overlaps can confuse people. I get mixed up on what is the difference between a psychopath and sociopath, and use the words interchangeably….though I THINK psychopaths are the violent and criminally inclined.

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        • I am still not entirely clear on the difference between a psychopath and a sociopath. I know they’re not exactly the same, but I use those terms interchangeably, and I prefer to use “psychopath.”
          I believe “sociopath” refers more to people with ASPD while”psychopath” refers to malignant narcissists very high on the spectrum.
          If ASPD and NPD should really be on the same spectrum (with ASPD higher), then it follows that a sociopath is worse than a a psychopath. I need to do more research on what the actual differences are.

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      • I use psychopath and sociopath interchangeably too–but I think sociopath refers more to someone with ASPD.
        Antisocials are prone to be criminals, but in the book I’m reading now– Martha Stout’s excellent “The Sociopath Next Door” (which focuses on people with ASPD rather than NPD) — Stout explains that people with ASPD,while likely to be criminals, are not always. They could also be a CEO or other high achiever or a lazy mooch who lives off the goodwill of others. This makes the difference between NPD and ASPD very confusing. That’s why I started thinking perhaps they are the same thing, but NPD is not as severe (and of course there is the issue of impulse control, which people with narcissism do not struggle with).

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  2. What I’ve heard is the difference is internal…the NPD needs constant validation (“narcissistic supply”) and is deep down quite insecure and overcompensating, while the ASPD’s sense of self, though it may also be delusional, is not reliant on validation from others.

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    • That’s true–the person with NPD “cares” a lot more what people think of them or how they are treated, but only to obtain supply,not because they really care if others like them or not. I read that any supply–negative or positive–is what they are seeking. They cannot stand to be ignored and will take negative attention over no attention.
      The person with ASPD doesn’t need narcissistic supply or validation, their attitude is just “I do what I want and f*ck you if you don’t like it.” Thanks for your observations.

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  3. You know what I am going to say. 🙂 Perhaps the reason that APA keeps changing the criteria is that these “disorders” were never valid or reliable in the first place.

    The so-called experts who say that ASPD is really a more serious form of NPD (conceptualized along a continuum) are being more realistic in my opinion. But if we admit that one can fade into the other, then we need to give up the notion that they are distinct entities. This is related to how the Newtonian laws of physics don’t work when one is considering relative space and time, or how something cannot be viewed as both a particle and wave at the same time.

    If thinks about real people, for example – the guy who is selfish and self-involved but always has a conscience telling him what he’s doing is wrong, the guy who is selfish but only sometimes feels guilty, the guy who commits a few minor criminal acts but then realizes the error of his ways and changes, the guy who commits criminal acts but never harms other people, the serial killer, etc…. we can see that they can’t really be reliably demarcated into two categories.

    But nevertheless, this post makes me think that I should include “antisocialus criminalus psychopathus” as another animal-thing to be exhibited in my zoo of mental disorders. I would just have to make sure to have much stronger perimeter fencing for this vile creature and to remind spectators to stand back at least 3 feet from its fence. I’m sure it will help sell tickets though.

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    • I tend to agree, BPDT. It does make more sense to me that ASPD should be on the same continuum as NPD (but closer to the top) for the reasons you said. Why they are considered separate disorders I can’t really answer. ASPD does differ in that someone with ASPD doesn’t try to obtain narcissistic supply — they just do what they do, and don’t give a f**k what you think, but they are selfish and have no empathy. The other qualitatitive difference here is inability to plan ahead/impulsiveness. People with NPD do not have this problem, but people with ASPD share this with those with BPD.

      You are aware that psychiatric designations really only exist for billing purposes–so insurance companies can get paid. Insurance companies require a billing code and diagnosis. Some labels, however, are valid (Bipolar, schizophrenia, anxiety disorders) and have been unchanged for years, while others seem like made up labels that are very arbitrary and seem subject to constant change.

      But labels also help therapists appropriately treat their patients. If someone walked in who was depressed or had some other disorder and you didn’t have a diagnosis to give them, how would you treat them?

