Continuing Education Activity

Antisocial personality disorder is characterized by a pervasive and enduring pattern of disregarding and violating the rights of others, typically emerging in childhood or early adolescence and persisting throughout an individual's life. This disorder significantly impacts interpersonal and occupational functioning, often leading to profound impairments in overall quality of life. Individuals with antisocial personality disorder frequently engage in criminal behavior and struggle to learn from the negative consequences of their actions. Coexisting psychiatric conditions and substance use disorders are common among those affected, adding to the complexity of the disorder.

This activity on antisocial personality disorder focuses on the underlying etiology, assessment, and treatment of the disorder. The multidisciplinary team managing this personality disorder must collaborate to provide comprehensive care. By equipping healthcare professionals with the knowledge and tools needed to address this complex condition, the activity aims to enhance overall patient outcomes. Through a thorough understanding of antisocial personality disorder and its management, healthcare providers can better support individuals affected by this challenging disorder and contribute to improved patient well-being.

Objectives:

• Identify the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition Text Revision diagnostic criteria for antisocial personality disorder.

• Differentiate antisocial personality disorder from other personality disorders.

• Apply evidence-based therapeutic interventions for managing antisocial personality disorder, with a focus on improving patients' quality of life and interpersonal relationships and reducing the risk of legal complications.

• Communicate with patients, families, and interdisciplinary team members about the diagnosis, prognosis, and management of antisocial personality disorder.

Introduction

Antisocial Personality Disorder (ASPD) is an adult diagnosis characterized by a persistent pattern of disregard for and violation of others' rights, beginning in childhood or early adolescence. Individuals with ASPD often manipulate others for personal gain, lack empathy, and seldom feel remorse for their actions. They struggle to develop stable interpersonal relationships and experience significant impairments in social and occupational functioning throughout their lifetime. Legal issues frequently arise from their repeated failure to learn from the repercussions of their behavior, often involving criminal acts.[1]

Antisocial behaviors exist on a spectrum. Conduct disorder, a condition specific to childhood, manifests as children and adolescents with a repetitive and persistent pattern of behavior violating the fundamental rights of others or significant societal norms or rules. Children with conduct disorder exhibit aggression toward people or animals, destruction of property, deceitfulness, theft, or other serious rule violations.[2] Variation exists in the trajectory of youth diagnosed with conduct disorder, with males more likely to progress to ASPD in adulthood than females.[3][4] 

Most children with conduct disorder will not develop ASPD, but conduct disorder is a risk factor for developing ASPD.[5] Psychopathy is also a distinct clinical construct.[6] Psychopathy is sometimes viewed as a subtype within the broader category of ASPD as a very severe form of ASPD with a heightened risk of violence.[6] Robert Hare's Psychopathy Checklist-Revised (PCL-R) serves as an assessment tool designed to measure psychopathic traits, contributing to a more nuanced understanding of the unique characteristics of psychopathy and its connection to ASPD.[7]

The roots of our understanding of antisocial personality disorder trace back to the 19th century when Philippe Pinel (1745-1826), a French physician, and Jean Etienne Dominique Esquirol (1772-1840), a French psychiatrist, made significant observations of individuals exhibiting behaviors consistent with ASPD.[8] Chronic antisocial behaviors and a lack of empathy or remorse are notable features in their descriptions.[9] 

In the early 20th century, an American psychiatrist, Hervey Cleckley (1903-1984), and later Canadian psychologist, Robert Hare (1934 -), delved into the concept of psychopathy.[7] Cleckley's seminal work, The Mask of Sanity (1941), laid the foundation for comprehending psychopathy as a distinct psychological construct.[10] The terms "psychopath" and "sociopath" were often used interchangeably to describe individuals displaying traits associated with ASPD.[11]

The Diagnostic and Statistical Manual of Mental Disorders (DSM) initially introduced ASPD in the third edition (1980). Initial emphasis focused on persistent patterns of antisocial behaviors beginning in adolescence or early adulthood. The Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) revised the diagnostic criteria, highlighting the importance of behaviors that reflect a disregard for the rights of others, which persists through to the current version of the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition Text Revision (DSM-5-TR).[12]

