Antisocial Personality Disorder

  • Medical Author:
    Roxanne Dryden-Edwards, MD

    Dr. Roxanne Dryden-Edwards is an adult, child, and adolescent psychiatrist. She is a former Chair of the Committee on Developmental Disabilities for the American Psychiatric Association, Assistant Professor of Psychiatry at Johns Hopkins Hospital in Baltimore, Maryland, and Medical Director of the National Center for Children and Families in Bethesda, Maryland.

  • Medical Editor: Melissa Conrad Stöppler, MD
    Melissa Conrad Stöppler, MD

    Melissa Conrad Stöppler, MD

    Melissa Conrad Stöppler, MD, is a U.S. board-certified Anatomic Pathologist with subspecialty training in the fields of Experimental and Molecular Pathology. Dr. Stöppler's educational background includes a BA with Highest Distinction from the University of Virginia and an MD from the University of North Carolina. She completed residency training in Anatomic Pathology at Georgetown University followed by subspecialty fellowship training in molecular diagnostics and experimental pathology.

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Antisocial personality disorder (APD or ASPD) facts

  • A personality disorder (PD) is a persistent pattern of internal experience and behavior that markedly differs from what is considered normal within the person's own culture.
  • Personality disorders are grouped into clusters A, B, and C based on the dominating symptoms.
  • Antisocial personality disorder is a diagnosis that is characterized by an enduring pattern of disregarding and violating the rights of others with symptoms having been present since 15 years of age and may include symptoms like breaking laws, repeated deceitfulness, starting fights, a lack of regard for their own safety or the safety of others, a lack of guilt and taking personal responsibility, a tendency to act impulsively, and irritability.
  • Although not a formal diagnosis, psychopathy is thought to be a more severe form of antisocial personality disorder. Specifically, in order to be considered a psychopath, a person must have a lack of remorse or guilt about their actions in addition to demonstrating antisocial behaviors.
  • Psychopaths tend to be highly suspicious or paranoid, even in comparison to individuals with antisocial personality disorder, which tends to lead the psychopathic person to interpret all aggression toward them as being arbitrary and unfair.
  • Antisocial personality disorder is likely the result of a combination of biologic/genetic and environmental factors.
  • Some theories about the biological risk factors for antisocial personality disorder include the malfunction of certain genes, hormones, or parts of the brain.
  • Diagnoses often associated with antisocial personality disorder include substance-related disorders, attention-deficit hyperactivity disorder (ADHD), and reading disorders.
  • Theories regarding the life circumstances that increase the risk for developing antisocial personality disorder include a history of childhood physical, sexual, or emotional abuse; neglect, deprivation, or abandonment; associating with peers who engage in antisocial behavior; or having a parent who is either antisocial or alcoholic.
  • Since there is no specific definitive test that can accurately diagnose antisocial personality disorder, health-care professionals perform a mental-health interview that assesses for the presence of antisocial symptoms. If the cultural context of the symptoms is not considered, antisocial personality disorder is often falsely diagnosed as being present.
  • Research indicates that members of ethnic minorities tend to be wrongly diagnosed with antisocial personality disorder, thereby inappropriately resulting in less treatment and more punishment for those individuals.
  • While antisocial personality disorder can be quite resistant to treatment, the most effective interventions tend to be a combination of firm but fair behavior therapy and programming that emphasizes teaching the antisocial personality disorder individuals skills that can be used to live independently and productively within the rules and limits of society.
  • While medications do not directly treat the behaviors that are associated with antisocial personality disorder, they can be useful in addressing conditions like depression, anxiety, and mood swings that often co-occur with this condition.
  • If untreated, people with antisocial personality disorder are at risk for developing or worsening many other mental disorders, as well as for self-mutilation or dying from homicide or suicide.
  • Many people with antisocial personality disorder experience a remission of symptoms by the time they are 50 years old.

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Antisocial Personality Disorder Symptoms

Impulsivity

Impulsivity is the tendency to act on impulse -- that is, without forethought about the appropriateness or consequences of the action. A certain degree of impulsivity is common in children and even some young adults often display impulsivity of behavior. Only when present to excess and accompanied by problems with normal function is impulsivity considered abnormal in young children.

