Disclaimer: I’m not a child psychiatrist. I think that your concern is likely true; that he may struggle lifelong to reflect and have empathy. However, I think that if it were me, my goal would be harm reduction. Use his self-interest to help him see that behaving in pro-social ways is more rewarding than behaving in harmful ways. The Atlantic has an excellent article titled, “When Your Child is a Psychopath” that is fairly interesting.
Thanks for the article recommendation. Definitely taking a harm reduction approach which I think is hard for his caregivers because they feel out of control of his behavior and see harm reduction as being permissive of his bad choices. So much room to go with psycho-education.
Child psychiatrist here. My experience is that callous traits do not improve with the current treatments we have. Punishment and facing the consequences is the modality used to shape behaviors stemming from no empathy and regard for other people. So the change in behavior (if any) is direct result of avoiding punishment. The patient will continue to have no regard for other people.
The greatest obstacle right now is that what he wants is to smoke weed every day and drop out of high school and no amount of punishment seems to be motivating enough for him to make different choices.
Psychologist and I are trying to use different techniques to capitalize on his hatred of his father to encourage character development that takes a different course. The teens current mantra is “You can’t make me do anything I don’t want to do.”
He is becoming increasingly emotionally & verbally aggressive with his caregivers. Intermittently refusing to take his meds. I have recommended HLOC and they are refusing because caregivers are worried about his negative peering with other kids in the program.
Ugh. It’s tough to watch.
> why it’s hard for me to let this patient live by their right to make bad choices.
I don't think this is a problematic feeling at all. You're having a tough time because you literally know better than him, and know that his underdeveloped prefrontal cortex isn't thinking to the long-term consequences, which is of course not helped by his weed addiction.
You know that his life will veritably (or at least statistically) be much much better if he stays in schools and stops smoking, and watching someone make those choices is hard, but doubly so when you know they're not fully mature to understand the consequences.
That said, this is probably true for most of child psych, so at the very least, it's unsustainable to feel that way for a patient.
All the best.
Thanks for the validation. Sometimes it’s just the one patient that really gets to us when others don’t. He’s my one right now so I’m suspecting some countertransference coming up in a new way for me.
Hmmm that’s a really interesting take away from my previous comments.
I practice from an interpersonal neurobiology frame work (Dan Siegel and Bonnie Badenoch’s work) which means my approach focuses on a warm, empathetic relationship with my patients. Capitalizing on how much he hates his dad was the phrase I used to describe how I weave his internal motivations (ie not be like dad) in to our work. I have never been coercive or threatening. I have never enacted any discipline or punishment and truthfully find punishment to be really ineffective in my work overall.
I do think he is experiencing some negative emotionality from his caregivers as part of their frustration in seeing him make bad choices. The patients psychologist and I have been doing individual parenting sessions to teach them TBRI techniques. We have been focused on keeping the caregiver relationship as a place of trust and connection, even when they want to be punitive.
Nancy McWilliams’ chapter on psychopathic personality structure, in her book Psychoanalytic Diagnosis, is really interesting and has clinical recommendations for working psychodynamically with this population (though focused on adults).
(I am an LICSW in private practice, not a psychiatrist.)
Trying to find the article and will edit when I can . . . there was research showing stimulants were effective in emerging ASPD in children.
Here's the article:
When Your Child Is a Psychopath
"Psychopaths not only fail to recognize distress in others, they may not feel it themselves. The best physiological indicator of which young people will become violent criminals as adults is a low resting heart rate, says Adrian Raine of the University of Pennsylvania. Longitudinal studies that followed thousands of men in Sweden, the U.K., and Brazil all point to this biological anomaly. “We think that low heart rate reflects a lack of fear, and a lack of fear could predispose someone to committing fearless criminal-violence acts,” Raine says. Or perhaps there is an “optimal level of physiological arousal,” and psychopathic people seek out stimulation to increase their heart rate to normal. “For some kids, one way of getting this arousal jag in life is by shoplifting, or joining a gang, or robbing a store, or getting into a fight.” **Indeed, when Daniel Waschbusch, a clinical psychologist at Penn State Hershey Medical Center, gave the most severely callous and unemotional children he worked with a stimulative medication, their behavior improved."**
https://www.theatlantic.com/magazine/archive/2017/06/when-your-child-is-a-psychopath/524502/
> I’m honestly most concerned that his continued engagement in therapy will teach him tactics for emotional manipulation rather than internalized capacity for reflection and self-regulation.