The DSM-5-TR divides personality disorders into clusters A, B, and C. Each cluster encompasses a distinct set of personality disorders with commonalities regarding symptoms, behaviors, and underlying psychological patterns.[13]

• Cluster A 
  • Personality disorders with odd or eccentric characteristics
  • Paranoid personality disorder, schizoid personality disorder, and schizotypal personality disorder
  • Often exhibit social withdrawal, peculiar or paranoid beliefs, and difficulties forming close relationships
• Cluster B 
  • Comprises personality disorders with dramatic, emotional, or erratic behaviors
  • Antisocial personality disorder, borderline personality disorder (BPD), histrionic personality disorder, and narcissistic personality disorder (NPD)
  • Often display impulsive actions, emotional instability, and challenges in maintaining stable relationships

• Cluster C 
  • Personality disorders with anxious and fearful characteristics
  • Avoidant personality disorder, dependent personality disorder, and obsessive-compulsive personality disorder
  • Often experience significant anxiety, fear of abandonment, and an excessive need for control or perfectionism

Although the historical context involves employing the cluster system, the literature does not consistently validate this approach when addressing personality disorders, revealing limitations.[14]

Etiology

The development of ASPD is multifactorial. Research on the etiology of ASPD is limited, and high-quality studies specifically investigating its causes are scarce. Several factors likely contribute to the development of ASPD, including genetic predisposition, childhood experiences, and environmental influences. However, the clinical significance of these factors is unclear.[15]

Personality Development

Personality is a complex summation of biological, psychological, social, and developmental factors; therefore, each personality is unique, even amongst those affected by a personality disorder. Personality is a pattern of behaviors that an individual develops uniquely in response to constantly changing internal and external stimuli. A person's temperament broadly refers to consistent biologically based individual differences in behavior and is relatively independent of learning.[16][17] 

However, temperament develops further through epigenetic mechanisms, namely through life experiences such as trauma and socioeconomic conditions. These are adaptive etiological factors in personality development.[18][19] 

• Temperament domains
  • Harm avoidance: Involves a bias towards inhibiting behavior that would result in punishment or non-reward.[20] Individuals with ASPD have low harm avoidance.
  • Novelty seeking: An inherent desire to initiate novel activities likely to produce a reward signal.[21] Individuals with ASPD have a high amount of novelty-seeking behaviors. 
  • Reward dependence: Describes the amount of desire to cater to behaviors in response to social reward cues.[22] Individuals with ASPD have low reward dependence. 
  • Persistence: Refers to the ability to maintain efforts and continue with behaviors despite obstacles, frustration, fatigue, or limited reinforcement.[22] Individuals with ASPD have low persistence and are more prone to abandon their pursuits when encountering challenges.

Genetics

Genetic studies propose a hereditary component of personality disorders, including ASPD. Twin studies find a monozygotic concordance rate of 67% compared to a 31% concordance rate in dizygotic twins.[23] Family studies estimate that 20% of individuals with ASPD have a first-degree relative with ASPD.[24] A twin study involving 1048 subjects investigating substance use disorder, ASPD, and disinhibition found a shared common heritability factor of 0.81.[25] Another twin study involving 2794 subjects reveals a 51% common-factor heritability for ASPD behaviors.[26] 

A large sample of male children who experienced childhood abuse reveals a functional polymorphism in the gene encoding monoamine oxidase A (MAO-A) that moderately predicts the development of ASPD, with low levels of MAO-A expression more likely to lead to the development of ASPD.[27] Children experiencing the same levels of abuse with the high-activity variant of the gene are not more likely to develop ASPD.

