Antisocial personality disorder is one of nine personality disorders defined in the Diagnostic and Statistical Manual of the American Psychiatric Association, 4th Edition (DSM-IV). For more information, see separate article Personality Disorders and Psychopathy.

People with antisocial personality disorder exhibit traits of impulsivity, high negative emotionality, low conscientiousness and associated behaviours including irresponsible and exploitative behaviour, recklessness and deceitfulness.^1,2

People with antisocial personality disorder have often grown up with parental conflict and harsh inconsistent parenting. Their childhoods have typically featured parental inadequacies and often transfer of care to outside agencies. Associated with this is a high incidence of truancy, delinquency and substance misuse.³ This in turn results in increased rates of unemployment, problems with housing and difficulties with relationships. Many people with antisocial personality disorder have a criminal conviction and are imprisoned or die prematurely as a result of reckless behaviour.^1,2

Criminal behaviour is central to the definition of antisocial personality disorder but there is much more to the disorder than just criminal behaviour. It is often preceded by other long-standing difficulties (socio-economic, educational, family, relationship). Psychopathy is considered to be a considerably severe form of antisocial personality disorder.²

The National Institute for Health and Clinical Excellence (NICE) guidance¹ exemplifies a progression from recognition and definition towards more effective management. The challenge posed by this guidance to the mental health services, substance misuse services, social care and criminal justice system is considerable.

Epidemiology⁴

• The prevalence of antisocial personality disorder in the general population is 3% in men and 1% in women.
• The prevalence of antisocial personality disorder among prisoners is less than 50%.
• However, only 47% of people with antisocial personality disorder have significant arrest records.

Presentation⁴

Features include:

• Unstable interpersonal relationships.
• Disregard for the consequences of their behaviour.
• A failure to learn from experience.
• Egocentricity.
• A disregard for the feelings of others.
• A wide range of interpersonal and social disturbance.
• Comorbid depression and anxiety.
• Comorbid alcohol and drug misuse.

It is important to note that antisocial personality disorder is not formally diagnosed before the age of 18 but there may be a history of conduct disorders before this age.

Conduct disorders may be manifested as antisocial, aggressive or defiant behaviour, which is persistent and repetitive. This includes aggressive behaviour (to people or animals), destruction of property, deceitfulness, theft and serious rule-breaking.

Diagnostic criteria^4,5

People with antisocial personality disorder have a pervasive pattern of disregard for and violation of the rights of others and the rules of society. A history of conduct disorder before the age of 15 is a requirement for a diagnosis of antisocial personality disorder (in the DSM-IV criteria) and includes the following features:

• Repeated breaches of the law. They may well have recurrent criminal convictions.
• Frequent lying and deception, even when there is no obvious gain.
• Physical aggression.
• Reckless disregard for safety of self or others.
• Utter irresponsibility in work and family environments.
• Lack of remorse.

The impending DSM-V classification may well see a re-assessment of the diagnostic criteria in due course.⁶

Differential diagnosis⁴

Diagnosis can be very difficult because of overlapping features and the high frequency of comorbid conditions and problems. Premorbid and developmental history from third parties can be helpful when making a diagnosis:

• Alcoholism.
• Mental disorders secondary to medical conditions (head injuries, seizure disorders).
• Anxiety disorders.
• Other personality disorders.
• Mental retardation.
• Brief psychotic disorder.
• Post-traumatic stress disorder.
• Depression.
• Schizoaffective disorder.
• Schizophrenia.
• Ganser's syndrome.

Investigations⁴

• Toxicology screen because substance abuse is common (as with many personality disorders). Intoxication can lead patients to present with some features of personality disorders.
• Screening for HIV and other sexually transmitted diseases may be appropriate because of the poor impulse control and disregard of risk associated with antisocial personality disorder.
• Psychological testing may support or direct the clinical diagnosis. For example:
  • The Minnesota Multiphasic Personality Inventory (MMPI)⁷
  • The Eysenck Personality Inventory (EPI)⁸
  • The Personality Diagnostic Questionnaire (PDQ)⁹
  These have not been reliably validated against DSM-IV Text Revision (DSM-IV-TR) diagnoses.
  
  The Structured Clinical Interview for DSM-IV-TR for Axis II Disorders (SCID-II) can also be used to aid in diagnosis.²

Associated diseases^2,4

• Anxiety.
• Alcohol misuse.
• Drug misuse.
• Depression.
• Attention deficit hyperactivity disorder (ADHD) in childhood.

Management^4,10

Antisocial personality disorder poses a big challenge to the different agencies which frequently and almost inevitably, have to manage individuals with this disorder. Management by any single agency is not usually possible or recommended. Management in general practice alone is not recommended and referral to psychiatric services is essential.