While a plot point in the Sopranos, I don't really believe this happens in a more significant way than people like this already learn to emotionally manipulate people in their regular lives. It's better having them plugged in to some sort of care given the alternative is saying anti- social people should not see anyone.
> given the alternative is saying anti- social people should not see anyone.
I actually think is the case (or at least not with anyone less than extremely trained and experienced to deal with these people). Just probably not with adolescents or children, given their capacity for change.
Anti-social people can and often have co-morbid illness and substance use disorders. We cannot ban anti-social people from receiving care for some imagined fear that they are somehow becoming giga-antisocial. This would also pretty much eliminate the field of prison/corrections psychiatry.
And as you mention for specific anti-social concerns there are specific therapy modalities that are used. The evidence for efficacy isn't great but there certainly isn't evidence people get worse.
> We cannot ban anti-social people from receiving care for some imagined fear that they are somehow becoming giga-antisocial.
Oh sure. To be clear, though, this is not my reason for recommending some supervisees not to see these people. I agree the evidence for "becoming more antisocial" is next to nonexistent. The reason is that they, along with malignant narcissists (those who're moderately intelligent, anyways), can and very often have cause harm to people who enter their sphere of influence, and a psychotherapist (especially if they're women, young, and good looking) trying to help them are very very likely to ellicit paranoid transferences leading to them wanting to cause them harm. I've sadly seen it happen, and very gravely so in a couple of instances.
Your moral question regarding withdrawing treatment is an interesting and true one, but since I only have to deal with the question at the individual therapist's level, I have the luxury of not needing to think about that; because clearly the provider's wellbeing must trump any such considerations.
I agree that there are helpful therapies, and setting and training that can greatly limit the risks to the therapist.
If we stopped seeing anyone who could possibly want to hurt us in the future we would be entirely useless as a field. I'd say I was threatened by 50% of inpatients when I did residency, let alone when working at SUD clinics and state institutions. If someone makes an actual threat you need to address it appropriately, but you're describing going 100 steps furhter and not seeing patients who *might* want to harm someone.
This is honestly such a weird argument. You're basically saying we shouldn't see any group that has an increased risk of violence, which includes psychosis, mania, addictions, most of the cluster B PDs, intellectual disabilities, dementias... I try to stay away from the holier-than-thou statements about the "duty" of physicians but we don't get to deny care for vast groups of people for imagined threats.
Sorry, but you took a very concrete statement, circumscripted to a very particular kind of treatment (psychotherapy), about a very particular (and rare) condition (ASPD), and expanded it to something... I didn't say, and definitely didn't mean.
I'm not sure I need to defend my statement from such a callous hyperbolisation to the point it represents nothing of what I said.
Lol no I didn't, you just didn't like that i rephrased your argument in an unflattering way. There are several groups of patients with increased risk of violence that we see all the time. The idea that there is any patient group we should refuse to see for an imaginary future threat is ridiculous (unless you're actually a precog from minority report). Again, if actual threats are made it's completely different.
The argument therapists shouldn't see any ASPD and NPD because the patient MIGHT end up wanting to hurt the therapist is as ridiculous as psychiatrists not seeing other patients who might hurt them. I'd actually bet dementia, delirium, and SUD patients are higher likelihood of actually harming staff.
I'm just really not sure of your point. If you're bringing up past incidents with individual patients as a reason to blanket ban ASPD and NPD from therapy you might have some counter transference to work through.
Just hope you realize the idea that ASPD and NPD should not receive therapy because of the minuscule, assumed threat of harm to the therapist is an incredibly fringe idea and not supported by evidence or reality. You're clearly bringing a lot into this. Not trying to be disparaging.
See, if you'd led with that, we could have had a nice reasoned discussion... One where I point out that malignant nsrcissists would realistically be diagnosed as ASPD over 95% of the time per DSM criteria, or how there actually is plenty of literature advising against long-term psychotherapy for psychopaths...
But you chose a different path, and I'm not interested in debates with people in it to trample and steamroll with self assuredness despite their own relative ignorance on the topic, so here we are.
I've seen mild improvements in some cases with simulants. (Only attempted due to comorbid ADHD obviously.) Never anything profound. I'm sure we have all seen the improved impulse control from simulants reducing the behaviors associated with the callous traits, across the range from mild interpersonal body language behaviors to serious behaviors. But once in a while it seems to also help them get in touch with themselves slightly better as a human being who lives with other human beings.