Serotonin may inhibit impulsive and violent behaviors and may mediate some antisocial behavior. A genetic variant in tryptophan hydroxylase is thought to influence 5-hydroxyindoleacetic acid (5-HIAA) concentrations, contributing to low 5-HIAA concentrations in the cerebrospinal fluid.[28] Low cerebrospinal fluid levels of the major metabolite of serotonin, 5-HIAA, are associated with violent, suicidal, and impulsive behaviors.[29][30] 

Neurodevelopment

Medical conditions, specifically those damaging neurons, are often associated with personality disorders or changes. Examples include head trauma, cerebrovascular diseases, cerebral tumors, epilepsy, Huntington disease, multiple sclerosis, endocrine disorders, heavy metal poisoning, neurosyphilis, and AIDS.[31] 

Subclinical injury to the brain in utero due to maternal tobacco smoke exposure or drug use and maternal starvation has been proposed as a predisposing factor for antisocial behavior.[32] Chemicals generated from tobacco and lower oxygen levels may contribute to neuronal injury in the developing fetus.[33][32] 

Family and Psychosocial Factors

Various psychoanalytic factors contribute to the development of personality traits and disorders. These include unconscious processes, early childhood experiences, and the influence of internal conflicts.[34]

Psychoanalyst Wilhelm Reich (1897-1957), an Austrian physician, contributed significantly to understanding defense mechanisms and their relationship to personality types. He introduced the concept of "character armor," which refers to defense mechanisms that develop within individuals to alleviate cognitive conflict arising from internal impulses and interpersonal anxiety.[35] For instance, those with antisocial tendencies tend to develop the defense mechanisms of displacement, denial, projection, rationalization, and regression.[36]

Parenting styles are likely to contribute to the development of ASPD. Adult antisocial personality traits are associated with experiences of parental neglect and abuse.[37] Children who experience abuse or neglect may be more predisposed to the development of ASPD.[38]

One study estimates that 14% to 21% of adults who report abusing their children are affected by ASPD.[39] Child and adolescent peer relations also impact personality development. Youth with traits of conduct disorder are more likely to engage with peers with similar qualities, with peer conflict identified as a key mechanism for future antisocial behavior.[40][41] 

The role of exposure to violent media through television, music, and video games is a common concern. Current data is conflicting but suggests patients who are prone to developing ASPD will likely develop ASPD despite exposure to violence in media.[42][43][44]

Epidemiology

The estimated prevalence of ASPD in the general population is 2% to 3%. These estimates lack data on individuals who are incarcerated or institutionalized. Studies of incarcerated individuals in the late 1990s reveal rates of ASPD in male inmates of 80% and up to 60% among female inmates.[45] The prevalence of ASPD in prisons may be declining in the US due to increasingly harsh sentencing laws. A recent study reveals an incidence of ASPD of 35% in incarcerated males.[46] 

The National Epidemiologic Survey on Alcohol and Related Conditions found the risk of ASPD was 3 times greater in males than females.[47] Some estimates place the risk at 5 times greater.[48] 

The prevalence of ASPD in patients with alcohol use disorder ranges between 16% and 49%.[45] Homelessness is also associated with the presence of ASPD. Possibly as a consequence of the inability to pay rent, maintain a job, and substance use disorders. ASPD results in a lower socioeconomic status. Higher education has a negative correlation with ASPD, with a higher prevalence of ASPD amongst those with lower IQs and reading levels.[48][49][50]

Additional psychiatric disorders like substance use disorder, mood and anxiety disorders, attention deficit hyperactivity disorder (ADHD), learning disorders, gambling disorders, and other personality disorders like BPD are commonly associated with ASPD. 