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      • That’s not hard to answer. If someone walked in who was unhappy or troubled, one would ask them what had happened, let them tell their story, and respond in an empathic, supportive way. One would try to help them find solutions for what was bothering them and making them feel understood. You would work with them to formulate a narrative about what had happened to them and why they are having problems. No label has to be involved.

        Here’s a good article making that point: http://www.madinamerica.com/2015/01/still-need-psychiatric-diagnosis/

        Psychiatric diagnoses are just not necessary to get better. Not everyone wants them. If some people find them useful, fine. But if people don’t want a diagnosis and can get better without it, there should be no problem with that either.

        As for schizophrenia and bipolar being valid, there is no strong evidence for their existence as illnesses. Several books argue convincingly that schizophrenia is not a unitary syndrome – i.e. that symptoms that supposedly allow one to infer the existence of “schizophrenia” do not occur reliably in concert (i.e. occurring at more than a chance level of frequency together). This is argued best by Mary Boyle in her book Schizophrenia: A Scientific Delusion. It’s also pointed out by Richard Bentall in the book Madness Explained, Paris Williams in Rethinking Madness, and John Read in Models of Madness.

        This viewpoint will probably seem out of touch with what most people think. But to me that would only demonstrate how thoroughly American psychiatry has brainwashed the public into believing that these fictitious conditions are reliable, separable entities. They need to do that, because otherwise they couldn’t promote psychiatry as a (pseudo) science and the business of selling medications would be greatly damaged.
        Of course, all the symptoms that comprise supposed schizophrenia and supposed bipolar do exist in different varieties and degrees. People really do suffer, have painful symptoms, and lose contact with reality in various ways.. There is just a lack of evidence that these problems form a unitary syndrome or illness (i.e. that groups of symptoms tend to co-occur above chance level). This is more clearly explained here:

        http://www.academia.edu/237139/Steps_Toward_a_Schizophrenia-Free_World

        A better way of thinking about all of this might be to suggest the construct of “madness” or “distress” that can occur in varying degrees along a continuum of severity, in different situations in different people.

        We should remember that these notions of schizophrenia and bipolar being valid entities have only existed for a couple of centuries. Before this most recent period of human history, there were no supposed mental illness “diagnoses”. Perhaps in the future people will look back at American psychiatry in the 20th/21st century as a mistaken and ignorant field of study, and compare its certainty in the existence of mental illnesses to the certainty of scientists centuries before that the sun orbited the earth.

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  4. Also, there is no reason that children under 18 can’t act in an antisocial way. It makes no sense how people over 18 are suddenly eligible for new disorders; there is no such cutoff (again things occur in gradations, not absolutes or either/ors). It’s scary to view the videos on Youtube of young girls and boys talking about how they want to kill their parents and mutilate other children (there are videos of antisocial youngsters if you search for them). But again, that doesn’t necessarily make them have a certain “disorder”. Making the argument that they are possessed like the little girl in the Exorcist would have almost as much validity as arguing that they have a distinct disorder!

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    • The age limit is arbitrary and I agree there are antisocial people younger than 18 (and some who still can’t be accurately diagnosed as adults) but I suppose they have to have a cutoff somewhere. I would imagine this is for legal reasons as well as psychiatric ones, to avoid people under 18 being tried as adults–of course that happens anyway so the arbitrary cutoff does seem sort of pointless, doesn’t it?

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      • I agree about the legal reasons point. It’s sad seeing that some 19 year olds who are more immature than certain 16 or 17 year olds get long prison sentences simply due to their age. But yes apparently we think there has to be a cut off somewhere.

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  5. I find that the best way to understand any of these disorders is to actually talk to the people that suffer from them. A Personality disorder is a Personality disorder and each of them are worthy of support and understanding. Not all people that suffer from ASPD or are considered Psychopathic are criminals, in fact last i heard, only 20% of incarcerated criminals suffer from ASPD or psychopathy. The majority of the people I know that have any of these Diagnoses are merely individuals doing their best to get by. And the lack of support, treatment and understanding offered them is next to non-existent. Purely because of the way society views these disorders. It seems that people are only willing to support those with the more socially acceptable mental health concerns and are happy to throw the more antisocial disorders out into the cold to fend for themselves. Not all Psychopaths and Narcissists behave in monstrous ways. We’re quite happy to accept that not all men are rapists yet it seems far beyond most people to accept that not all people with personality disorders are unpleasant or destructive. I’ve met far more abusive neurotypicals than I have abusive atypicals.