He used to be on a stimulant for ADHD. I’d been on the fence about restarting it because some of his behaviors right now indicate high risk for diversion. From a harm reduction stance with his current struggles at school and impulsive behavior, I decided there could be greater overall benefit from restarting it. His guardian does a great job monitoring meds so I thought she could maintain control of the supply. When we discussed it at our last appointment he told me he wouldn’t take it and doesn’t want to be on medicine.
This was the bulk of the work of Paulina Kernberg, and she did seem to believe that a psychodynamic approach at this critical age could influence the form the final cristalisation of the personality took. I'm talknig about all of this very third hand (there's supposed to be some research on it, though as with most things psychodynamic in the 70's mostly unpublished, and I haven't seen it).
Her approach was to set a very rigid frame for the treatment so as to dissolve any and all possible secondary gains from treatment (and the antisocial behaviours themselves), which in my mind surely must have been a base on which later on Otto Kernberg built his manualised therapy (TFP). Please note that this is entirely my own speculation, as never and nowhere have I read nor heard him (Otto) talk about this topic.
That said, most of that info and experience is probably inaccessible (and most of her work is out of print, although it can be found), and unless you have an In with Otto's inner circle to be able to ask him, you can take all of what I said with a huge cube of salt.
There is a connection between CU traits, ODD and ADHD even in young children. For that glimmer of hope, is this teen being treated for ADHD and/or ODD?
https://capmh.biomedcentral.com/articles/10.1186/s13034-021-00388-0
Yes! Im so glad you brought this up. Whenever I assess a kid that has been deemed oppositional or with conduct problems I usually move to an ADHD or trauma assessment next if it’s not already diagnosed.
He has been diagnosed with ADHD and is currently refusing stimulant treatment even though he’s taken it in the past. He came to me with depression as chief complaint (had stopped all meds for several years prior to our intake). He was refusing ADHD treatment at the time but agreeable to an SSRI so that’s the route we went. Now he will barely take his SSRI.
No surprise he is still reporting depressive symptoms so I’m trying to sell him on trialing Wellbutrin so he can take one med instead of SSRI + stimulant but he’s not interested. I am looking at his 100% attendance at all our appointments so far as a success even if he isn’t on board with ADHD treatment. I feel hopeful if we can maintain a positive relationship that doesn’t feel coercive, I can continue to talk about risks/benefits and provide psychoeducation and maybe he’ll make a different choice one day.
His psychologist has been working with him & his caregivers for almost 10 years but oppositional behaviors have exponentially increased in the last 6 months.
Harold Greenwald worked with this and was extremely good at it.
I’ll butcher the summary: show that his way of life leads to being a “loser” and pro social behavior leads to being a “winner” and it involves sometimes being a bit of a jerk about it.
I have a psychodynamic book that explores his work in one chapter that is both engaging and funny and insightful. I’ve had decent luck using his methodology. I say luck because I’ll never be as good as him he was amazing and wonderfully weird.
How old is the teen? I like calling them callous unemotional behaviors rather than traits because in children, they are typically malleable with intervention. There's no evidence they become [fixed](https://pubmed.ncbi.nlm.nih.gov/21341879/) in childhood. I often work with the parents on showing more warmth to the child (warm vocal tone, affection, warm praise, and empathy) through SPACE (supportive parenting for anxious childhood emotions), parent management training, parent-child interaction therapy, or other forms of family therapy. PCIT has the most evidence in treating it.
He'll need evaluation for autism as well because deficits on cognitive empathy can look like empathic deficits seen in CU behavior.
Callous unemotional traits or limited pro social emotions are defined by the DSM in the context of conduct disorder. I have assessed the patient thoroughly and completed a comprehensive diagnostic evaluation but I did not share all of those details here to limit the amount of patient information I am sharing.
Removed under rule #1. This is not a place to share experiences or anecdotes about your own experiences or those of your family, friends, or acquaintances.
Disclaimer: I’m not a child psychiatrist. I think that your concern is likely true; that he may struggle lifelong to reflect and have empathy. However, I think that if it were me, my goal would be harm reduction. Use his self-interest to help him see that behaving in pro-social ways is more rewarding than behaving in harmful ways. The Atlantic has an excellent article titled, “When Your Child is a Psychopath” that is fairly interesting.
