Antisocial Personality Disorder (ASPD)
(See also Overview of Personality Disorders.)
People with antisocial personality disorder commit unlawful, deceitful, exploitative, reckless acts for personal profit or pleasure and without remorse; they may do the following:
For antisocial personality disorder, estimated 12-month prevalence rates in the US (based on older Diagnostic and Statistical Manual of Mental Disorders [DSM] criteria) range from about 0.2 to 3.3%. Antisocial personality disorder is more common among men than among women (6:1), and there is a strong heritable component. Prevalence decreases with age, suggesting that patients can learn over time to change their maladaptive behavior and try to build a life.
Comorbidities are common. Most patients also have a substance use disorder (and about half of those with a substance use disorder meet criteria for antisocial personality disorder). Patients with antisocial personality disorder often also have an impulse control disorder, attention-deficit/hyperactivity disorder, or borderline personality disorder.
Both genetic and environmental factors (eg, abuse during childhood) contribute to the development of antisocial personality disorder. A possible mechanism is impulsive 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. Risk of developing this disorder is increased in both adopted and biologic children of parents with the disorder.
If conduct disorder accompanied by attention-deficit/hyperactivity disorder develops before age 10 years, risk of developing antisocial personality disorder during adulthood is increased. 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).
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, not planning ahead and not considering the consequences for or the safety of self or others. As a result, they may suddenly change jobs, homes, or relationships. They may speed when driving and drive while intoxicated, sometimes leading to accidents. They may consume excessive amounts of alcohol or take illegal drugs that may have harmful effects.
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 tend to have a high opinion of themselves and 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, patients must have
This disregard is shown by the presence of ≥ 3 of the following:
Disregarding the law, indicated by repeatedly committing acts that are grounds for arrest
Being deceitful, indicated by lying repeatedly, using aliases, or conning others for personal gain or pleasure
Acting impulsively or not planning ahead
Being easily provoked or aggressive, indicated by constantly getting into physical fights or assaulting others
Recklessly disregarding their safety or the safety of others
Consistently acting irresponsibly, indicated by quitting a job with no plans for another one or not paying bills
Not feeling remorse, indicated by indifference to or rationalization of hurting or mistreating others
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.
Antisocial personality disorder should be distinguished from the following:
Substance use disorder: Determining whether impulsivity and irresponsibility result from substance use disorder or from antisocial personality disorder can be difficult but is possible based on a review of the patient's history, including early history, to check for periods of sobriety. Sometimes antisocial personality disorder can be diagnosed more easily after a coexisting substance use disorder is treated, but antisocial personality disorders can be diagnosed even when substance use disorder is present.
Conduct disorder: Conduct disorder has a similar pervasive pattern of violating social norms and laws, but conduct disorder must be present before age 15.
Narcissistic personality disorder: Patients are similarly exploitative and lacking in empathy, but they tend not to be aggressive and deceitful as occurs in antisocial personality disorder.
Borderline personality disorder: Patients are similarly manipulative but do so to be nurtured rather than to get what they want (eg, money, power) as occurs in antisocial personality disorder.
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) is indicated.
Aggressive patients with prominent impulsivity and labile affect may benefit from treatment with cognitive-behavioral therapy or drugs (eg, lithium, valproate, selective serotonin reuptake inhibitors). Atypical antipsychotics can help, but there is less evidence for their use.