What is the difference between antisocial personality disorder and psychopathy?

Psychopathy, although not a mental-health disorder formally recognized by the American Psychiatric Association, is considered to be a more severe form of antisocial personality disorder. Specifically, in order to be considered a psychopath, also called a sociopath, a person must have a lack of remorse or guilt about their actions in addition to demonstrating antisocial behaviors. Other core symptoms of this condition are thought to include a severe lack of caring for others, a lack of emotion, overconfidence, selfishness and a higher propensity for aggression compared to other people with antisocial personality disorder. While statistics indicate that 50%-80% of incarcerated individuals have been found to have antisocial personality disorder, only 15% of those convicted criminals have been shown to have the more severe antisocial personality disorder type of psychopathy.

Psychopaths tend to be highly suspicious or paranoid, even compared to people with antisocial personality disorder. The implications of this suspicious stance can be dire, in that paranoid thoughts (ideations) tend to lead the psychopathic person to interpret all aggressive behaviors toward them, even those that are justified, as being arbitrary and unfair. A televised case study of a psychopath provided a vivid illustration of the resulting psychopathic anger. Specifically, the criminal featured in the story apparently abducted a girl and sexually abused her over the course of a number of days in an attempt to prove to investigating authorities that his stepdaughter's allegations that he sexually abused her were false.

What are causes and risk factors of antisocial personality disorder?

One of the most frequently asked questions about antisocial personality disorder by both professionals and laypeople is whether or not it is genetic. Many wonder if it is hereditary, just as much as hair, eye, or skin color; if this were the case, children of antisocial people would be highly expected to become antisocial themselves, whether or not they live with the antisocial parent. Fortunately, human beings are just not that simple. Like all personality disorders, and most mental disorders, antisocial personality disorder tends to be the result of a combination of biologic/genetic and environmental factors.

Although there are no clear biological causes for this disorder, studies on the possible biologic risk factors for developing antisocial personality disorder reveal that, in those with the illness, the part of the brain that is primarily responsible for learning from one's mistakes and for responding to sad and fearful facial expressions (the amygdala) tends to be smaller and respond less robustly to the happy, sad, or fearful facial expressions of others. That lack of response may have something to do with the lack of empathy that antisocial individuals tend to have with the feelings, rights, and suffering of others. While some individuals may be more vulnerable to developing antisocial personality disorder as a result of their particular genetic background, that is thought to be a factor only when the person is also exposed to life events such as abuse or neglect that tend to put the person at risk for development of the disorder. Similarly, while there are some theories about the role of premenstrual syndrome (PMS) and other hormonal fluctuations in the development of antisocial personality disorder, the disorder can, so far, not be explained as the direct result of such problems.

Other conditions that are thought to be risk factors for antisocial personality disorder include substance abuse, attention-deficit hyperactivity disorder (ADHD), reading disorder, or conduct disorder, which is diagnosed in children. People who experience a temporary or permanent brain dysfunction, often also called organic brain damage, are at risk for developing violent or otherwise criminal behaviors. Theories about the life experiences that increase the risk for developing antisocial symptoms in teenagers and adults provide important clues for its prevention. Examples of such life experiences include a history of prenatal drug exposure or malnutrition, childhood physical, sexual, or emotional abuse; neglect; deprivation or abandonment; associating with peers who engage in antisocial behavior; or a parent who is either antisocial or alcoholic.

What are antisocial personality disorder symptoms and signs?

To understand antisocial personality disorder (ASPD or APD), it is necessary to learn what having any personality disorder involves. As defined by the Diagnostic and Statistical Manual for Mental Disorders (DSM-V, 2013), a personality disorder (PD) is a consistent, enduring pattern of inner experiences and behaviors that is significantly different from what is thought to be normal within the individual's own culture.

Mental-health professionals group personality disorders based on a commonality of symptoms.

Cluster A personality disorders are those that include symptoms of social isolation, and/or strange, eccentric behavior. These disorders include

Cluster B personality disorders are those that involve dramatic or erratic behaviors (counter-social behaviors). These personality disorders include

Cluster C personality disorders are characterized by difficulties with anxiety and inhibited behavior. These disorders include

  • avoidant personality disorder,
  • dependent personality disorder,
  • obsessive compulsive personality disorder (OCD).

