Antisocial Personality Disorder (ASPD)

Both genetic and environmental factors (eg, abuse during childhood Overview of Child Maltreatment Child maltreatment includes all types of abuse and neglect of a child under the age of 18 by a parent, caregiver, or another person in a custodial role (eg, clergy, coach, teacher) that results... read more ) contribute to the development of antisocial personality disorder. A possible mechanism is impulsive rather than planned aggression, related to abnormal serotonin transporter functioning. Disregard for the pain of others during early childhood has been linked to antisocial behavior during late adolescence.

Antisocial personality disorder is more common among 1st-degree relatives of patients with the disorder than among the general population (1 Etiology references Antisocial personality disorder is characterized by a pervasive pattern of disregard for consequences and for the rights of others. Diagnosis is by clinical criteria. Treatment may include cognitive-behavioral... read more ). Risk of developing this disorder is increased in both adopted and biologic children of parents with the disorder.

If conduct disorder Conduct Disorder Conduct disorder is a recurrent or persistent pattern of behavior that violates the rights of others or violates major age-appropriate societal norms or rules. Diagnosis is by clinical criteria... read more accompanied by attention-deficit/hyperactivity disorder Attention-Deficit/Hyperactivity Disorder (ADD, ADHD) Attention-deficit/hyperactivity disorder (ADHD) is a syndrome of inattention, hyperactivity, and impulsivity. The 3 types of ADHD are predominantly inattentive, predominantly hyperactive/impulsive... read more develops before age 10 years, risk of developing antisocial personality disorder during adulthood is increased (2 Etiology references Antisocial personality disorder is characterized by a pervasive pattern of disregard for consequences and for the rights of others. Diagnosis is by clinical criteria. Treatment may include cognitive-behavioral... read more ). Risk of conduct disorder evolving into antisocial personality disorder may be increased when parents abuse or neglect the child or are inconsistent in discipline or in parenting style (eg, switching from warm and supportive to cold and critical [ 3 Etiology references Antisocial personality disorder is characterized by a pervasive pattern of disregard for consequences and for the rights of others. Diagnosis is by clinical criteria. Treatment may include cognitive-behavioral... read more ]).

Patients with antisocial personality disorder may express their disregard for others and for the law by destroying property, harassing others, or stealing. They may deceive, exploit, con, or manipulate people to get what they want (eg, money, power, sex). They may use an alias.

These patients are impulsive; they do not plan ahead or consider the consequences for or the safety of self or others. As a result, they may suddenly change jobs, homes, or relationships. They may speed and drive while intoxicated, sometimes leading to crashes. They may consume excessive amounts of alcohol or take illicit drugs.

Patients with antisocial personality disorder are socially and financially irresponsible. They may change jobs with no plan for getting another. They may not seek employment when opportunities are available. They may not pay their bills, default on loans, or not pay child support.

These patients are often easily provoked and physically aggressive; they may start fights or abuse their spouse or partner. In sexual relationships, they may be irresponsible and exploit their partner and be unable to remain monogamous.

Remorse for actions is lacking. Patients with antisocial personality disorder may rationalize their actions by blaming those they hurt (eg, they deserved it) or the way life is (eg, unfair). They are determined not to be pushed around and to do what they think is best for themselves at any cost.

These patients lack empathy for others and may be contemptuous of or indifferent to the feelings, rights, and suffering of others.

Patients with antisocial personality disorder may be very opinionated, self-assured, or arrogant. They may be charming, voluble, and verbally facile in their efforts to get what they want.

For a diagnosis of antisocial personality disorder (1 Diagnosis reference Antisocial personality disorder is characterized by a pervasive pattern of disregard for consequences and for the rights of others. Diagnosis is by clinical criteria. Treatment may include cognitive-behavioral... read more ), patients must have

This disregard is shown by the presence of ≥ 3 of the following:

Also, patients must have evidence that a conduct disorder has been present before age 15 years. Antisocial personality disorder is diagnosed only in people ≥ 18 years.

There is no evidence that any particular treatment leads to long-term improvement. Thus, treatment aims to reach some other short-term goal, such as avoiding legal consequences, rather than changing the patient. Contingency management (ie, giving or withholding what patients want depending on their behavior) may be of limited benefit (1 Treatment reference Antisocial personality disorder is characterized by a pervasive pattern of disregard for consequences and for the rights of others. Diagnosis is by clinical criteria. Treatment may include cognitive-behavioral... read more ). Comorbid disorders (eg, mood disorders Overview of Mood Disorders Mood disorders are emotional disturbances consisting of prolonged periods of excessive sadness, excessive elevated mood, or both. Mood disorders can occur in adults, adolescents, or children... read more , substance use disorders Substance Use Disorders Substance use disorders involve a pathologic pattern of behaviors in which patients continue to use a substance despite experiencing significant problems related to its use. Diagnosis of substance... read more ) should also be treated according to their preferred approach.

Aggressive patients with prominent impulsivity and labile affect may benefit from treatment with medications (eg, atypical antipsychotics, lithium, and valproate [see Drug Treatment of Bipolar Disorders Medications for Treatment of Bipolar Disorders Choice of pharmacologic agents to treat bipolar disorders can be difficult because all medications can potentially have significant adverse effects, drug interactions are common, and no medication... read more ], selective serotonin reuptake inhibitors Selective Serotonin Reuptake Inhibitors (SSRIs) Several drug classes and drugs can be used to treat depression: Selective serotonin reuptake inhibitors (SSRIs) Serotonin modulators (5-HT2 blockers) Serotonin-norepinephrine reuptake inhibitors... read more ).