Unmasking the Sociopath: Comprehensive Treatment for Antisocial Personality Disorder in Palm Beach | Mark G. Agresti, MD
In the serene, sun-drenched environment of Palm Beach, Florida, where the waves of the Atlantic meet the calm of the Intracoastal Waterway, it is easy to forget that human nature possesses a darker, more turbulent side. While many patients come to my office seeking relief from the crushing weight of depression or the frantic energy of anxiety, there is another category of patient that presents a unique, complex challenge to the field of psychiatry: the individual with Antisocial Personality Disorder (ASPD).
At Mark G. Agresti MD LLC, located right next to West Palm Beach and overlooking the lush greens of The Breakers golf course, we specialize in the diagnosis and management of the most complex mental health conditions. Whether you are a family member suffering from the chaos inflicted by a loved one, or an individual realizing your own behaviors are destroying your life, understanding ASPD is the first step toward management.
When you visit our office, you might be greeted by Bella, my energetic Boykin Spaniel. When she isn’t playing along the beaches of Palm Beach, chasing the surf, she is here offering a grounding presence. But for those with ASPD, “grounding” is often the last thing they feel. Instead, they are often driven by an insatiable need for stimulation, dominance, and self-gratification, regardless of the cost to others.
What is Antisocial Personality Disorder (ASPD)?
often referred to in pop culture as “sociopathy” or “psychopathy,” Antisocial Personality Disorder is a mental health condition characterized by a long-term pattern of manipulating, exploiting, or violating the rights of others without any remorse.
This is not merely “being anti-social” in the sense of wanting to stay home on a Friday night. It is a pervasive disregard for the moral and legal standards of society.
Prevalence and Demographics
Research indicates that the prevalence of ASPD in the general population is approximately 1% to 4%. However, these numbers spike dramatically in specific settings. In prison populations, it is estimated that up to 47% of male inmates and 21% of female inmates meet the criteria for ASPD.
Interestingly, ASPD is significantly more common in men than in women. While the disorder is often associated with criminality, not every person with ASPD is a criminal. Many are “high-functioning” individuals who walk among us in high-powered careers, using their lack of empathy as a tactical advantage.
The Diagnostic Criteria
According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), an individual must be at least 18 years old to be diagnosed with ASPD, though there must be evidence of Conduct Disorder with onset before age 15.
The diagnosis requires a pervasive pattern of disregard for and violation of the rights of others, indicated by three (or more) of the following:
1. Failure to conform to social norms with respect to lawful behaviors (repeatedly performing acts that are grounds for arrest).
2. Deceitfulness, indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure.
3. Impulsivity or failure to plan ahead.
4. Irritability and aggressiveness, indicated by repeated physical fights or assaults.
5. Reckless disregard for the safety of self or others.
6. Consistent irresponsibility, indicated by repeated failure to sustain consistent work behavior or honor financial obligations.
7. Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another.
The Professional “Mask”: High-Functioning ASPD
One of the most fascinating aspects of this disorder is where these individuals end up professionally. Because people with ASPD often possess low fear responses, high charisma, and a ruthlessness that allows them to make “hard decisions” without emotional baggage, they often gravitate toward high-stakes professions.
Research suggests that professions with the highest rates of psychopathic traits include:
• CEOs and Corporate Executives
• Lawyers
• Media and Television Personalities
• Salespeople
• Surgeons
• Special Forces and Military Combat roles
In a military context, specifically within Special Forces, the ability to remain cool under extreme pressure and to compartmentalize trauma can be a tactical asset. However, without proper psychological oversight, these same traits can lead to destructive behaviors when the individual returns to civilian life.
The Impact on Society and Recidivism
The societal cost of ASPD is staggering. Individuals with this disorder are responsible for a disproportionate amount of violent crime and financial fraud. The concept of recidivism (the tendency of a convicted criminal to reoffend) is central to ASPD. Because they typically lack remorse and do not learn from punishment in the same way neurotypical people do, the traditional penal system often fails to rehabilitate them.
They leave prison—or therapy—and often go right back to their old ways unless the treatment is highly specialized, strict, and consequences-based. This is why seeing a seasoned specialist like Dr. Mark Agresti is crucial. We move beyond “talk therapy” and deal with the brutal reality of behavior modification.
5 Comprehensive Case Vignettes
To illustrate the complexity of ASPD, I have compiled five detailed case vignettes based on the types of patients we see at Mark G. Agresti MD LLC.
(Note: Names and details are fictionalized composites to protect patient privacy.)
Case Study 1: The “Shark” in the Boardroom
Patient: Julian, 45, Investment Banker.
The Life Before Treatment:
Julian was wealthy, charming, and utterly destructive. He viewed his colleagues as chess pieces. He had been married three times, with each wife leaving him due to his “coldness” and serial infidelity. He came to my Palm Beach office not because he wanted to “be a better person,” but because his board of directors gave him an ultimatum: get therapy for his anger outbursts, or lose his firm. Julian didn’t care about hurting people; he cared about losing his status.
