Antisocial personality disorder (ASPD) is characterized by a pervasive disregard for and violation of the rights of others. ASPD, like all personality disorders, is a consistent pattern of behavior that deviates from the expectations of the person’s culture. It is persistent, inflexible and typically stable throughout the lifespan, and leads to functional difficulties in most aspects of life.
Treatment for ASPD typically includes therapies that target antisocial thinking and maladaptive behavior. There is no specific medication at this time that is Food and Drug Administration (FDA) approved for treating ASPD, however medications are commonly used to treat co-occurring mental health and substance abuse disorders. The best clinical outcomes for ASPD are when it is treated long-term with ongoing lifetime follow-up.
The costs of treating ASPD vary given insurance coverage and resources accessible to the person; specialized ASPD interventions are not widely available, so most people will likely be treated by local clinicians and physicians. Inpatient treatment is also common for people with ASPD, given their higher rates of incarceration and institutionalization.8,9,10
What Is Antisocial Personality Disorder?
Antisocial personality disorder is characterized by violating the rights of others, with symptoms present since the age of 15. ASPD is listed as a Cluster B disorder in the Diagnostics and Statistics Manual, 5th Edition (DSM-5). Cluster B disorders share similar symptoms and presentations, and are often characterized by emotional lability, impulsivity, and unpredictable behavior. Other Cluster B disorders along with ASPD are Narcissistic Personality Disorder, Histrionic Personality Disorder, and Borderline Personality Disorder.
To be diagnosed with ASPD, a person must meet a minimum of three of the following criteria:
- Failure to conform to social norms and laws, and repeatedly breaking the law, whether getting caught or not
- Lying, using aliases, using other people for self-gain or profit
- Impulsivity, difficulty planning, poor executive functioning
- Frequent fights, displays of aggression, irritability
- Recklessness, no regard for safety of self or others
- Irresponsibility with regards to employment, finances
- Apathy, indifference to the feelings of others, able to rationalize behavior
According to the DSM-5, the person must be at least the age of 18 years old to be diagnosed, signs of Conduct disorder (CD) must have been present before the age of 15, and the behavior cannot only be present when other disorders such as bipolar and schizophrenia are in active phases. While ASPD cannot be diagnosed before the age of 18, its symptoms often present in children as Oppositional defiant disorder (ODD) and/or Conduct disorder (CD).1
ASPD, Sociopathy, & Psychopathy
ASPD is often synonymous with non-diagnostic terms, such as sociopathy and psychopathy. There are differing perspectives on the usage of terminology, but neither is a DSM-5 disorder, and hence are not used diagnostically.2 Some believe they are similar disorders, others believe psychopathy is a more severe form of ASPD.
Psychopathy is most commonly measured using the Psychopathy Checklist Revised (PCL-R). It separates biological or innate characteristics such as low empathy, callousness from more social ones such as difficulty with employment, unstable housing. This dimensional measure of psychopathy is used in legal, clinical and research settings. It is often used as an actuarial risk assessment tool in measuring recidivism.
Not all people meeting criteria for ASPD will score high enough on the PCL-5 to be classified as having psychopathy—however, those with psychopathy will likely always meet criteria for ASPD.3
Prevalence rates using DSM criteria are between 0.2 and 3.3% but these rates vary depending on the population and research methodology. Populations with the highest prevalence are men with substance abuse disorder, are incarcerated or in forensic settings, or that experience lower socioeconomic background or adverse sociocultural factors.1
Signs of Antisocial Personality Disorder: What It Looks Like
Adults living with ASPD typically display signs of antisocial behavior before the age of 8, with 80 percent presenting these behaviors by age 11.4 They will often show dysfunction in the ability to maintain employment, pay bills, and retain stable housing, promiscuity, volatility towards others, gambling addiction and substance abuse issues. These behaviors often culminate in criminal behavior and incarceration.
