Antisocial Personality Disorder

Antisocial Personality Disorder (ASPD) is a personality disorder characterized by a history of continuous and chronic behaviour where there is disregard for and violation of the rights of others. Individuals repeatedly engage in unlawful activities (e.g. - drug use, assault, or theft), endanger the well-being of others, and frequently lie. They tend to be aggressive and impulsive and may find it difficult to maintain employment for long. Contrary to the name, having antisocial personality does not mean the individual does not have friends; on the contrary, they may have a superficial charm and be very deceptive.

Epidemiology
  • The 12-month prevalence rate is between 0.2 to 3.3%.[1]
    • In forensic populations, the prevalence can be >50%.
Prognosis
  • Individuals with ASPD are more likely to die prematurely by violent means (e.g. - suicide, homicide, or accidents),[2] have greater recidivism rates (i.e. - more likely to re-offend)[3]
    • Suicide attempt rates are higher in ASPD compared to the general population[4]
  • Although ASPD is chronic, symptoms may be less evident by the fourth decade of life, with less engagement in criminal behaviour.
Comorbidity
Risk Factors
  • Childhood onset of conduct disorder (before age 10 years) plus co-morbid attention-deficit/hyperactivity disorder is a risk factor for developing ASPD.[5]
  • ASPD is more common among first-degree biological relatives (both male and female) of those diagnosed with ASPD
  • In families with a member diagnosed with ASPD, other males in the family more likely to also have the diagnosis, and/or a substance use disorder; females within that family are more likely to have somatic symptom disorder.
  • Other factors including child abuse or neglect, unstable or erratic parenting, or inconsistent parental discipline increase the likelihood that a conduct disorder diagnosis will evolve into ASPD.[6]
History

The conceptualization of antisocial personality disorder dates back to the 1800s, and has its origins in society and the attitudes towards crime and civil liberties. The framework for the current approach to antisocial personality had its origins in 1939, when psychiatrist Dr. David Henderson began describing various types of antisocial behaviour beyond just criminal activity.[7]

Sociopath, Psychopath, or Antisocial Personality?

These three terms are often used interchangeably, but not the same:
  • Antisocial personality disorder is a diagnosis in the DSM-5 and the ICD-10 (also called dissocial personality disorder in the ICD)
  • Sociopathy is considered to be a synonym for antisocial personality.
  • Psychopathy is not a clinical diagnosis in a medical setting per se, but rather it is diagnosed using the Psychopathy Checklist—revised (PCL-R), created by Canadian psychologist Robert D. Hare.[8][9]
    • Psychopathy is defined as individuals who have an inability to experience emotions as others do and also engage in a range of antisocial behaviours.
    • The concept of psychopathy was in part introduced because ASPD was of limited use in correctional settings (i.e. - about 75% of individuals in jail have ASPD but only about 15% meet criteria for psychopathy)
    • Most offenders who meet criteria for psychopathy will also meet criteria for ASPD, but most individuals who have ASPD do not meet criteria for psychopathy!

'I'm So Antisocial!'

The term “antisocial” is often misused by the lay public (e.g - “I'm feeling so antisocial tonight! I don't want to go this party.”). What an individual actually mean to say is they are feeling “asocial,” or feeling indifferent to social activities. The term antisocial means “against society,” or behaviour that is actively hostile or harmful towards society, as in antisocial personality disorder.
Criterion A

A pervasive pattern of disregard for and violation of the rights of others, occurring since age 15 years, as indicated by 3 (or more) of the following:

  1. Failure to conform to social norms with respect to lawful behaviors, as indicated by repeatedly performing acts that are grounds for arrest
  2. Deceitfulness, as 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, as indicated by repeated physical fights or assaults
  5. Reckless disregard for safety of self or others
  6. Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behaviour or honour financial obligations
  7. Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another
Criterion B

The individual is at least age 18 years.

Criterion C

There is evidence of conduct disorder with onset before age 15 years.

Criterion D

The occurrence of antisocial behaviour is not exclusively during the course of schizophrenia or bipolar disorder.

Patients must be 18 years or older to be diagnosed with the antisocial personality. They typically have a history of conduct disorder in adolescence. Conduct disorder becomes antisocial personality disorder once an individual turns 18.

