A 19-year-old man comes to the office for evaluation of a hand injury. He says, "I was just minding my own business at work when this dog bit me." The patient recently started operating a dog-fighting club and adds that his "entrepreneurial skills" have made him "richer than a doctor." He has been fired from multiple jobs, most recently while working as a car salesman, due to getting into arguments with coworkers and being repeatedly late to shifts. The patient says, "I was only late a few times. Haven't you ever been late before, doc?" During middle school, he was recurrently truant and spent time at a juvenile detention center for tampering with his teacher's car brakes after failing a class. Which of the following is the most likely diagnosis?

Question

A 19-year-old man comes to the office for evaluation of a hand injury.  He says, "I was just minding my own business at work when this dog bit me."  The patient recently started operating a dog-fighting club and adds that his "entrepreneurial skills" have made him "richer than a doctor."  He has been fired from multiple jobs, most recently while working as a car salesman, due to getting into arguments with coworkers and being repeatedly late to shifts.  The patient says, "I was only late a few times.  Haven't you ever been late before, doc?"  During middle school, he was recurrently truant and spent time at a juvenile detention center for tampering with his teacher's car brakes after failing a class.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec160b_3639_c64c_9249_65337c08cb5f_MD0001_00 This patient's operation of an illegal dog-fighting ring, unstable employment history, irritability with coworkers, and repeated tardiness to work are most consistent with a diagnosis of antisocial personality disorder (ASPD). This disorder is characterized by a pattern of disregard for and violation of the rights of others, beginning by early adolescence and persisting into adulthood (age ≥18 required for diagnosis). An essential feature for diagnosis of ASPD is evidence of conduct disorder prior to age 15 (eg, this patient's history of truancy and vindictive behavior toward his teacher). Individuals with ASPD display consistent irresponsibility along with impulsivity and irritability, which may result in physical aggression. Engagement in criminal activities (eg, theft, illegal occupations) and lack of remorse for transgressions are typical in this disorder. (Choice B) Borderline personality disorder also consists of a pattern of impulsivity and manipulation. These individuals have marked emotional lability, tend to be less physically aggressive, and display exploitative behaviors that are often driven by abandonment fears as opposed to personal gain and/or profit. (Choice C) When individuals with conduct disorder continue to display a pattern of violating the rights of others into adulthood (age ≥18), they are diagnosed with ASPD. (Choice D) Disruptive mood dysregulation disorder is characterized by severe, persistent irritability in childhood, accompanied by frequent verbal and/or aggressive outbursts. This diagnosis is usually restricted to individuals age <18. (Choice E) Intermittent explosive disorder also consists of recurrent impulsive and destructive outbursts, but they are neither premeditated nor related to achieving secondary gain (eg, profit, intimidation). (Choice F) Although this patient exhibits some grandiosity, lack of empathy, and exploitative behaviors that are also characteristic of narcissistic personality disorder, these would not explain his lifelong pattern of involvement in violent and/or criminal activities. (Choice G) Oppositional defiant disorder similarly consists of irritability and vindictiveness as well as a lack of personal accountability for behaviors. However, individuals with this disorder do not have a pattern of engaging in criminal activities. Educational objective: Antisocial personality disorder involves a pattern of violating the rights of others, engaging in unlawful behaviors (eg, physical aggression, illegal occupations), and lacking remorse for transgressions. Individuals must be age ≥18 for diagnosis and have a history of conduct disorder prior to age 15. __________ References: Antisocial personality disorder: a current review. (http://www.ncbi.nlm.nih.gov/pubmed/24249521)

A 19-Year-Old Man Comes to the Office for Evaluation of a Hand