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Bad Boys, Bad Men: Confronting Antisocial Personality Disorder (Sociopathy)

by Donald W. Black , M.D. New York, Oxford University Press, 2013, 360 pp., $22.95.

Reviewed by John R. DeQuardo, M.D.
Am J Psychiatry 2013;170:808-809. doi:10.1176/appi.ajp.2013.13040454
View Author and Article Information

The author has served on the speakers’ bureaus of Otsuka and Sunovion; he has also served as a consultant to Eli Lilly.

Aurora, Colo.
Dr. DeQuardo is affiliated with the Colorado Mental Health Institute at Pueblo.

Accepted April , 2013.

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Bad Boys, Bad Men is an updated edition of Dr. Black’s original work published in 1999. The book stems from Dr. Black’s career-long interest in antisocial personality disorder and from his team’s study of 71 individuals with antisocial personality disorder evaluated at the University of Iowa Hospital in the 1950s and 1960s. The team, through extensive detective work, tracked down most of these individuals and plotted their life course, and it is the result of this effort that is the backbone of this book. The book is well written and is an excellent resource and beginning point for anyone interested in learning more about antisocial personality disorder.

The first two chapters of the book describe the history of the concept of antisocial personality disorder, dating back more than 200 years. It also describes the efforts of Dr. Black and his team to identify cases, locate individuals, and document the histories of these individuals. The third chapter is particularly valuable in that it describes in detail the clinical features of antisocial personality disorder. Dr. Black clearly lays out common traits and symptoms associated with the disorder, as well as the adverse behavioral consequences, such as substance abuse, violent behavior, social and occupational impairment, and criminal involvement. Unfortunately, in this chapter and continuing throughout much of the book, Dr. Black, in my view, confuses symptoms of antisocial personality disorder with behavioral correlates, often describing criminal acts as symptoms. This, I believe, serves to further cloud the concept in the minds of the lay public, as well as less well-informed professional readers.

In Chapter 4, Dr. Black describes the process of diagnosing an individual with antisocial personality disorder through psychiatric assessment. The chapter describes the breadth of information used to render psychiatric diagnoses—and serves to demystify the process of psychiatric assessment—and the thinking behind the diagnostic process in general and as it relates to antisocial personality disorder specifically.

Chapter 5 lays out the natural history of antisocial personality disorder and features that are common to people with the disorder, as well as how various environmental factors can result in divergent life courses in different individuals. As with virtually all chapters in the book, Dr. Black beautifully illustrates important points by describing the live course of several patients with the disorder.

Chapter 6 outlines possible genetic contributions and specific environmental correlates related to the development of antisocial personality disorder. Dr. Black summarizes neurochemical, neuroanatomic, and psychophysiologic investigations in people with the disorder. The chapter concludes with descriptions of how family environment, abuse, social interactions, and societal factors, such as pervasive media violence, may interact with constitutional features to produce the disorder.

Chapter 7 describes available treatments for antisocial personality disorder. It discusses psychotherapeutic, behavioral, and pharmacologic therapies, as well as therapies designed to treat comorbid conditions. It also describes treatments designed to address some of the social consequences of antisocial personality disorder-associated behavior, such as family discord, failed academic attainment, and occupational shortcomings. A limitation of this chapter is the order in which treatments are presented and how each is emphasized. Treatment of comorbid conditions, particularly substance abuse, has the greatest potential to diminish problems in individuals with antisocial personality disorder, yet it is addressed briefly and late in the chapter. Instead, Dr. Black emphasizes psychotherapeutic techniques in the first half of the chapter, which, as he points out, have little in the way of proven efficacy. Although psychotherapeutic and behavioral treatments may offer the greatest hope in terms of long-term changes in attitude, outlook, and ultimately behavior in individuals with antisocial personality disorder, scientific support for these treatments is extremely limited. Strengths of the chapter are the focus on approaching treatment on a case-by-case basis and the need to remain persistent in treatment, to set limits, and to bring consequences to bear. Treatment of antisocial personality disorder, much like treatment of substance abuse, such as alcohol dependence, is a life-long endeavor, and with this change comes slowly, if at all. Overall, Dr. Black seems to paint a much more positive view of the outcome of treatment of this disorder than the literature supports.

Chapters 8 and 9 focus on high-profile cases and the broad range of aberrant behaviors, some quite horrendous, manifested by individuals with antisocial personality, such as Saddam Hussein and John Wayne Gacy. At times, these descriptions are sensationalistic, but this may be a necessary feature of a book that is geared toward the lay public. Overall, it serves to inform the reader of the breadth of outcomes of antisocial personality disorder and reinforces the idea that this disorder is not limited to a particular socioeconomic or racial group.

The final chapter, Chapter 10, focuses on families and the environment in which antisocial personality-disordered individuals live. It describes ways that families (broadly defined) can protect themselves, as well as serve as a support and motivation for change in individuals with the disorder. The strength of this chapter is the emphasis that Dr. Black places on how family members, and others who come in contact with individuals with antisocial personality disorder, should protect themselves, remain firm in their resolve to set limits, and, when possible, bring consequences to bear, which is ultimately what is likely to lead to change in people with the disorder. He emphasizes here, as well as throughout the book, that the skill with which antisocial personality-disordered individuals use to evade consequences simply reinforces aberrant traits and leads to further adverse behavioral consequences.

This book is well annotated and describes in detail the sources of information contained within. It is written in a way that makes antisocial personality disorder understandable and accessible to the average person and points out that virtually everyone knows someone with the disorder, or knows of an individual with the disorder. The most obvious strength of this book is the use of specific, detailed case histories, which puts flesh on the bones of this diagnostic entity. I must re-emphasize that one of the few weaknesses of the book is Dr. Black’s tendency to equate criminal behavior with symptoms.

Bad Boys, Bad Men is an outstanding contribution to the literature on antisocial personality disorder. It makes this concept accessible to the lay person and should be required reading for psychiatry and psychology trainees and social workers, as well as individuals involved in the criminal justice system at all levels. The use of cases brings this concept to life and makes it easy to remember and understand. I have to agree with the liner notes by Dr. John Oldham, this book was difficult to put down. It is a very easy read.

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