Pathophysiology

Underarousal of the autonomic nervous system is the suggested underlying pathophysiology for some individuals with ASPD. This hypothesis proposes that individuals with ASPD require higher sensory input to produce normal brain functioning than normal subjects, causing affected individuals to seek higher sensory input to raise their arousal levels to more tolerable amounts. The result may be a higher risk tolerance for situations with higher arousal.[51][52] Findings to support this suggestion are lower pulse rates, lower skin conductance, and increased amplitude on event-related potentials in patients with ASPD.[30][53] 

Furthermore, nearly 50% of individuals with ASPD exhibit various electroencephalogram (EEG) abnormalities, including more slow-wave activity.[52][54] Individuals with ASPD have a higher occurrence of minor facial abnormalities and, in childhood, have a higher occurrence of learning disorders, attention deficit and hyperactivity disorder, and persistent enuresis.[52][54]

Researchers have uncovered additional findings on central nervous system (CNS) imaging, unveiling abnormal CNS functioning associated with ASPD. The prefrontal cortex, the superior temporal cortex, the amygdala-hippocampal complex, and the anterior cingulate cortex are likely involved.[55] Examples of these findings include:

• Individuals with a violent military history exhibit low glucose metabolism in the right temporal lobe on positron emission tomography (PET).[56]

• A study comparing 21 individuals with ASPD to 34 control subjects showed reduced prefrontal gray matter compared to control subjects on structural magnetic resonance imaging (MRI).[57]

• In a study comparing 18 men with ASPD and psychopathy to healthy controls, a smaller orbitofrontal cortex volume was observed using structural MRI.[47]

History and Physical

The presentation of ASPD is variable. Therefore, obtaining a thorough history of the condition, medical history, and social history is essential. A history of childhood behavior is necessary as there must be evidence of conduct disorder to diagnose ASPD. Approximately 80% of patients with ASPD exhibit antisocial traits by age 11, although some occur as early as preschool years.[58] 

Common childhood behaviors include fighting, conflict with parents and authority, stealing, vandalism, fire setting, cruelty to animals, school behavioral problems, poor academics, and running away.[58] Asking an adult with suspected ASPD about exposure to the juvenile detention system or other early-life criminal activity can help determine if there was evidence of conduct disorder in the past. Collateral information from family and friends is also helpful as they may be more accurate historians than individuals with ASPD.[59] 

As individuals with ASPD age, similar behavior patterns manifest in new age-appropriate ways. Typical findings are poor job performance and ethics, a lack of responsibility, frequent job changes, or being fired. Additionally, affected patients use aliases and other deceitful behaviors in attempts to manipulate people. Sexual promiscuity and unstable relationships coupled with physical or emotional abuse of their partner lead to high separation and divorce rates.[60] 

Antisocial actions can vary greatly, from minor acts of lying to stealing to more extreme acts of sexual assault and murder. Obtaining a timeline of incarceration history can help establish a pattern of behavior over an individual's lifetime. ASPD should be considered in the differential diagnoses when a patient presents with drug-seeking behavior, signs of malingering, injuries from reckless behavior, recurrent sexually transmitted diseases, or evidence of abuse.[61][62][63]

The mental status examination, conducted during psychiatric evaluations, is crucial in assessing individuals with ASPD. Given their propensity to manipulate, lie, or use aliases for drug-seeking behaviors, incorporating the mental status examination in the diagnostic evaluation is essential.[61] The specific elements and findings of the examination are unique to each individual. Assessment of patients should include:

• Appearance: Note the patient's general grooming and appearance. Individuals with ASPD may have minor facial anomalies or tattoos associated with gang affiliation.[54][64] Although tattoos alone are not indicative of pathology, individuals with ASPD tend to have more tattoos and total body surface area covered in tattoos.[65]

• Behavior: Behavior is likely to vary depending on the context and current goals of an individual with ASPD. Behaviors can be manipulative, disinhibited, aggressive, or deceitful.  

• Speech: Individuals with ASPD do not generally have problems with speech initiation or vocabulary.

• Affect: Affect varies in patients with ASPD, mainly depending on the setting of the clinical evaluation. Frustration tolerance is generally low, allowing a higher propensity for anger.

• Thought content: Assessing suicide and homicide risk is essential. Delusions are not consistent with ASPD, but individuals with ASPD who have a substance use disorder may experience psychotic symptoms, including delusions, due to their substance use. 