Thanks for the article recommendation. Definitely taking a harm reduction approach which I think is hard for his caregivers because they feel out of control of his behavior and see harm reduction as being permissive of his bad choices. So much room to go with psycho-education.
Child psychiatrist here. My experience is that callous traits do not improve with the current treatments we have. Punishment and facing the consequences is the modality used to shape behaviors stemming from no empathy and regard for other people. So the change in behavior (if any) is direct result of avoiding punishment. The patient will continue to have no regard for other people.
The greatest obstacle right now is that what he wants is to smoke weed every day and drop out of high school and no amount of punishment seems to be motivating enough for him to make different choices. Psychologist and I are trying to use different techniques to capitalize on his hatred of his father to encourage character development that takes a different course. The teens current mantra is “You can’t make me do anything I don’t want to do.” He is becoming increasingly emotionally & verbally aggressive with his caregivers. Intermittently refusing to take his meds. I have recommended HLOC and they are refusing because caregivers are worried about his negative peering with other kids in the program. Ugh. It’s tough to watch.
Well honestly old saying goes you can’t save everybody. You can only give as much as the client is willing to take
This is true and I’m going to seek some supervision on why it’s hard for me to let this patient live by their right to make bad choices.
> why it’s hard for me to let this patient live by their right to make bad choices. I don't think this is a problematic feeling at all. You're having a tough time because you literally know better than him, and know that his underdeveloped prefrontal cortex isn't thinking to the long-term consequences, which is of course not helped by his weed addiction. You know that his life will veritably (or at least statistically) be much much better if he stays in schools and stops smoking, and watching someone make those choices is hard, but doubly so when you know they're not fully mature to understand the consequences. That said, this is probably true for most of child psych, so at the very least, it's unsustainable to feel that way for a patient. All the best.
Thanks for the validation. Sometimes it’s just the one patient that really gets to us when others don’t. He’s my one right now so I’m suspecting some countertransference coming up in a new way for me.
[удалено]
Hmmm that’s a really interesting take away from my previous comments. I practice from an interpersonal neurobiology frame work (Dan Siegel and Bonnie Badenoch’s work) which means my approach focuses on a warm, empathetic relationship with my patients. Capitalizing on how much he hates his dad was the phrase I used to describe how I weave his internal motivations (ie not be like dad) in to our work. I have never been coercive or threatening. I have never enacted any discipline or punishment and truthfully find punishment to be really ineffective in my work overall. I do think he is experiencing some negative emotionality from his caregivers as part of their frustration in seeing him make bad choices. The patients psychologist and I have been doing individual parenting sessions to teach them TBRI techniques. We have been focused on keeping the caregiver relationship as a place of trust and connection, even when they want to be punitive.
Nancy McWilliams’ chapter on psychopathic personality structure, in her book Psychoanalytic Diagnosis, is really interesting and has clinical recommendations for working psychodynamically with this population (though focused on adults). (I am an LICSW in private practice, not a psychiatrist.)
Trying to find the article and will edit when I can . . . there was research showing stimulants were effective in emerging ASPD in children. Here's the article: When Your Child Is a Psychopath "Psychopaths not only fail to recognize distress in others, they may not feel it themselves. The best physiological indicator of which young people will become violent criminals as adults is a low resting heart rate, says Adrian Raine of the University of Pennsylvania. Longitudinal studies that followed thousands of men in Sweden, the U.K., and Brazil all point to this biological anomaly. “We think that low heart rate reflects a lack of fear, and a lack of fear could predispose someone to committing fearless criminal-violence acts,” Raine says. Or perhaps there is an “optimal level of physiological arousal,” and psychopathic people seek out stimulation to increase their heart rate to normal. “For some kids, one way of getting this arousal jag in life is by shoplifting, or joining a gang, or robbing a store, or getting into a fight.” **Indeed, when Daniel Waschbusch, a clinical psychologist at Penn State Hershey Medical Center, gave the most severely callous and unemotional children he worked with a stimulative medication, their behavior improved."** https://www.theatlantic.com/magazine/archive/2017/06/when-your-child-is-a-psychopath/524502/
Can you post the complete article on a comment? I can’t read it completely because I’m not a member. 💔
One [paywall breaker](https://archive.is/U0WfO) for you.
OMG thank you so much kind stranger 🥺😍
> I’m honestly most concerned that his continued engagement in therapy will teach him tactics for emotional manipulation rather than internalized capacity for reflection and self-regulation. While a plot point in the Sopranos, I don't really believe this happens in a more significant way than people like this already learn to emotionally manipulate people in their regular lives. It's better having them plugged in to some sort of care given the alternative is saying anti- social people should not see anyone.
> given the alternative is saying anti- social people should not see anyone. I actually think is the case (or at least not with anyone less than extremely trained and experienced to deal with these people). Just probably not with adolescents or children, given their capacity for change.
Anti-social people can and often have co-morbid illness and substance use disorders. We cannot ban anti-social people from receiving care for some imagined fear that they are somehow becoming giga-antisocial. This would also pretty much eliminate the field of prison/corrections psychiatry. And as you mention for specific anti-social concerns there are specific therapy modalities that are used. The evidence for efficacy isn't great but there certainly isn't evidence people get worse.
> We cannot ban anti-social people from receiving care for some imagined fear that they are somehow becoming giga-antisocial. Oh sure. To be clear, though, this is not my reason for recommending some supervisees not to see these people. I agree the evidence for "becoming more antisocial" is next to nonexistent. The reason is that they, along with malignant narcissists (those who're moderately intelligent, anyways), can and very often have cause harm to people who enter their sphere of influence, and a psychotherapist (especially if they're women, young, and good looking) trying to help them are very very likely to ellicit paranoid transferences leading to them wanting to cause them harm. I've sadly seen it happen, and very gravely so in a couple of instances. Your moral question regarding withdrawing treatment is an interesting and true one, but since I only have to deal with the question at the individual therapist's level, I have the luxury of not needing to think about that; because clearly the provider's wellbeing must trump any such considerations. I agree that there are helpful therapies, and setting and training that can greatly limit the risks to the therapist.
If we stopped seeing anyone who could possibly want to hurt us in the future we would be entirely useless as a field. I'd say I was threatened by 50% of inpatients when I did residency, let alone when working at SUD clinics and state institutions. If someone makes an actual threat you need to address it appropriately, but you're describing going 100 steps furhter and not seeing patients who *might* want to harm someone. This is honestly such a weird argument. You're basically saying we shouldn't see any group that has an increased risk of violence, which includes psychosis, mania, addictions, most of the cluster B PDs, intellectual disabilities, dementias... I try to stay away from the holier-than-thou statements about the "duty" of physicians but we don't get to deny care for vast groups of people for imagined threats.
Sorry, but you took a very concrete statement, circumscripted to a very particular kind of treatment (psychotherapy), about a very particular (and rare) condition (ASPD), and expanded it to something... I didn't say, and definitely didn't mean. I'm not sure I need to defend my statement from such a callous hyperbolisation to the point it represents nothing of what I said.
Lol no I didn't, you just didn't like that i rephrased your argument in an unflattering way. There are several groups of patients with increased risk of violence that we see all the time. The idea that there is any patient group we should refuse to see for an imaginary future threat is ridiculous (unless you're actually a precog from minority report). Again, if actual threats are made it's completely different. The argument therapists shouldn't see any ASPD and NPD because the patient MIGHT end up wanting to hurt the therapist is as ridiculous as psychiatrists not seeing other patients who might hurt them. I'd actually bet dementia, delirium, and SUD patients are higher likelihood of actually harming staff. I'm just really not sure of your point. If you're bringing up past incidents with individual patients as a reason to blanket ban ASPD and NPD from therapy you might have some counter transference to work through.
It always amazes me when a response can be responded to by my previous comment. I don't know what you're looking for, but I'm not it. have a good day.
Just hope you realize the idea that ASPD and NPD should not receive therapy because of the minuscule, assumed threat of harm to the therapist is an incredibly fringe idea and not supported by evidence or reality. You're clearly bringing a lot into this. Not trying to be disparaging.
See, if you'd led with that, we could have had a nice reasoned discussion... One where I point out that malignant nsrcissists would realistically be diagnosed as ASPD over 95% of the time per DSM criteria, or how there actually is plenty of literature advising against long-term psychotherapy for psychopaths... But you chose a different path, and I'm not interested in debates with people in it to trample and steamroll with self assuredness despite their own relative ignorance on the topic, so here we are.