Antisocial personality disorder is specifically a persistent pattern of disregarding and violating the rights of others. Diagnostic criteria for this disorder state that this pattern must include at least three of the following specific signs and symptoms:

  • Repeatedly breaking laws, as evidenced by repeatedly engaging in behaviors that are grounds for arrest
  • Repeated deceitfulness in relationships with others, such as telling lies, using false names, or conning others for profit or pleasure
  • Failure to think or plan ahead (impulsivity)
  • Tendency to irritability, hostility, anger, and aggressiveness, as shown by repeatedly assaulting others or getting into frequent physical fights
  • Disregard for their own safety or the safety of others, such that they have a lack of restraint in their behavior
  • Persistent lack of taking responsibility, such as failing to establish a pattern of good work habits or keeping financial obligations
  • A disregard for other people such that there is a lack of feeling guilty about wrong-doing

Other important characteristics of this disorder include that it is not diagnosed in children (individuals younger than 18 years of age), but the affected person must have shown symptoms of this diagnosis (conduct disorder) at least since 15 years of age. Additionally, it cannot be diagnosed if the person only shows symptoms of antisocial personality disorder at the same time they are suffering from symptoms of schizophrenia or when having a manic episode. This disorder tends to occur in about 1% of women and 3% of men in the United States. Antisocial personality symptoms in women tend to include self-harm and more of the other symptoms of borderline personality disorder (BPD) than in men.

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What tests do health-care professionals use to diagnose antisocial personality disorder?

There is no specific definitive test, such as a blood test, that can accurately assess whether a person has antisocial personality disorder. Mental-health practitioners like psychiatrists, psychoanalysts, or clinical psychologists conduct a mental-health interview that gathers information to look for the presence of the symptoms previously described. Due to the use of a mental-health interview in making the diagnosis and the fact that this disorder can be quite resistant to treatment, it is important that the mental-health practitioner know to assess the symptoms in the context of the person's culture so the individual is not assessed as having antisocial personality disorder when he or she does not. Unfortunately, research shows that many practitioners lack the knowledge, experience, and sometimes the willingness to factor cultural context into their assessments.

What are the treatments for antisocial personality disorder?

Another very common question asked is, can antisocial personality disorder be cured? While it can be quite resistant to change, research shows there are a number of effective treatments for this disorder. For example, teenagers who receive therapy that helps them change the thinking that leads to their maladaptive behavior (cognitive behavioral psychotherapy) have been found to experience a significant decrease the incidence of engaging in repeat antisocial behaviors.

On the other hand, attempting to treat antisocial personality disorder like other conditions is not often effective. For example, programs that have tried to use a purely reflective (insight-oriented talk therapy) approach to treating depression or eating disorders in people with antisocial personality disorder often worsen rather than improve outcomes in those individuals. In those cases, firm but fair behavior therapy to reward appropriate actions and programming that emphasizes teaching individuals with antisocial personality disorder the skills that can be used to live independently and productively within the rules and limits of society has been the more effective treatment for this condition. Family therapy that helps loved ones of people with antisocial personality disorder appropriately cope with the negative behaviors and promote the positive behaviors of the antisocial personality disorder sufferer can also be an important part of treatment for this condition.

While medications do not directly treat the behaviors that characterize antisocial personality disorder, they can be useful in addressing conditions that co-occur with this condition. Specifically, depressed or anxious individuals who also have antisocial personality disorder may benefit from antidepressants like fluoxetine (Prozac), escitalopram (Lexapro), or duloxetine (Cymbalta), and those who exhibit impulsive anger may improve when given mood stabilizers like lithium, divalproex (Depakote), or lamotrigine (Lamictal).

What are complications if antisocial personality disorder is not treated? What is the prognosis of antisocial personality disorder?