• Perceptions: ASPD does not present with hallucinations, but individuals with ASPD who have a substance use disorder may experience psychotic symptoms as a result of their substance use.

• Thought process: Individuals with ASPD generally have a linear thought process but are limited in range and logic. Affected individuals consistently fail to plan or to learn from previous mistakes. 

• Cognition: General cognition and orientation are typically unimpaired. 

• Insight: Individuals with ASPD typically have poor understanding or remorse for how their actions impact their social and occupational functioning.

• Judgment and impulse control: Individuals with ASPD generally exhibit poor judgment and impulse control. 

Evaluation

The diagnosis of a personality disorder involves a longitudinal observation of a patient's behaviors across various circumstances to give a broader understanding of long-term functioning.[66] Because many personality disorder features can overlap with symptoms observed during acute psychiatric conditions, when possible, a personality disorder should not be diagnosed in the presence of an acute psychiatric illness. However, longitudinal observation may not always be feasible or required, mainly when an underlying personality disorder significantly contributes to hospitalizations or relapse of another psychiatric condition like a major depressive episode.[67] Several visits with a patient are likely necessary to establish a firm diagnosis of ASPD. 

Psychological testing can help diagnose personality disorders but is typically unnecessary for a diagnosis of ASPD when sufficient history is available. However, it may be more useful when collateral information or childhood and adolescent behavior history is unavailable or when the patient refuses to allow for an interview.[68] 

The Minnesota Multiphasic Personality Inventory (MMPI) assesses personality functioning, including ASPD, with higher scoring patterns for psychopathic deviance.[69] For severe ASPD, the Psychopathy Personality Inventory (PPI) is a potentially helpful tool.[70]

Individuals must meet the diagnostic criteria specified in the DSM-5-TR to obtain a formal diagnosis of ASPD. The diagnosis involves a thorough evaluation that considers multiple sources of information, including personal history, collateral information, and a mental status examination. This comprehensive assessment allows clinicians to assess the individual's symptoms, functioning, and overall presentation concerning the established diagnostic criteria.

Antisocial Personality Disorder DSM-5-TR Criteria 

1. The presence of a pervasive pattern of disregard for and violation of the rights of others. This behavior begins by age 15 and is present in various contexts. Clinical features include ≥3 of the following:
1. Failure to conform to social norms concerning lawful behaviors, such as performing acts that are grounds for arrest.
2. Deceitfulness, repeated lying, use of aliases, or conning others for pleasure or personal profit.
3. Impulsivity or failure to plan.
4. Irritability and aggressiveness, often with physical fights or assaults.
5. Reckless disregard for the safety of self or others.
6. Consistent irresponsibility, failure to sustain consistent work behavior, or honor monetary obligations.
7. Lack of remorse, indifference to or rationalizing having hurt, mistreated, or stolen from another person.
2. The individual is at least age 18.
3. There is evidence of conduct disorder with onset before age 15.
4. The occurrence of antisocial behavior is not exclusively during the course of schizophrenia or bipolar disorder. 

Adults who do not have evidence of conduct disorder in childhood and adolescence but otherwise meet the diagnostic criteria for ASPD can be diagnosed with adult antisocial behavior. While adult antisocial behavior is not a formal DSM-5-TR diagnosis, the DSM-5-TR lists it as a V code, used in the DSM and International Classification of Diseases, Ninth Revision (ICD-9), or Z code used in the ICD-10. These codes are used to identify factors influencing a patient's mental health status or contact with mental health services. 

Treatment / Management

No standard treatment algorithm exists despite numerous interventions tested in the past. Early treatment intervention for children with conduct disorder is considered the least costly and most effective way of treating and preventing ASPD.[71]

Often, patients request treatment at the behest of a first-degree relative or friend. Generally, this occurs after maladaptive behaviors have created stress on another rather than internal distress from the individual with ASPD. Therefore, assessing the treatment goals in each specific case is essential. As ASPD is unlikely to remit with or without treatment, the focus of treatment may be reducing interpersonal conflict and stabilizing psychosocial functioning.[72][73] Case management can assist patients with ASPD in maintaining income, shelter, and connection to medical and mental health services and providing assistance with other basic needs.

Frequently, patients with ASPD present due to their comorbid psychiatric conditions. In the absence of a comorbid psychiatric illness, limited evidence exists that pharmacotherapy helps treat ASPD. Treatment should begin with standard therapy for the comorbid diagnosis.

If the patient is also experiencing violent behavior that leads to legal difficulties or impaired psychosocial functioning, a trial of a second-generation antipsychotic medication for 8 to 12 weeks is an acceptable choice. If not helpful, a trial of another second-generation antipsychotic may help. If still not beneficial, then a trial of an SSRI is a viable next option.

Following this, carbamazepine or lithium may be considered. Patients who have sustained a prior head trauma may benefit from propranolol, buspirone, or trazodone. However, these medications show inconsistent and limited success and no FDA-approved medications exist for the treatment of ASPD.[74][75][76][77][78][79] Benzodiazepines and stimulants should be avoided due to the risk of potential abuse, addiction, and behavioral disinhibition.[80]

Psychotherapy also has limited evidence of efficacy. Transfered-focused therapy may have more success than other types of therapies.[81][82] Cognitive behavioral therapy (CBT) strategies reveal varying outcomes. A common CBT strategy is to focus on the patient's beliefs about themselves and how their behaviors impair social functioning to motivate change. Family therapy engages family members to help them gain a better understanding of how the disorder has impacted their relationships and guides their interactions with their relatives with ASPD.

Hospitalization is not cost-effective as it provides little to no benefit to those with ASPD and is very costly. Additionally, behavior displayed by patients with ASPD in a psychiatric hospital can disrupt the environment, adversely affecting the treatment of other patients. Reserve hospitalization for treating concurrent psychiatric conditions or possible complications, such as substance intoxication or withdrawal or recent suicidal behavior.[83]

Patients with cluster B personality disorders may display transference or a projection of their prior conflicts onto the clinician. Clinicians may develop counter-transference, where the clinician projects unresolved conflicts onto the patient. [84] Clinicians must recognize signs of counter-transference when they occur to remove any treatment bias that may impact the clinical care of a patient with ASPD.[85] 

Sublimation is a psychological defense mechanism that helps individuals transform unwanted or unhelpful impulses into less harmful or helpful ones. When clinicians begin to feel frustrated with patients who may be suffering from a personality disorder, a useful tactic is to sublimate negative feelings of counter-transference and use those feelings as an evaluation tool to guide the differential diagnosis toward a personality disorder, which may ultimately direct the treatment plan.[86]

Differential Diagnosis

The following list includes the differential diagnoses of ASPD:

• BPD
• Substance use disorders
• Psychotic or mood disorders
• Intermittent explosive disorder
• Temporal lobe epilepsy 
• Brain tumor
• Cerebrovascular accident
• Isolated acts of misbehavior
• NPD
• Substance abuse causing antisocial behavior

Many behaviors observed in ASPD may overlap with symptoms of other psychiatric illnesses, so assessing if ASPD occurs in isolation or conjunction with another psychiatric condition is crucial. Irritability and aggression can occur in the psychotic spectrum and bipolar spectrum illnesses. However, no decreased need for sleep exists in isolated ASPD. Additionally, manic and hypomanic episodes are acute episodes that are relatively short-lived, and both mania and psychosis tend to respond to medication treatment, while ASPD is chronic and rigid and does not respond well to medication treatments.[87]

A thorough history is generally sufficient to distinguish ASPD from isolated acts of misbehavior, which are inconsistent with antisocial traits. Intermittent explosive disorder involves isolated episodes of assaultive and destructive behavior. However, the condition is not associated with a history of conduct disorder or other impairments of social and occupational functioning. Intermittent explosive disorder cannot be diagnosed as a comorbid condition with ASPD.[88]

ASPD can be differentiated from BPD, as BPD is associated with much greater inward conflict, such as fear of abandonment, identity issues, and frequent mood swings.[89] ASPD can be differentiated from NPD, as individuals with NPD are generally not aggressive and are more compassionate. However, the shared commonality is deceitful and exploitation behaviors.[90] Chronic alcohol and drug use can contribute to antisocial behaviors, both during acute intoxication as well as pathological adaptions to maintain a substance addiction. ASPD persists through intoxicated and sobriety states. 

