CPCP: Antisocial Personality Disorder by Medical Student Kirsten Goetz

Kirsten Goetz M4
Kirsten Goetz M4

Coming at you with another great Clinical Problems in Consultation Psychiatry (CPCP) presentation, this one by senior medical student, Kirsten Goetz. She is interested in pursuing a residency in either Dermatology or Anesthesia.

The challenge of caring for patients with Antisocial Personality Disorder (ASPD) in the general hospital arises frequently, often because of the reckless lifestyle many of them lead. Something new I learned from Kirsten is that the National Institute for Health Care and Excellence NICE Guidelines for helping young people with conduct disorders and antisocial behavior.

A couple of the articles Kirsten found were written by members of our department, Michael Garvey and Donald Black. Dr. Black, as my regular readers know, literally wrote the book on Antisocial Personality Disorder, “Bad Boys, Bad Men: Confronting Antisocial Personality Disorder.”

And you can find one of many articles about Conduct Disorder on Brain Posts for the month of May in 2015 at the blog by Dr. William R. Yates, MD, one of my former teachers.

I know many of us got a chuckle reading Pitbull’s recent putdown of presidential candidate Donald Trump, warning him to watch out for El Chapo, the Mexican drug lord who escaped from prison last week. We can speculate about whether El Chapo actually has ASPD. We can also speculate about the story implying that El Chapo poisoned Chicago.

Did he? Or was it Al Capone who did that? You could legitimately wonder whether Chicago and countless other cities were already susceptible to the poison of narcotics trafficking long before El Chapo was born.The truth is that ASPD is a robust thread running through societies worldwide and you can find both men and women with this disorder in every walk of life. They’re not all represented by the stereotypical image of the disheveled convict covered with tattoos. They are Chief Executive Officers of large companies, physicians, lawyers, police officers, politicians, artists, and more.

You can wonder why such a destructive genetic code would persist over millenia, especially the extreme version of ASPD called psychopathy. Remember the so-called “warrior gene”? We have to be careful when we try to apply the genetic studies of the relationship of the Monoamine Oxidase Inhibitor-A allele to aggression and antisocial behavior in our legal system:

Gonzalez-Tapia, M. I. and I. Obsuth (2015). “”Bad genes” & criminal responsibility.” Int J Law Psychiatry 39: 60-71.
The genetics of the accused is trying to break into the courts. To date several candidate genes have been put forward and their links to antisocial behavior have been examined and documented with some consistency. In this paper, we focus on the so called “warrior gene”, or the low-activity allele of the MAOA gene, which has been most consistently related to human behavior and specifically to violence and antisocial behavior. In preparing this paper we had two objectives. First, to summarize and analyze the current scientific evidence, in order to gain an in depth understanding of the state of the issue and determine whether a dominant line of generally accepted scientific knowledge in this field can be asserted. Second, to derive conclusions and put forward recommendations related to the use of genetic information, specifically the presence of the low-activity genotype of the MAOA gene, in modulation of criminal responsibility in European and US courts.

However, as the authors of this paper point out,”…although the positive link between MAOA-L and aggression is currently the predominant view, the effects are generally small and they do not suggest that this so called “warrior gene” is alone responsible for aggressive behavior….” And partly because of the relative paucity of effective treatments for ASPD, they go on to say,

“…as scientific evidence has only demonstrated effects of the interaction between MAOA-L and early maltreatment, such that it would permit invoking only a possible mitigation of the individual’s criminal responsibility, the individual’s dangerousness should be evaluated with equal weight. These effects drastically deny the legitimacy of further security measures or any aggravation of the criminal punishment. Given the current state of scientific knowledge, as we proposed here, lawmakers and court officials could rightfully assume diminished responsibility based on the research findings. However, given the lack of specific treatments and a number of aspects requiring further understanding, it would be difficult to justify a more severe legal response to these cases. Uncertainty and risk of mistakes should always fall on the side of the less costly solution.

This will be the panorama and the risk. New scientific studies gradually reveal more about the biosocial roots of antisocial behavior. Asked by science to take into consideration its findings, Law will always wield a double-edged sword. It cannot and does not mean, however, that science should not be allowed to advance in this field. It is only that, at the same time, science should also focus on providing effective treatment alternatives, preferably minimally invasive, affordable and respectful of human dignity. This should be, in our view, the highest priority for behavioral genetics and neuroscience, in order to be useful and enlightening to the criminal law and the society overall.”

It may also be “less costly” to retain the hope that individuals with conduct disorder and even ASPD can change.

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