Some societal costs of antisocial personality disorder, like the suffering endured by victims of the crimes committed by people with this disorder, are clear. However, when people with ASPD are the charismatic leaders of religious cults, the devastation they can create is often not known unless and until a catastrophe occurs. The multiple murders orchestrated by Charles Manson and the mass suicide that occurred at the command of the Reverend Jim Jones in Guyana in 1978 are just two such examples.

Individuals who suffer from antisocial personality disorder have a higher risk of abusing alcohol and other drugs and repeatedly committing crimes. Imprisonment is a potential consequence. People with antisocial personality disorder are also vulnerable to mood problems, such as major depression, anxiety, and bipolar disorder; having other personality disorders, especially borderline (BPD) and narcissistic personality disorders; self-mutilation and other forms of self-harm, as well as dying from homicide, suicide, or accident.

Antisocial personality disorder tends to make the prognosis of virtually any other condition more problematic. Having antisocial personality disorder makes the treatment for problems of substance abuse or emotional or physical substance dependence more difficult. People who have both antisocial personality disorder and schizophrenia are less likely to comply with treatment programs and are more likely to remain institutionalized in a prison or a hospital. These risks become magnified if antisocial personality disorder is not treated. Statistics indicate that many people with antisocial personality disorder experience a remission of symptoms by the time they reach 50 years of age.

Where can people find more information on specialists who treat antisocial personality disorder?

To find information on specialists who treat ASPD, visit

National Alliance on Mental Illness
http://www.nami.org

National Institute of Mental Health
http://www.nimh.nih.gov

REFERENCES:

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, Virginia: American Psychiatric Association, 2013.

Armelius, B.A., and T.H. Andreassen. "Cognitive-Behavioral Treatment for Antisocial Behavior in Youth in Residential Treatment." Cochrane Database Systems Review 17.4 Oct. 2007: CD 005650.

Azrin, N.H., B. Donohue, G.A. Teichner, et al. "A controlled evaluation and description of individual-cognitive problem solving and family-behavior therapies in dually-diagnosed conduct disordered and substance-dependent youth." Journal of Child and Adolescent Substance Abuse 11 (2001): 1-43.

Barnow, S., I. Ulrich, H.J. Grabe, H.J. Freyberger, and C. Spitzer. "The Influence of Parental Drinking Behavior and Antisocial Personality Disorder on Adolescent Behavioural Problems: Results of the Greifswalder Family Study." Alcohol and Alcoholism Advance Access, Oxford University Press, 8/1/07.

Bienenfeld, D. "Personality Disorders." eMedicine.com. July 17, 2008. <http://emedicine.medscape.com/article/294307-overview>.

Blackburn, R., and J.M. Lee-Evans. "Reactions of Primary and Secondary Psychopaths to Anger-Evoking Situations." British Journal of Clinical Psychology 24.2 May 1985: 93-100.

Blair, RJR. "Neurobiological Basis of Psychopathy." The British Journal of Psychiatry 182 (2003): 5-7.

Caldwell, M., J. Skeem, R. Salekin, and G.V. Rubroek. "Treatment Response of Adolescent Offenders With Psychopathy Features." Criminal Justice and Behavior 33.5 (2006): 571-596.

Caspi, A., J. McClay, T.E. Moffitt, J. Mill, J. Martin, I.W. Craig, A. Taylor, and R. Poulton. "Role of Genotype in the Cycle of Violence in Maltreated Children." Science 297.5582 Aug. 2, 2002: 851-854.

Compton, W.M., L.B. Cottler, J.L. Jacobs, A. Ben-Abdallah, and E.L. Spitznagel. "The Role of Psychiatric Disorders in Predicting Drug Dependence Treatment Outcomes." American Journal of Psychiatry 160 May 2003: 890-895.

Deeley, Q., E. Daly, S. Surguladze, N. Tunstall, G. Mezey, D. Beer, A. Ambikapathy, et al. "Facial Emotion Processing in Criminal Psychopathy. Preliminary Functional Magnetic Resonance Imaging Study." British Journal of Psychiatry 189 Dec. 2006: 533-539.

Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Treatment Revision. Washington, D.C.: American Psychiatric Association, 2000.

Dolan, M., and G. Davies. "Psychopathy and Institutional Outcome in Patients With Schizophrenia in Forensic Settings n the U.K." Schizophrenia Research 81.2-3 (2003): 277-281.