People with ASPD also often display glibness, superficial charm, manipulation, disregard for safety of self and others, impulsivity, are angry, arrogant, and prone to fits of rage.1
Research shows that some elderly adults show a decrease in ASPD-related behaviors over time, or that their offenses tend to change. Research shows a reduction in aggression and violent behaviors. Sexual offenses are the most commonly reported crime amongst elderly people with ASPD, and even those behaviors typically reduce with advancing age. However, there is a level of stability in antisocial behaviors that will likely be present throughout lifetime.5
ASPD cannot be diagnosed before the age of 18. Oppositional Defiance Disorder (ODD) and Conduct Disorder (CD) are commonly diagnosed in children displaying antisocial behaviors. Children diagnosed with ADHD with or without CD also show an increased risk of developing ASPD.6
The disorder presents in children with behaviors such as stealing, vandalism, truancy, disobedience, and chronic delinquency. Abusing animals and fire-setting during childhood are also common predictors in the development of ASPD. Antisocial behavior is also correlated to adolescent substance abuse resulting from both genetic and environmental influences.6
People with ASPD often do not know they have a personality disorder, as they often have an inflated sense of self and poor insight. Often, they do not seek treatment unless court-ordered or pressured by family or friends.7 People with ASPD often have contact with the criminal justice system and can be identified and treated. This has also led to most research on ASPD being on forensic or inpatient populations, which may not be indicative or generalizable of the general population.4
Symptoms of Antisocial Personality Disorder
Whereas signs of ASPD are often what people see and perceive in the person with the disorder, symptoms are the subjective experience of the person with ASPD. Symptoms of this ASPD often co-occur with other disorders which can complicate clinical presentation.
However, common features of ASPD symptoms include:
- Lack of empathy and inability to view situations from other perspectives.
- Hostility, anger, and fits of rage
- Feeling impulsive, high need for stimulation which can lead to substance abuse, promiscuity, and reckless behaviors
- Desire for control, lying, and manipulation of others
- Inability to feel remorse
- Flat affect
- Boredom
- Grandiosity
- Feeling superior to others
- Lack of insight
- Difficulty feeling emotions, ability to mimic them
- Low autonomic nervous system arousal1,2,7
Causes & Triggers of Antisocial Personality Disorder
There is no singular process identified that causes ASPD to develop. As with all personality disorders, certain factors contribute to the genesis of disordered personality, such as genetic and congenital vulnerabilities, life stressors, traumas and neurological changes in brain functioning. Childhood trauma such as abuse or neglect is believed to also be contributing factors in the development of the disorder, as is having an alcoholic or antisocial parent.
There are certain factors that consistently emerge in people diagnosed with ASPD and antisocial behaviors:
- Diagnosis of childhood conduct disorder
- Men are more likely to be diagnosed with ASPD
- Family history of antisocial personality disorder, personality disorders, or mental health disorders
- Being subjected to abuse or neglect during childhood
- Unstable and chaotic family life during childhood
- Parents with substance abuse disorders
- Firesetting and animal abuse in childhood
- Low socioeconomic status (SES)
Common consequences of ASPD and antisocial behavior include:
- Spouse abuse or child abuse or neglect
- Problems with alcohol, substance abuse and gambling disorders
- Incarceration
- Homicidal or suicidal behaviors
- Co-occurring mental health disorders
- Low social and economic status and homelessness
- Premature death 7
Treatment of Antisocial Personality Disorder
Effectively treating personality disorders is notoriously difficult, and Antisocial Personality Disorder is no exception. Types of therapies commonly used to treat ASPD include Schema therapy and Dialectical Behavior Therapy, as well as some newer modalities such as reward-based therapy and decompression.
Many barriers impede effective treatment of ASPD, such as poor personal insight, resistance to seeking treatment, and the inflexible stability of personality traits and temperaments. There may also be underlying neurological anomalies contributing to the condition such low amygdala response, poor executive functioning, neurotransmitter deficiencies/sensitivities or other neurological vulnerabilities.8,9
Psychotherapy
Evidence-based psychotherapy and medications for symptoms of aggression and mood have shown some effectiveness. Psychotherapies targeting anger, substance abuse, or other co-occurring disorders are the most common form of treatment. Schema therapy, a combination of cognitive, psychodynamic and gestalt methods, developed for use in the treatment of personality disorders, has shown promise in treating what was once considered “untreatable.”10
Dialectical Behavioral Therapy (DBT) in forensic settings, revised from the fidelity model for incarcerated populations, has also shown promise.11 Treating childhood trauma, unlearning maladaptive coping responses, and reducing aggression are all important aspects of effectively treating ASPD.
Newer treatment modalities such as reward-based therapy and decompression have shown promise, particularly with treatment in younger inpatient populations. Reinforcement learning is a guiding principle in behavioral regulation, and research indicates that people with ASPD respond more strongly to reward than to punishment.
Behavioral treatments that focus on reward-dominant learning have shown more promise than treatment as usual. Inpatient hospitals treating children and adolescence have also produced effective behavioral shaping in patients by utilizing a technique called “decompression.”
