Antisocial personality disorder: current evidence and challenges

Antisocial personality disorder (ASPD) is characterized by a pattern of socially irresponsible, exploitative and guiltless behaviors that affects all important life domains ¹ . Behaviors can include criminal acts, failure to sustain consistent employment, manipulation of others for personal gain, deliberate deception, and disturbed relationships. Other attributes include a lack of empathy for others, impulsivity and aggression, and failure to follow a life plan.

Antisociality occurs along a spectrum ranging from relatively minor acts at one end (e.g., lying) to serious acts of violence at the other. Formal diagnostic criteria were introduced in 1980, strongly influenced by the work of L. Robins, who carefully charted the course of former child guidance clinic patients ² , ³ . The DSM criteria have since been refined, but remain true to Robins’ vision of a chronic behavioral disorder with a childhood onset ⁴ .

Surveys in the US and UK show that 2‐5% of the general adult population meets criteria for lifetime ASPD ⁵ . Risk factors include male sex, younger age, urban residence, and lower educational achievement. The disorder is often associated with substance use disorders, mood/anxiety disorders, learning disorders, or attention‐deficit/hyperactivity disorder (ADHD). Rates of suicide attempts and completed suicide are elevated.

Robins and others have documented the early onset of ASPD ³ , ⁶ . If symptoms are sufficiently severe, a child may warrant the diagnosis of conduct disorder. This diagnosis converts to ASPD if antisocial symptoms persist past age 18. The severity of ASPD is greater early in its course, but tends to lessen with advancing age ⁶ . Improvement often follows many years of behavioral symptoms that stunt the person's educational and work achievement and contribute to his/her unstable relationships and impoverished home life.

ASPD is thought to result from the interplay of genes and environment ⁷ . Family, twin and adoption studies suggest a heritable component, yet how the disorder is transmitted is unclear even as newer genetic methods are being applied. Some experts have suggested that ASPD may result from the consequences of a neurodevelopmental insult, chronic central nervous system underarousal, or deficient cognitive processing, while others have pointed to childhood maltreatment, poor parenting, and disturbed peer relationships as potential contributors. Roles have been proposed for serotonin, dopamine and testosterone. Structural and functional brain imaging studies have shown anomalies in frontal and temporal cortices, regions that mediate emotions and behavior.

The patient's history is the most important basis for diagnosing ASPD ⁸ . While the patient is the best source of information, family members are often more accurate in describing antisocial behavior than the patient, who may have little motivation to be truthful. Records of previous clinic or hospital visits can provide additional diagnostic clues. The patient interview should be wide‐ranging and include a full assessment of the personal, social, medical and family history.

Psychological testing is not diagnostic, but can be helpful if informants are unavailable ⁸ . The Minnesota Multiphasic Personality Inventory yields a broad profile of personality functioning, and a certain pattern of results is suggestive of antisociality (i.e., the “4‐9 profile”). The Psychopathic Checklist‐Revised can be used to measure the severity of the individual's psychopathic traits, which might be particularly important in forensic settings. ASPD can be assessed using a structured diagnostic interview (e.g., Alcohol Use Disorder and Associated Disabilities Interview Schedule‐5; Structured Clinical Interview for DSM‐IV Personality Disorders), but these instruments are not commonly utilized in clinical practice. Because some antisocial persons have specific learning disorders, cognitive and intellectual testing can be useful.

The medical history is important to assess. People with ASPD tend to engage in impulsive and/or risky behaviors that put them at risk for sexually transmitted diseases and injuries from accidents and other physical trauma. Antisocial persons are at increased risk for suicide and should be asked about suicidal thoughts and past suicidal behaviors.

Laboratory tests are unnecessary unless they are prompted by the medical history or presenting symptoms, for example blood alcohol level, urine drug screen, or liver enzymes for those who misuse alcohol or drugs. Likewise, structural or functional brain imaging is unnecessary in the absence of localizing neurological signs.

The differential diagnosis of ASPD includes other personality disorders (e.g., narcissistic, borderline), substance use disorders, psychotic and mood disorders, intermittent explosive disorder, and medical conditions that might cause violent outbursts (e.g., partial complex seizures) or personality changes. The DSM‐5 Z‐code diagnosis “adult antisocial behavior” is used in persons who meet adult ASPD criteria but have no history of conduct disorder prior to age 15 ⁴ .

The treatment needs of persons with ASPD should be addressed in outpatient settings. There is usually little reason to psychiatrically hospitalize these persons, and they can be disruptive to the ward milieu. Exceptions include crisis stabilization for recent or imminent suicidal behavior, recent or threatened violence or assaultive acts, and/or medical monitoring of alcohol or drug withdrawal ⁷ .

While the disorder is often thought untreatable, this conclusion is premature because of the lack of relevant treatment research ⁹ . No medication is currently approved to treat ASPD, nor are any routinely used. Medications are sometimes used “off‐label” to treat the antisocial patient's aggression and irritability, including lithium and other mood stabilizers, antidepressants, and atypical antipsychotics. Response is variable. Improvement might only mean that the individual has fewer outbursts or has a “longer fuse” giving him/her more time to reflect before acting out. There is no guarantee that the antisocial person will agree to take medication if prescribed.

Medications can be used to treat the patient's co‐occurring disorders, for example antidepressants to address comorbid mood and anxiety disorders, or lithium to treat comorbid bipolar disorder. Because benzodiazepines can be disinhibiting and are habit‐forming, their use is not recommended. Stimulant medications for comorbid ADHD should be avoided as well. Instead, non‐addicting alternatives such as bupropion, clonidine or atomoxetine could be considered. Those who misuse drugs or alcohol should be referred to evidence‐based treatment programs. Successful treatment of the person's co‐occurring disorders has the potential to reduce the overall severity of his/her antisocial behavior.

Several psychosocial treatments have been studied in patient samples comprising persons with ASPD, including cognitive‐behavioral therapy, mentalization‐based treatment, contingency management, psychoeducation, skills training, and motivational interviewing. Taken together, these studies suggest that significant positive changes can occur in people with ASPD, warranting further research. Moreover, there is no evidence that the above treatments make ASPD people worse.

In summary, ASPD is common and problematic. It begins early and is typically chronic and lifelong, with a trend toward improvement with advancing age. It likely results from the interplay of genes and environment. Diagnosis rests on the patient's history of recurrent behavioral problems, because there are no diagnostic tests. Treatment is vexing and unsatisfying. Research is needed to identify the genetic roots and underlying neurobiology of the disorder. Treatment research should include studies of medications to target anger, irritability and other antisocial symptoms, while psychotherapy should target interpersonal, social and cognitive aspects of the disorder.