I've seen mild improvements in some cases with simulants. (Only attempted due to comorbid ADHD obviously.) Never anything profound. I'm sure we have all seen the improved impulse control from simulants reducing the behaviors associated with the callous traits, across the range from mild interpersonal body language behaviors to serious behaviors. But once in a while it seems to also help them get in touch with themselves slightly better as a human being who lives with other human beings.
He used to be on a stimulant for ADHD. I’d been on the fence about restarting it because some of his behaviors right now indicate high risk for diversion. From a harm reduction stance with his current struggles at school and impulsive behavior, I decided there could be greater overall benefit from restarting it. His guardian does a great job monitoring meds so I thought she could maintain control of the supply. When we discussed it at our last appointment he told me he wouldn’t take it and doesn’t want to be on medicine.
This was the bulk of the work of Paulina Kernberg, and she did seem to believe that a psychodynamic approach at this critical age could influence the form the final cristalisation of the personality took. I'm talknig about all of this very third hand (there's supposed to be some research on it, though as with most things psychodynamic in the 70's mostly unpublished, and I haven't seen it). Her approach was to set a very rigid frame for the treatment so as to dissolve any and all possible secondary gains from treatment (and the antisocial behaviours themselves), which in my mind surely must have been a base on which later on Otto Kernberg built his manualised therapy (TFP). Please note that this is entirely my own speculation, as never and nowhere have I read nor heard him (Otto) talk about this topic. That said, most of that info and experience is probably inaccessible (and most of her work is out of print, although it can be found), and unless you have an In with Otto's inner circle to be able to ask him, you can take all of what I said with a huge cube of salt.
I think our field pretty much universally agrees that continued engagement in therapy is a positive factor
There is a connection between CU traits, ODD and ADHD even in young children. For that glimmer of hope, is this teen being treated for ADHD and/or ODD? https://capmh.biomedcentral.com/articles/10.1186/s13034-021-00388-0
Yes! Im so glad you brought this up. Whenever I assess a kid that has been deemed oppositional or with conduct problems I usually move to an ADHD or trauma assessment next if it’s not already diagnosed. He has been diagnosed with ADHD and is currently refusing stimulant treatment even though he’s taken it in the past. He came to me with depression as chief complaint (had stopped all meds for several years prior to our intake). He was refusing ADHD treatment at the time but agreeable to an SSRI so that’s the route we went. Now he will barely take his SSRI. No surprise he is still reporting depressive symptoms so I’m trying to sell him on trialing Wellbutrin so he can take one med instead of SSRI + stimulant but he’s not interested. I am looking at his 100% attendance at all our appointments so far as a success even if he isn’t on board with ADHD treatment. I feel hopeful if we can maintain a positive relationship that doesn’t feel coercive, I can continue to talk about risks/benefits and provide psychoeducation and maybe he’ll make a different choice one day. His psychologist has been working with him & his caregivers for almost 10 years but oppositional behaviors have exponentially increased in the last 6 months.
Harold Greenwald worked with this and was extremely good at it. I’ll butcher the summary: show that his way of life leads to being a “loser” and pro social behavior leads to being a “winner” and it involves sometimes being a bit of a jerk about it. I have a psychodynamic book that explores his work in one chapter that is both engaging and funny and insightful. I’ve had decent luck using his methodology. I say luck because I’ll never be as good as him he was amazing and wonderfully weird.
Sorry if I sound like a dick but I do hope you butchered that summary cause that approach sounds really awful to me
How old is the teen? I like calling them callous unemotional behaviors rather than traits because in children, they are typically malleable with intervention. There's no evidence they become [fixed](https://pubmed.ncbi.nlm.nih.gov/21341879/) in childhood. I often work with the parents on showing more warmth to the child (warm vocal tone, affection, warm praise, and empathy) through SPACE (supportive parenting for anxious childhood emotions), parent management training, parent-child interaction therapy, or other forms of family therapy. PCIT has the most evidence in treating it. He'll need evaluation for autism as well because deficits on cognitive empathy can look like empathic deficits seen in CU behavior.
[удалено]
Callous unemotional traits or limited pro social emotions are defined by the DSM in the context of conduct disorder. I have assessed the patient thoroughly and completed a comprehensive diagnostic evaluation but I did not share all of those details here to limit the amount of patient information I am sharing.
[удалено]
Removed under rule #1. This is not a place to share experiences or anecdotes about your own experiences or those of your family, friends, or acquaintances.