Mnemonic

The mnemonic CORRUPT can be used to remember the criteria for antisocial personality disorder.[10]

  • C - Cannot conform to the law
  • O - Obligations ignored
  • R - Reckless disregard for safety
  • R - Remorseless
  • U - Underhanded (deceitful)
  • P - Planning insufficient (impulsive)
  • T - Temper (irritable, aggressive)

Adoption studies suggest that both genetic and environmental factors contribute to the development of ASPD.[11] Adopted children raised by adoptive parents have a greater risk of developing ASPD, if their biological parents have ASPD. However, a healthy adoptive family environment can reduce the risk of the individual developing ASPD.[12] Some neuroimaging studies have suggested that structural and functional changes to the limbic and paralimbic systems may be related to the core features of psychopathy and antisocial personality disorder.[13] Psychological defenses used in ASPD include primitive defenses such as omnipotent control, projective identification, dissociation, rationalizing, and acting out.

Age Limit

Remember that antisocial personality disorder is the only personality disorder that cannot be diagnosed before age 18. Additionally, ASPD can only be diagnosed if the individual at least has some symptoms of conduct disorder before age 15 years. For individuals older than 18 years, a diagnosis of conduct disorder is given only if the criteria for antisocial personality disorder are not met.
    • When antisocial behavior in an adult is associated with a substance use disorder, the diagnosis of ASPD is not made unless at least some signs of ASPD were also present in childhood and have continued into adulthood. If both substance use and antisocial behavior began in childhood and continued into adulthood, both ASPD and a substance use disorder should be diagnosed if the criteria for both are met. This diagnosis is made even if some antisocial behaviours were a consequence of the substance use disorder (e.g. - selling illegal drugs, stealing to obtain money to drugs).
  • Schizophrenia and bipolar disorders
    • Antisocial behavior that occurs exclusively during the course of an episode of schizophrenia or bipolar disorder should not be diagnosed as ASPD.
    • Both types of personality disorders have a tendency to be excitement seeking, impulsive, superficial, reckless, seductive, and/or manipulative. However, in histrionic personality disorder, individuals tend to be more exaggerated in their emotions and do not typically engage in antisocial behaviors. Individuals with histrionic personality disorder may manipulate others to gain emotional connections, whereas in ASPD, the motivation to manipulative is to gain profit, power, or some other material gratification.
    • Although antisocial behavior may be seen in individuals with paranoid personality disorder, it is not typically motivated by personal gain or wish to exploit others as in ASPD, but rather is more driven by a desire for revenge.
    • Individuals with ASPD tend to have less emotional dysregulation and are more aggressive than those with borderline personality disorder.
    • Both personality disorders may share a tendency for the individual to be superficial, exploitative, tough-minded, glib, and/or lack empathy. However, in narcissistic personality disorder, individuals do not have characteristic impulsivity, aggression, and deceit. In addition, individuals with ASPD require less admiration and envy from others. Individuals with narcissistic personality disorder also usually lack the history of conduct disorder in childhood or criminal behavior in adulthood.
  • Criminal behavior not associated with a personality disorder
    • Just because an individual is involved in criminal behavior does not mean they have ASPD! ASPD specifically concerns the personality features that are the hallmark of this disorder. A diagnosis of ASPD is made only if the antisocial personality features are inflexible, maladaptive, and persistent and also cause significant functional impairment or subjective distress.

Evidence is limited in this area, but individual psychodynamic therapy is not recommended.

  • Group cognitive behavioural therapy may be helpful in addressing specific symptoms such as impulsivity, interpersonal difficulties, and challenging behaviours.
  • In general, peer therapy settings may be more effective than individual therapy.[14]
  • General therapy principles include setting firm limits, and using mentalizing-based approaches. Perhaps most importantly, the therapist must understand and process their own countertransference when engaging in therapy with individuals with ASPD. Individuals with ASPD may exhibit behaviours such as lack of remorse, or discuss behaviours that therapists find difficult.

There is little evidence for the use of medications. Some limited evidence exists to support the role of lithium or phenytoin in preventing impulsive aggression in those with antisocial personality.[15]

Personality Disorder Guidelines

Guideline Location Year PDF Website
World Federation of Societies of Biological Psychiatry (WFSBP) International 2009 - Link

Antisocial Personality Guidelines

Guideline Location Year PDF Website
National Institute for Health and Care Excellence (NICE) UK 2009 - Link
1) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
2) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
5) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
6) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
8) Hare, R. D., Clark, D., Grann, M., & Thornton, D. (2000). Psychopathy and the predictive validity of the PCL‐R: An international perspective. Behavioral sciences & the law, 18(5), 623-645.
9) Hare, R. D. (2003). The psychopathy checklist–Revised. Toronto, ON.
11) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
12) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.