Pertinent Studies and Ongoing Trials

High-quality population studies are lacking in the field of personality disorders. Significant limitations exist in the current models used to describe all personality disorders. The DSM implements the cluster system, making it the most commonly utilized framework. The individual uniqueness of each person remains a barrier to the diagnosis and research into each personality disorder.[14] 

Experts in personality disorders suggest switching to a dimensional model of personality rather than a cluster model. The proposed dimensional models generally describe temperament, utilization of defense mechanisms, and identifying pathological personality traits.[91] Although the DSM-5 does not incorporate these recommendations due to the sudden radical change it would imply for clinical use. The paradigm will likely shift in the coming decades as further research solidifies in congruence with evolving clinical guidelines.

This change is particularly evident as the DSM-5-TR presents this research into publication under the "Emerging Measures and Models" section. Notably, in this section of the DSM-5-TR, some of the "cluster" model personality disorders have been removed, but ASPD remains a named personality disorder.

Prognosis

ASPD is typically a lifelong condition refractory to treatment interventions. Nearly 25% of girls and 40% of boys diagnosed with conduct disorder eventually develop ASPD. As patients age, 27% to 31% of patients improve with the most violent and dangerous features remitting. The rates and severity of crimes also reflect this, with peak crime rates and the highest severity of crimes at younger ages. Studies in the past reveal remission rates of 12% to 27%, but many remain symptomatic, and some never improve.

In patients who achieve remission, the mean age is 35. Those with less baseline symptomatology show better remission rates. Those with later presentations of antisocial behavior manifest fewer severe behavioral problems. Individuals who were either never imprisoned or imprisoned for more extended periods displayed greater remission rates than those detained for shorter periods.[92] Factors that predict improved outcomes are older age at presentation, improved community ties, job stability, and marital attachment.[93][94]

Complications

Individuals affected by a personality disorder face a heightened risk of suicide and suicide attempts compared to those without such disorders. Regular screening for suicidal ideation is necessary for individuals with ASPD.[95] ASPD serves as a predictor for overall mortality, likely attributed to factors such as neglect of medical conditions, noncompliance with treatment, or inadequate health insurance. Those with ASPD also exhibit an increased incidence of death resulting from accidental incidents, suicides, or homicides.[95]

Patients with personality disorders commonly exhibit substance use disorders, though the specific personality disorders posing the most significant risk for particular substance use disorders remain unclear.[95] Due to the elevated risk associated with high-risk sexual and substance use behaviors in individuals with ASPD, regular medical evaluations are essential. These evaluations help identify and address potential medical conditions, including sexually transmitted infections, infectious diseases such as hepatitis C from intravenous drug use, and other accidents or physical traumas resulting from reckless behaviors.[95]

Deterrence and Patient Education

A persistent pattern of socially irresponsible, exploitative, and guiltless behavior characterizes ASPD. Symptoms typically emerge in childhood or early adolescence and are fully evident by the late 20s or early 30s. The disorder tends to be lifelong and disrupts various aspects of functioning, including family relations, school, and work.

Key behaviors associated with ASPD include engaging in criminal activities, violating laws, struggling to maintain consistent employment, manipulating others for personal gain, and having difficulty establishing stable interpersonal relationships. Individuals with ASPD often lack empathy for others, rarely experience remorse, and exhibit a consistent failure to learn from negative experiences. The cause of ASPD is multifactorial, with genetic, socioeconomic, and neurodevelopmental factors playing a role.

Patients affected by ASPD often present due to a coexisting psychiatric illness. Treatment begins by treating that illness. Various medications show inconsistent results for treating ASPD. Most importantly, individuals with ASPD require a safe and supportive therapeutic environment. Patients are encouraged to express the symptoms they wish to have addressed and communicate any psychosocial stressors that a treatment team can help alleviate. Rather than primarily focusing on changing the patient's worldview, clinicians should aim to understand and address the specific concerns and challenges that the patient is facing. This approach is particularly relevant when the patient is not in acute distress or crisis when alone.[96] 

Involving the patient's family is another way of monitoring for decompensation and providing education on how to provide stable social factors for the patient.[96] Utilizing standardized assessments for quality of life may reveal ways to optimize the ability to function in significant areas of life for an individual with ASPD.[97]

The symptoms of ASPD often decrease with age. Social factors providing a more promising outlook are older age at presentation, improved community ties, job stability, and marital attachment. Some patients will achieve remission, others will improve, while others will remain symptomatic with no improvement. Patients with ASPD are at increased risk of death due to suicide, homicide, and accidents, as well as all-cause mortality, and warrant close surveillance by their healthcare team. 

Pearls and Other Issues

Key points to keep in mind about ASPD include the following:

• ASPD is a personality disorder characterized by a pervasive pattern of disregard for and violation of the rights of others, beginning in childhood or adolescence.

• Diagnosis is based on specific criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

• Many individuals with ASPD have a history of conduct disorder during childhood or adolescence, characterized by behaviors such as aggression, destruction of property, and deceitfulness.

• Individuals with ASPD often engage in behaviors such as manipulation, exploitation, and criminal activity. They may disregard social norms and laws, leading to frequent legal issues.

• ASPD commonly coexists with other mental health conditions, such as substance use disorders, mood disorders, and other personality disorders.

• ASPD is often chronic and resistant to treatment. However, some individuals may show improvement with age, particularly regarding reduced impulsivity and aggressiveness.

• Risk factors for ASPD include a history of childhood abuse or neglect, genetic predisposition, and environmental factors such as growing up in a dysfunctional family environment.

• Management of ASPD involves psychotherapy, particularly cognitive-behavioral approaches aimed at addressing maladaptive behaviors and thought patterns. Medications may target specific symptoms or comorbid conditions, but there is no specific pharmacological treatment for ASPD.

• Drug-seeking behaviors are common among individuals with ASPD, particularly in an institutionalized setting.[98] These behaviors may include malingering and other deceitful actions to obtain medications with the potential for abuse.[99] In addition to illicit substances, psychiatric medications are commonly sought for abuse in the correctional setting, generally by using the medications through alternate administration routes. Reports of nasal insufflation of buspirone inducing psychosis and a euphoric sensation exist.[100][101] Similarly, abuse of bupropion and quetiapine prescriptions are reported.[100][102][103][104][105]

Enhancing Healthcare Team Outcomes

The care of patients with ASPD requires a multidisciplinary approach. In general, patients with ASPD are resistant to treatment and have a high risk for all-cause mortality as well as accidental death, suicide, and homicide. Primary care, psychiatry, and emergency medicine clinicians and all individuals caring for these patients require the clinical skills and knowledge to diagnose and manage patients with ASPD. These skills include expertise in establishing the diagnosis based on diagnostic criteria and implementing a treatment regimen that addresses ASPD and any additional comorbid psychiatric diagnoses. Patient and family education helps loved ones understand the impact of ASPD on their relationship and provide guidance for future interactions. 

A strategic approach to treatment is essential to address the multifaceted effects ASPD has on physical and emotional health. Each healthcare professional must contribute their unique expertise and provide seamless communication, allowing collaborative decision-making among team members. A comprehensive, multidisciplinary approach, including psychologists and social workers, will provide a highly structured treatment strategy for patients with ASPD, providing proper support and screening for self-harm, routine health maintenance, substance use disorders, and concurrent psychiatric illnesses. This collaborative approach will improve overall patient outcomes and decrease morbidity and mortality.