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    • Caffeinated OM,
      Good points. Most narcissists and even people with ASPD (a worse disorder than NPD) are not in prison. Not all are criminals either, even if cagey enough not to get caught. More ASPD’s are criminals than NPDers though.

      As far as people with NPD and ASPC being “bad” people, I would agree that not all narcissists are evil or deserving of all the hatred against them, especially by many ACONs (whose hatred though is understandable because of the abuse they had to endure by narcissistic parents growing up). Narcissism, like autism, is a spectrum disorder, which means that narcissists low on the spectrum are not necessarily bad or don’t have feelings, but they do have difficulty with empathy — that is, being able to feel what others are feeling. They may be arrogant or manipulative, but that still doesn’t make them bad people. They may still have a good heart. When you get higher on the narcissism spectrum, then you get into malignant narcissism and those people are much more likely to be sadistic and enjoy hurting others, or be explosive and very scary to others. Most are probably not criminals, but at this level, even if they put on a good impression at first, they do not have good hearts and are not well intentioned. At the top of the scale is psychopathy/sociopathy and that speaks for itself. Most of them may be at least petty criminals, but not al of them are either.

      For an ACON, I’m probably more sympathetic to people with narcissism than most. There is a lot of vitriol spewed on the Internet toward those people who suffer from NPD, and there are those who really do suffer. I know there exist narcissists who can’t stand their disorder and really want to get help. They know they lack empathy and they know this keeps them from being able to really love someome or have a rewarding relationship. ASPDs, really being another name for psychopathy/sociopathy, are really at the top of the narcissism scale (I recommend the blog The Narcissistic Continuum over at Blogspot) and are pretty much devoid of a conscience at all, even if they are not in prison or criminals.

      As far as neurotypicals vs. atypicals, I find that as an Aspie , I find many neurotypicals (whether they are narcissistic or not) as intolerable as many narcs, but that’s just because of my odd wiring. They may be nice people but most of them drive me crazy.

      Thanks for the feedback. 🙂

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      • I feel much the same way about neurotypicals, lol. In all honesty, I have spoken to a few psychopaths and have found them to be very similar to myself in a lot of ways, at least in their methods of fitting in with those around them like a social chameleon (I have BPD) and find it curious that people that could be considered polar opposites of one another could be so similar in the way they exhibit symptoms. I think that providing people are doing their best to live their lives without causing harm to others, they should be entitled to just as much respect and support as everyone else and feel that the stigma and stereotypes surrounding all cluster b personality disorders can be extremely problematic for those attempting to seek help. I also feel that symptoms as described in the DSM V, whilst being correct as far as symptoms go, quite often fail to address the bigger picture. Most narcissistic behaviour for example stems from a severe lack of self esteem and self worth, therefore the individual feels a great need for validation. In much the same way as someone with BPD would. We do it because we fear abandonment, they do it because they fear being worthless. Also, it’s worth remembering that most of us suffering from personality disorders have suffered abuse and trauma of some description at some point and whilst this doesn’t in any way excuse us from bad behaviour, it can go a long way to understanding it better. Whilst it’s perfectly acceptable to write someone off as abusive for your own peace of mind, it seems that many people these days will write articles claiming psychopaths and Narcissists should be avoided at all costs which tends to add to stigma and make things even harder for those that genuinely just want to get along with people.

