A 21-year-old man comes to the emergency department due to injuries sustained during a fight. He has a broken nose and requires stitches for scalp and arm lacerations. His girlfriend says, "We were having a beer when he got angry and paranoid about the way a guy was looking at me. We're not allowed to go back to that bar again because he's started so many fights there." The patient says, "The other guy looks much worse than I do, but he had it coming." The patient has had multiple jobs in the past year and was recently fired from his sales job for repeated absences. He states, "That job was beneath me-I can easily make more money doing something else." Starting in middle school, the patient has had repeated suspensions for truancy and fighting; he blames his failure to be accepted into college on the teachers who reported this. He uses alcohol, marijuana, and crack cocaine "for fun" but had only 1 beer at the time of the fight. Which of the following is the most likely diagnosis?

Question

A 21-year-old man comes to the emergency department due to injuries sustained during a fight.  He has a broken nose and requires stitches for scalp and arm lacerations.  His girlfriend says, "We were having a beer when he got angry and paranoid about the way a guy was looking at me.  We're not allowed to go back to that bar again because he's started so many fights there."  The patient says, "The other guy looks much worse than I do, but he had it coming."  The patient has had multiple jobs in the past year and was recently fired from his sales job for repeated absences.  He states, "That job was beneath me-I can easily make more money doing something else."  Starting in middle school, the patient has had repeated suspensions for truancy and fighting; he blames his failure to be accepted into college on the teachers who reported this.  He uses alcohol, marijuana, and crack cocaine "for fun" but had only 1 beer at the time of the fight.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec25c8_d7e0_e63a_bc81_fbd5cdb33bb0_MD0003_00 This patient's reckless disregard for safety of self and others, unstable employment history, and lack of remorse are suggestive of antisocial personality disorder (ASPD). ASPD is a lifelong disorder characterized by a pervasive pattern of disregard for and violation of the rights of others, beginning in childhood or early adolescence and continuing 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 fighting from middle school onward). Individuals with ASPD tend to be physically aggressive and impulsive and may repeatedly get into fights. Additional typical behaviors include illegal activities (eg, illicit drug use, theft), lying, and manipulation of others for personal gain. This patient's arrogant self-appraisal, lack of remorse, and failure to accept responsibility for his own behavior (eg, blaming teachers for not getting into college) are characteristic of ASPD. (Choice B) Individuals with borderline personality disorder can also exhibit manipulative and impulsive behavior. However, their motivation is to avoid abandonment and maintain relationships; they readily experience feelings of guilt and shame; and they do not routinely engage in illegal activities. In contrast, individuals with ASPD exploit others for personal gain without remorse. (Choice C) When individuals with conduct disorder exhibit persistent symptoms into adulthood (age ≥18), they are diagnosed with ASPD. (Choice D) Intermittent explosive disorder (IED) involves episodes of assaultive or destructive behavior that are not premeditated and typically result in feelings of remorse. In contrast, the aggressive behaviors in ASPD are designed to intimidate or gain advantage over others, with no evidence of remorse (as in this patient). IED should be diagnosed only in the absence of ASPD. (Choices E and F) Individuals with narcissistic personality disorder often have an exaggerated sense of self-importance and lack empathy but are less impulsive and do not typically engage in violent or illegal activities. In paranoid personality disorder, behavior is motivated by distrust and suspiciousness rather than a desire for personal gain or to exploit others. (Choice G) Although drug use can contribute to antisocial behavior, this patient's symptoms of conduct disorder in adolescence along with antisocial behavior while sober make ASPD more likely. Educational objective: Antisocial personality disorder involves a pervasive pattern of violating the rights of others and lack of remorse. Individuals must be ≥age 18 for diagnosis and have a history of conduct disorder symptoms before age 15. References: The natural history of antisocial personality disorder. (http://www.ncbi.nlm.nih.gov/pubmed/26175389)

A 21-Year-Old Man Comes to the Emergency Department Due to Injuries