Foulks, E.F. "Commentary: Racial Bias in Diagnosis and Medication of Mentally Ill Minorities in Prisons and Communities." Journal of the American Academy of Psychiatry and the Law 32 (2004): 34-35.

Grekin, E.R., P.A. Brennan, S. Hodgins, and S.A. Mednick. "Male Criminals With Organic Brain Syndrome: Two Distinct Types Based on Age at First Arrest." American Journal of Psychiatry 158 July 2001: 1099-1104.

Harris, G.T., and M.E. Rice. "What Treatment Should Psychopaths Receive?" Cross Currents Spring 2006.

Hirstein, W. "What Is a Psychopath?" Psychology Today January 2013.

Liu, J. "Early health risk factors for violence: conceptualization, review of the evidence and implications." Aggressive Violent Behavior 16.1 (2011): 63-73.

Luntz, B.K., and C.S. Widom. "Antisocial Personality Disorder in Abused and Neglected Children Grown Up." American Journal of Psychiatry 151. 5 May 1994: 670-674.

Martens, W.H.J. "Antisocial and Psychopathic Personality Disorders: Causes, Course and Remission- A Review Article." International Journal of Offender Therapy and Comparative Criminology 44.4 (2000): 406-430.

Ogloff, J.R.P. "Psychopathy/Antisocial Personality Disorder Conundrum." Wiley Interscience Nov. 2005.

Pearson, C. "A Psychopath Unplugged." Neurological Correlates Mar. 19, 2008.

Simonoff, E., J. Elander, J. Holmshaw, A. Pickles, et al. "Predictors of Antisocial Personality: Continuities From Childhood to Adult Life." The British Journal of Psychiatry 184 (2004): 118-127.

Sjoberg, R.L., F. Ducci, C.S. Barr, T.K. Newman, L. Dell'Osso, M. Virkkunen, and D. Goldman. "A Non-additive Interaction of a Functional MAO-A VNTR and Testosterone Predicts Antisocial Behavior." Neuropsychopharmacology 33 (2008): 425-430.

Verona, E., J. Sprague, and S. Javdani. "Gender and factor-level interactions in psychopathy: Implications for self-directed violence risk and borderline personality disorder symptoms." Personality Disorders: Theory, Research, and Treatment 3.3 July 2012: 247-262.

Virkkunen, M. "Self-mutilation in Antisocial Personality (Disorder). Acta Psychiatrica Scandinavica 54.5 Aug. 23, 2007: 347-352.

Westen, D., and J. Harnden-Fischer. "Personality Profiles in Eating Disorders: Rethinking the Distinction Between Axis I and Axis II." American Journal of Psychiatry 158 Apr. 2001: 547-562.

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References
REFERENCES:

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, Virginia: American Psychiatric Association, 2013.

Armelius, B.A., and T.H. Andreassen. "Cognitive-Behavioral Treatment for Antisocial Behavior in Youth in Residential Treatment." Cochrane Database Systems Review 17.4 Oct. 2007: CD 005650.

Azrin, N.H., B. Donohue, G.A. Teichner, et al. "A controlled evaluation and description of individual-cognitive problem solving and family-behavior therapies in dually-diagnosed conduct disordered and substance-dependent youth." Journal of Child and Adolescent Substance Abuse 11 (2001): 1-43.

Barnow, S., I. Ulrich, H.J. Grabe, H.J. Freyberger, and C. Spitzer. "The Influence of Parental Drinking Behavior and Antisocial Personality Disorder on Adolescent Behavioural Problems: Results of the Greifswalder Family Study." Alcohol and Alcoholism Advance Access, Oxford University Press, 8/1/07.

Bienenfeld, D. "Personality Disorders." eMedicine.com. July 17, 2008. <http://emedicine.medscape.com/article/294307-overview>.

Blackburn, R., and J.M. Lee-Evans. "Reactions of Primary and Secondary Psychopaths to Anger-Evoking Situations." British Journal of Clinical Psychology 24.2 May 1985: 93-100.

Blair, RJR. "Neurobiological Basis of Psychopathy." The British Journal of Psychiatry 182 (2003): 5-7.