Decompression is not giving up or avoiding the problem behavior or person, but rather giving them total presence. Many people with ASPD have backgrounds of abuse and neglect or have been shunned due to their antisocial behaviors. This technique has found success in inpatient environments and has helped to build meaningful connections to the antisocial person and their treatment providers.12,13
Successful treatment relies on the person’s commitment to treatment, the clinician’s knowledge of the disorder, the severity of symptoms, and the minimization of treatment barriers. Long-term treatment and follow-up may be beneficial in effectively treating ASPD.
Psychotherapy is not always effective, especially if symptoms are severe and the person is unable to take responsibility for their disorder and the subsequent problems it creates. Also, the pervasive and false belief that ASPD is untreatable is an important bias for clinicians to be aware of when treating antisocial individuals, as it can impact successful therapeutic alliance and treatment outcomes.14
Medications
Currently, there are no medications approved by the Food and Drug Administration (FDA) for treating ASPD specifically, but the antipsychotic medication clozapine, and mood stabilizer lithium, have shown promise in research trials and in off-label clinical use. Treating underlying mental health disorders and health conditions is also an important component of effectively treating ASPD.15,16
How to Get Help for Antisocial Personality Disorder
If you or someone you care about is struggling with antisocial behaviors, and possibly ASPD, there are resources in the medical, mental health and school counseling fields. Treatment for ASPD is typically covered by insurance. Finding a specialty treatment provider for ASPD may prove difficult, but utilizing the directories provided by insurance companies may be a useful starting point.7
Getting treatment for a disorder that a person does not know or cannot admit that they have is nearly impossible. This is why many people who seek treatment for ASPD have been mandated by adjudication processes, or at the insistence of friends and family.
Antisocial Personality Disorder Statistics
Consider the following statistics regarding ASPD:
- The prevalence of ASPD using DSM criteria is between 0.2 and 3.3%1
- ASPD is more common in men (3%) than women (1%)7
- ASPD prevalence rates in prisons is high: 47% of male prisoners and 21% of female prisoners7
- ASPD was once considered untreatable, but newer psychotherapy treatment modalities have shown promise12,13,14
- ASPD most commonly co-occurs with substance abuse disorder, ADHD, and somatic disorders 18
Living with Antisocial Personality Disorder: Coping & Managing Symptoms
Living with ASPD can be challenging as the person navigates the world with little insight into their destructive and maladaptive behaviors. However, with treatment and support they can lead meaningful lives.
Ways of managing ASPD include:
- Treating underlying disorders such as substance abuse, mood disorders, and other mental health conditions
- Working to heal past traumas and restructuring false schemas and maladaptive behaviors
- Taking responsibility: This means taking medications, attending appointments and fostering accountability
- Managing stress, anger, and triggers, and learning how to cope with feelings of hatred toward others
Antisocial Personality Disorder vs Other Disorders
There are many shared characteristics of all DSM-5 Cluster B personality disorders, and a person may have more than one personality disorder. These personality disorders are: Narcissistic Personality Disorder, Borderline Personality Disorder, and Histrionic Personality Disorder. Cluster B disorders share many similar criteria and should be considered during differential diagnoses of ASPD.1
ASPD vs Bipolar Disorder
The symptom presentation of ASPD must be consistently present, and not only during active manic or depressive phases of Bipolar Disorder. Both disorders share symptoms of impulsivity, increased likelihood of criminal offending, substance abuse disorder and suicidal ideation.
Symptoms of ASPD and Bipolar Disorder often present as more severe when in combination. This is particularly true of people with an early onset of Bipolar and with a primarily manic presentation.19
ASPD vs ADHD
ADHD commonly co-occurs with ASPD. It is estimated that approximately 65 percent of people diagnosed with ASPD also meet criteria for ADHD. Children diagnosed with ADHD have increased risk for developing ASPD, and for criminal offending.20
ASPD vs Schizophrenia-Related Disorders
Prevalence of ASPD in people with Schizophrenia spectrum disorder is higher than the general population. Antisocial behaviors cannot solely be present during active phase psychosis. Research has shown that Schizophrenia spectrum disorder is 7 times higher in men with ASPD and 11 times higher in women with ASPD.21
Common Co-occurring Disorders
Anxiety disorders, ADHD, Substance abuse disorder, Gambling disorder and Somatic disorders are the most common comorbid disorders with ASPD. Research shows approximately 50 percent prevalence of anxiety disorders with those who have been diagnosed with ASPD. ADHD has been found to be as high as 65 percent comorbidity, and substance abuse has been estimated from 40-50 percent comorbidity. Prevalence rates often vary due to research methodology.18
For Further Reading
For more information on resources available to assist in the treatment and prevention of ASPD, visit these sites:
