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A Doctor’s view

Determining the cause of bad behavior

Helps steer appropriate treatment

Anthony Russo for The Boston Globe

I’ve been a psychiatrist for more than 30 years, but I’m learning new things about human behavior every day.

For example, I’ve been reading lately about politicians said to engage in sexual harassment going in for a few weeks of “rehab” or “intensive therapy.”

Now, I’m all for psychotherapy, and I have seen how it can be lifesaving for patients with severe depression or deep-seated emotional problems that have tormented them their entire lives. But two weeks of rehab for guys who are accused of patting a woman on the buttocks, making unwanted sexual advances, or texting sexually inappropriate messages? I can’t comment on particular individuals or their mental states but the premise underlying this quick-fix treatment seems doubtful to me.

The first thing to be said about anyone, male or female, whose behavior undergoes a drastic change at a late age — say, over age 40 — is that a thorough neurological evaluation is mandatory. There is no way rehab is going to work if the person’s altered behavior is because of a frontal lobe tumor. These malignancies are notorious for producing what psychiatrists call disinhibited behavior — including inappropriate sexual behaviors.

So, the 60-year-old bank vice president who mysteriously starts urinating in the parking lot, or inappropriately touching his employees, is a prime candidate for a head CT or MRI.

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When, in 1937, a young George Gershwin began behaving badly — for example, pushing his chauffeur out of a moving car — doctors diagnosed “hysteria.” A few months later, he was dead of complications stemming from a brain tumor in his temporal lobe.

Certain types of dementia can also lead to disinhibited behavior. While most cases of dementia are attributable to the more familiar Alzheimer’s disease, many cases are related to so-called frontotemporal dementia. This form of dementia often causes abnormal moods, impulsive behavior, and what is sometimes called “violations of social and moral norms.”

There are also people whose personalities are such that violations of social or moral norms seem, well, normal to them. In extreme cases, these individuals are diagnosed with Antisocial Personality Disorder.

The just-released (and quite controversial) fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, commonly referred to as the DSM-5, describes Antisocial Personality Disorder as “. . . a pervasive pattern of disregard for and violation of the rights of others, occurring since age 15 years . . .” and often characterized by a “lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another.”

Those with the disorder often lack empathy for the suffering of others, and feel that victims of their inappropriate behavior had it coming. It’s important to note that, like all personality disorders listed in the DSM-5, the diagnosis of Antisocial Personality Disorder requires “clinically significant distress or impairment” in social, vocational, or other important areas of function — it’s not enough simply to engage in disapproved-of behaviors. And people don’t suddenly develop personality disorders at the age of 60 or 70.

Anyone whose behavior undergoes a drastic change at a late age must have a thorough neurological evaluation. Rehab is not going to work if a person’s altered behavior is because of a frontal lobe tumor.

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So that leaves us with personality traits that don’t meet the threshold for psychiatric disorders or mental illness — but which others find annoying, obnoxious, disgusting, or disgraceful.

People who possess these traits are often blissfully unaware that they have a problem, and function quite well until someone calls them on their bad behavior. Too little attention has been devoted to the ranks of our leaders, politicians, actors, and other powerful personages who behave badly simply because they can.

Some of these very entitled individuals may require clear limit-setting, disciplinary action, and — in more severe cases of abusive behavior — prosecution. We can do so respectfully, of course, and without condemning the person as a hopeless sinner or thoroughgoing scoundrel. After all, some may have suffered, themselves, from the abusive behavior of others.

Some well-motivated individuals who have engaged in sexual harassment may respond to long-term treatment, involving 90-100 sessions of cognitive therapy, empathy training, and behavioral modification.

But one thing I can say with some confidence: Those who have been lifelong, unrepentant cads or harrassers are not likely to change their stripes after a few weeks of “rehab” or intensive therapy.

Ronald Pies is a psychiatrist and bioethicist, whose most recent book is “The Three-Petalled Rose,” a synthesis of Jewish, Buddhist, and Stoic traditions. He can be reached at piesr@upstate.edu.
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