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        • C-OM, I agree with almost everything you said here. As someone with BPD (and Aspergers, what a combo!) I was afraid to “come out” about the BPD on this blog, because Cluser B disorders in general are thought of as “bad” or character disorders. There’s a lot of misunderstanding about both BPD and NPD–you are right that people with NPD do NOT love themselves–people who love themselves are a joy to be around–and are able to love others too. People with NPD are MISERABLE, and often very lonely. It must be hell to go through life unable to feel for others, ever have a satisfying relationship, drive people away from you, and be stigmatized as evil, demonic monsters. I also don’t believe they are beyond hope, at least not on the lower parts of the spectrum. It may be difficult for them to get better, but it’s not impossible. The trouble is, most will not enter therapy because they don’t see themselves as having the problem-they see everyone else as the problem. People with NPD who have insight AND a willingness to change probably could get better even if they can’t really be cured.
          The behaviors of someone with NPD and BPD can be very similar and they are often misdiagnosed as having the other disoder, but you are correct, people with BPD act the way they do because they fear abandonment, while a narcissist fears their True Self being exposed.

          My rather unpopular opinion here is that most narcissists became the way they are as a defencse mechanism– a way to protect a true self that was TOO vulnerable and sensitive. The False Self protects the true one, and will attack when it thinks its armor is being cracked. In fact, I think some narcissists started life as potential empaths. I’ll try to find the link to the article I posted about that.

          I only take a little issue with your last point. I agree that all the “no contact” talk can be stigmatizing to someone with NPD, but for someone who has been abused by one or more of them (they really make horrible parents), for our own mental health and recovery of our own self esteem, sometimes going No Contact is the only thing that works. I can understand the hatred (and it’s healthy when you know you must escape from one because that anger can motivate you), but I won’t argue with the fact that people with NPD have been vilified to a horrifying degree. High on the spectrum though, it makes more sense.

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          • I totally agree, I’m pretty certain my mother falls somewhere on the NPD spectrum and suffered a great deal of abuse from my ex husband who was diagnosed with BPD (but I suspect leans more towards NPD), I would give anything to avoid contact with both of them and can completely understand sufferers of abuse doing so. I simply worry that all NPDs and ASPDs become tarnished with the same brush unnecessarily. I’d be really interested in any articles you can send my way, always happy to read more on the subject 🙂

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            • All the articles can be found here, you can use the search bar, categories list (it’s looooong!) or tag cloud, if you want to read more on “healing NPD” I actually have a page for that n my header (it’s a topic that is deeply interesting to me).
              One day soon I want to prepare a table of contents or some sort of index to make articles about certain topics easier to find.

              I am reading Dr. James Masterson’s book now, (The Emerging Self–Healing Narcissistic Disorders of the Self); many of the treatments and therapies used on people with NPD would work on those with BPD as well.

              I think one of the reasons NPD has become so mixed up with ASPD is due to the recent popularity of the idea of “malignant narcissism” which is basically severe NPD shading into ASPD. They are on the same spectrum. I don’t think people with ASPD (psychopaths and sociopaths) have any hope of getting better at all.

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            • I talk to a few who are doing their best to get by in life just the same as those of us with bpd are. It’s hard to manage symptoms and find better ways of coping when even therapists aren’t willing to work with them because they feel there’s no hope. They used to say the same thing about people with bpd and there are plenty of treatments these days and plenty of people doing well in life despite their diagnosis. Those with disorders such as NPD and ASPD WON’T have any hope of getting better if no-one’s willing to even bother looking for ways to help them.

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            • It really is a lot of hard work! But we’re worth it 🙂 I still struggle but I’m so much better than I was. I actually had a Psychiatrist congratulate me the other day and tell me I was an inspiration. Something I NEVER thought I’d hear from anyone, let alone a professional. Writing helps a lot I find. Are you on tumblr at all? I’ve learnt so much about both my own personality disorder and all the other cluster Bs just from talking to people on there. It helps a lot when you can see that you’re really not alone 🙂

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            • Wow, that must have made your day, C-OM! Writing does help a lot, and I’m not going to stop now. Being that I cannot afford a therapist, it’s the only lifeline to sanity I have. And it’s been an incredible blessing.
              No, I do not have a tumblr account. Never could figure out how it works.
              But you should be proud your psychiatrist told you he was proud of you!

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