Caldwell, M., J. Skeem, R. Salekin, and G.V. Rubroek. "Treatment Response of Adolescent Offenders With Psychopathy Features." Criminal Justice and Behavior 33.5 (2006): 571-596.

Caspi, A., J. McClay, T.E. Moffitt, J. Mill, J. Martin, I.W. Craig, A. Taylor, and R. Poulton. "Role of Genotype in the Cycle of Violence in Maltreated Children." Science 297.5582 Aug. 2, 2002: 851-854.

Compton, W.M., L.B. Cottler, J.L. Jacobs, A. Ben-Abdallah, and E.L. Spitznagel. "The Role of Psychiatric Disorders in Predicting Drug Dependence Treatment Outcomes." American Journal of Psychiatry 160 May 2003: 890-895.

Deeley, Q., E. Daly, S. Surguladze, N. Tunstall, G. Mezey, D. Beer, A. Ambikapathy, et al. "Facial Emotion Processing in Criminal Psychopathy. Preliminary Functional Magnetic Resonance Imaging Study." British Journal of Psychiatry 189 Dec. 2006: 533-539.

Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Treatment Revision. Washington, D.C.: American Psychiatric Association, 2000.

Dolan, M., and G. Davies. "Psychopathy and Institutional Outcome in Patients With Schizophrenia in Forensic Settings n the U.K." Schizophrenia Research 81.2-3 (2003): 277-281.

Foulks, E.F. "Commentary: Racial Bias in Diagnosis and Medication of Mentally Ill Minorities in Prisons and Communities." Journal of the American Academy of Psychiatry and the Law 32 (2004): 34-35.

Grekin, E.R., P.A. Brennan, S. Hodgins, and S.A. Mednick. "Male Criminals With Organic Brain Syndrome: Two Distinct Types Based on Age at First Arrest." American Journal of Psychiatry 158 July 2001: 1099-1104.

Harris, G.T., and M.E. Rice. "What Treatment Should Psychopaths Receive?" Cross Currents Spring 2006.

Hirstein, W. "What Is a Psychopath?" Psychology Today January 2013.

Liu, J. "Early health risk factors for violence: conceptualization, review of the evidence and implications." Aggressive Violent Behavior 16.1 (2011): 63-73.

Luntz, B.K., and C.S. Widom. "Antisocial Personality Disorder in Abused and Neglected Children Grown Up." American Journal of Psychiatry 151. 5 May 1994: 670-674.

Martens, W.H.J. "Antisocial and Psychopathic Personality Disorders: Causes, Course and Remission- A Review Article." International Journal of Offender Therapy and Comparative Criminology 44.4 (2000): 406-430.

Ogloff, J.R.P. "Psychopathy/Antisocial Personality Disorder Conundrum." Wiley Interscience Nov. 2005.

Pearson, C. "A Psychopath Unplugged." Neurological Correlates Mar. 19, 2008.

Simonoff, E., J. Elander, J. Holmshaw, A. Pickles, et al. "Predictors of Antisocial Personality: Continuities From Childhood to Adult Life." The British Journal of Psychiatry 184 (2004): 118-127.

Sjoberg, R.L., F. Ducci, C.S. Barr, T.K. Newman, L. Dell'Osso, M. Virkkunen, and D. Goldman. "A Non-additive Interaction of a Functional MAO-A VNTR and Testosterone Predicts Antisocial Behavior." Neuropsychopharmacology 33 (2008): 425-430.

Verona, E., J. Sprague, and S. Javdani. "Gender and factor-level interactions in psychopathy: Implications for self-directed violence risk and borderline personality disorder symptoms." Personality Disorders: Theory, Research, and Treatment 3.3 July 2012: 247-262.

Virkkunen, M. "Self-mutilation in Antisocial Personality (Disorder). Acta Psychiatrica Scandinavica 54.5 Aug. 23, 2007: 347-352.

Westen, D., and J. Harnden-Fischer. "Personality Profiles in Eating Disorders: Rethinking the Distinction Between Axis I and Axis II." American Journal of Psychiatry 158 Apr. 2001: 547-562.

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