The Treatment at Mark G. Agresti MD LLC:
Treating Julian required a unique approach. Trying to teach him “empathy” was futile. Instead, we focused on cognitive self-interest. I helped Julian understand that his impulsive anger was a liability to his net worth. We used a strict, logic-based Cognitive Behavioral Therapy (CBT) approach.
The Outcome:
Julian is still not a warm person, but he is no longer destructive. He learned that maintaining relationships is a necessary “transaction cost” for his success. By framing good behavior as a strategy for winning, he became a stable father and a more effective leader. He continues to see me to keep his impulses in check, ensuring his “mask” remains a productive one.
Case Study 2: The Adrenaline Junkie
Patient: Derek, 28, former military contractor.
The Life Before Treatment:
Derek had a history of conduct disorder as a child and excelled in military situations that required aggression. Upon returning to civilian life in West Palm Beach, he couldn’t handle the boredom. He began street racing, getting into bar fights, and engaging in high-risk substance abuse. He had been arrested twice for reckless endangerment. His family was terrified he would end up in prison or dead.
The Life After Treatment:
Derek needed high stimulation, not just medication. We worked on channeling his drive. We treated the underlying ADHD that often comorbids with ASPD, which helped reduce his impulsivity. We also directed him toward high-intensity, legal hobbies (competitive martial arts). By managing his neurochemistry and giving him a “safe” outlet for his aggression, Derek has avoided jail for three years and has started a security consulting business.
Case Study 3: The Chameleon
Patient: Sarah, 32, Pharmaceutical Sales Rep.
The Life Before Treatment:
Sarah was the life of the party. She was also a pathological liar. She would borrow money from friends with no intention of paying it back, concoct elaborate stories about fake illnesses to gain sympathy, and gaslight her partners until they questioned their own sanity. She felt no guilt, only annoyance when she was caught. She came to see me only because she was facing a lawsuit for fraud.
The Life After Treatment:
We utilized Dialectical Behavior Therapy (DBT) skills, focusing on “Radical Acceptance.” Sarah had to accept that her deceit was closing doors, not opening them. We worked on identifying the “void” she was trying to fill with her manipulations. While Sarah still struggles with the urge to deceive, she now has a “check system” in place. She checks in with me weekly to ground herself in reality. Her legal issues were mitigated because she could show the court she was in active, rigorous psychiatric treatment.
Case Study 4: The Estranged Son
Patient: Brandon, 22, Unemployed.
The Life Before Treatment:
Brandon’s parents, wealthy residents of Palm Beach, brought him in. Brandon had stolen jewelry from his mother, wrecked his father’s car, and refused to get a job. He blamed everyone else for his problems. “If you hadn’t made me mad, I wouldn’t have stolen it,” was his mantra. He had zero insight into his condition and viewed his parents solely as a bank account.
The Life After Treatment:
In this case, the “patient” was the entire family unit. I worked with Brandon’s parents to establish iron-clad boundaries. We stopped the enabling. Brandon was told: “Treatment and rules, or no financial support.” Forced into accountability for the first time, Brandon hit rock bottom. He is now in a structured living facility and seeing me for maintenance. He is slowly learning that actions have consequences—a lesson he missed in childhood.
Case Study 5: The Charming Conman
Patient: Robert, 50, Real Estate Developer.
The Life Before Treatment:
Robert was incredibly charismatic. He could sell ice to an Eskimo. However, he had a trail of investors who had lost their life savings due to his shady deals. He rationalized it as “business is war.” He slept soundly at night while his clients went bankrupt. He came to my office suffering from anxiety—not because he felt guilty, but because he was paranoid about getting caught.
The Life After Treatment:
We focused on the reality of his situation: the anxiety was a signal that his lifestyle was unsustainable. Through rigorous confrontation and medication to manage his anxiety, Robert began to dismantle his own rationalizations. He realized that “going straight” was the only way to alleviate his paranoia. He is now operating a legitimate business. It is smaller, less glamorous, but he is not looking over his shoulder.
Why Dr. Mark Agresti is the Right Choice for ASPD
Treating Antisocial Personality Disorder is not for the faint of heart. It requires a psychiatrist who is not easily manipulated, who can see through the charm and the lies, and who can hold a firm boundary while still offering a path to redemption.
At Mark G. Agresti MD LLC, we use a combination of:
• Psychopharmacology: To treat the rage, anxiety, and impulsivity that drives the behavior.
• Cognitive Behavioral Therapy (CBT): To restructure the twisted logic that justifies hurting others.
• Contingency Management: A behavioral approach that rewards positive behavior and punishes negative behavior.
Our office is a sanctuary. Whether you are looking out at the boats drifting down the Intracoastal Waterway or petting Bella, my Boykin Spaniel, you will find an environment that is serious about mental health. We are located in the heart of Palm Beach, serving the greater West Palm Beach area.
We understand that for patients with ASPD, the goal is often not “curing” the personality, but managing the behaviors to allow for a successful, legal, and productive life.
Research and Further Reading
For those interested in the clinical depths of this disorder, much of the leading research is currently being conducted at institutions such as:
• The National Institute of Mental Health (NIMH)
• The Mayo Clinic Department of Psychiatry
• The University of Wisconsin-Madison (renowned for psychopathy research involving brain imaging)