• Mental health services.
• Substance misuse services.
• Social care.
• The criminal justice system and associated forensic mental health services.²

Drug treatment

No drug has UK marketing authorisation specifically for the treatment of antisocial personality disorder. However, antidepressants and antipsychotics are often used to treat some of the associated problems and symptoms.

Psychological treatments

Psychotherapy is at the core of care for personality disorders generally. In theory, psychotherapy aims to help patients cope with the disorder by, for example:

• Improving perceptions of social and environmental stressors.
• Improving responses to social and environmental stressors.

Different types of psychotherapy have been used to try to achieve such aims. Cognitive behavioural therapy and group therapy are perhaps the most widely used and available forms of psychotherapy. These should target reduction in offending and antisocial behaviour.¹

Other considerations

• Good communication is essential between all concerned but especially between healthcare professionals and people with antisocial personality disorder.
• NICE recommends that services should consider establishing antisocial personality disorder networks, where possible linked to other personality disorder networks. They may be organised at the level of primary care trusts, local authorities, strategic health authorities or government offices.¹ These networks should be multi-agency.
• Treatment and care should take into account people's needs and preferences. People with antisocial personality disorder should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals.¹ If the person is under 16, healthcare professionals should follow the guidelines in 'Seeking consent: working with children'.¹¹
• If the person agrees, carers (who may include family and friends) should have the opportunity to be involved in decisions about treatment and care. Families and carers should also be given the information and support they need.¹

Complications⁴

• Suicide
• Substance abuse
• Accidental injury
• Depression
• Homicide

Prognosis²

The disorder used to be thought of as lifelong. However, a growing body of research suggests that positive changes can be seen over time. Many patients no longer meet the diagnostic criteria for the condition after a decade. It is acknowledged that the condition is difficult to diagnose and that misdiagnosis may be partly to blame for this 'improvement' but it is also considered that many patients do respond to therapeutic interventions. Core characteristics such as lack of empathy do not lessen but evidence suggests that patients develop more control over their impulsivity and cultivate a sense of responsibility.²

Prevention⁴

The incidence of antisocial personality disorder is reduced during times of war and in many Asian cultures. This suggests that social cohesion and an emphasis on communities rather than individuals are significant preventative factors.² Families or carers are thus important in prevention and treatment of antisocial personality disorder.¹ NICE suggests that services should establish robust methods to identify children at risk of developing conduct problems and that vulnerable parents could be identified antenatally. For example, identifying:

• Parents with other mental health problems, or with significant drug or alcohol problems.
• Mothers aged younger than 18 years, particularly those with a history of maltreatment in childhood.
• Parents with a history of residential care.
• Parents with significant previous or current contact with the criminal justice system.

The interventions employed after identification of at-risk parents are many and varied according to the problems identified and the age. Examples include:

• Parenting courses
• Anger management
• Cognitive problem solving
• Family therapy
• Multi-systemic therapy
• Multidimensional treatment
• Foster care

Document references

1. Antisocial personality disorder, NICE Clinical Guideline (January 2009); Antisocial personality disorder: treatment, management and prevention
2. A guide to working with offenders with personality disorders, Dept of Health (February 2011)
3. Lewis CF; Substance use and violent behavior in women with antisocial personality disorder. Behav Sci Law. 2011 Sep;29(5):667-76. doi: 10.1002/bsl.1006. [abstract]
4. Bienenfeld D, Personality Disorders, Medscape, Jun 2010
5. General Diagnostic Criteria for Personality Disorder, American Psychiatric Association, 2010
6. Pickersgill M; Standardising antisocial personality disorder: the social shaping of a Sociol Health Illn. 2011 Oct 21. doi: 10.1111/j.1467-9566.2011.01404.x. [abstract]
7. Framingham, J; Minnesota Multiphasic Personality Inventory (MMPI). Psych Central, 2011.
8. Francis L et al; The Short-form revised Eynsenck Personality Questionnaire, Social Behaviour and Personality, 2006, 34(2), 197-204
9. Personality Diagnostic Questionnaire for the DSM IV, PDQ-4 website, 2011
10. Rodrigo C, Rajapakse S, Jayananda G; The 'antisocial' person: an insight in to biology, classification and current Ann Gen Psychiatry. 2010 Jul 6;9:31. [abstract]
11. Seeking consent: working with children, Dept of Health (2001)

Internet and further reading

• Douglas K, Chan G, Gelernter J, et al; 5-HTTLPR as a potential moderator of the effects of adverse childhood experiences Psychiatr Genet. 2011 Oct;21(5):240-8. doi: 10.1097/YPG.0b013e3283457c15. [abstract]