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Chapter: Essentials of Psychiatry: Personality Disorders

Antisocial Personality Disorder

Antisocial PD (ASPD) is a pervasive pattern of disregard for and violation of the rights of others (American Psychiatric Association, 2000). Persons with ASPD will also be irresponsible and exploitative in their sexual relationships, and irresponsible as employees and parents.

Antisocial Personality Disorder




Antisocial PD (ASPD) is a pervasive pattern of disregard for and violation of the rights of others (American Psychiatric Association, 2000). Persons with ASPD will also be irresponsible and exploitative in their sexual relationships, and irresponsible as employees and parents. They may display a lack of empathy, an inflated or arrogant self-appraisal, a callous, cynical and contemp-tuous response to the suffering of others, and a glib, superficial charm. This disorder has also been referred to as psychopathy, sociopathy, or dissocial personality disorder. The presence of ASPD is indicated by the occurrence of a conduct disorder prior to age 15 years and by three of the seven adult diagnostic criteria presented in DSM-IV Criteria for ASPD.


Etiology and Pathology


There is considerable support from twin, family and adoption studies for a genetic contribution to the etiology of the criminal, delinquent tendencies of persons with ASPD. The genetic dispo-sition may be somewhat stronger in ASPD females due perhaps to a greater social pressure on females against aggressive, exploit-ative and criminal behavior. What is inherited by persons with ASPD, however, is unclear; it could be impulsivity, antagonistic callousness, or abnormally low anxiousness.


A predominant theory for the etiology of ASPD is that it results from abnormally low levels of behavioral inhibition and high levels of behavioral activation systems that are important for normal, adaptive functioning. The behavioral inhibition sys-tem (BIS) is responsible for inhibiting behavior in response to punishment and acts in opposition to the behavioral activation system (BAS) that activates behavior in response to reward. The BIS has input into the reticular activating system providing ex-periences of anxiety or arousal. The clinical symptoms of ASPD might be manifestations of a weak or deficient BIS in combina-tion with a normal or strong BAS that reduce normal sensitiv-ity and anxiety in response to threatening and stressful situa-tions. Activities that the average person would find stimulating, antisocial persons would find dull, impelling them to engage in risky, reckless, prohibited and impulsive activities. Low arousal would also help minimize feelings of anxiety, guilt, or remorse and help resist aversive conditioning. Studies have indicated an electrodermal response hyporeactivity in psychopathic persons. This hyporeactivity may be particularly associated with a deficit in anticipatory anxiety and worrying, while not impairing the alarm reactions of flight versus fight. Abnormally low levels of behavioral inhibition may be mediated by the septohippocam-pal system (and the neurotransmitter serotonin). Deficiencies in response modulation (difficulties suspending a dominant set in response to negative feedback) are apparent in animals with sep-tohippocampal dysfunction.


There are also substantial data to support the contribu-tion of family, peer, and other environmental factors. No single environmental factor appears to be specific to its development. Modeling by parental figures and peers, excessively harsh, lenient, or erratic discipline, and a tough, harsh environment in which feelings of empathy and warmth are discouraged (if not punished) and tough-mindedness, aggressiveness and exploita-tion are encouraged (if not rewarded) have all been associated with the development of ASPD. For example, ASPD in some cases could be the result of an interaction of early experiences of physical or sexual abuse, exposure to aggressive parental models and erratic discipline that develop a view of the world as a hostile environment, which is further affirmed over time through selec-tive attention on cues for antagonism, encouragement and model-ing of aggression by peers, and the immediate benefits that result from aggressive, exploitative behavior. Persons with ASPD may have had their feelings of anxiety, guilt and remorse extinguished through progressive and cumulative experiences of harsh aggres-sion, violence, abuse and exploitation.


The development of adequate guilt, conscience and shame may also require a degree of distress-proneness (anxiousness or neuroticism) and attentional self-regulation (constraint). Normal levels of neuroticism will promote the internalization of a con-science (the introjection of the family’s moral values) by associat-ing distress and anxiety with wrongdoing, and the temperament of self-regulation will help modulate impulses into a socially acceptable manner. Studies have indicated that high levels of arousal at age 15 years serve as a protective factor against crimi-nal activities at age 30 years in persons at high risk for becoming criminals. Additional factors may also help to avoid the develop-ment of ASPD, such as high intelligence which may contribute to the availability of alternative life paths, while other factors may exacerbate or escalate its development, such as drug or alcohol dependence. In sum, ASPD appears to be the result of a constel-lation of factors, including genetic predisposition, experiences within the family and sociological factors, coupled with the ab-sence of preventive factors.


Assessment and Differential Diagnosis


All of the DSM-IV-TR assessment instruments described ear-lier include the assessment of ASPD. However, an instrument that is focused on the assessment of ASPD is the Psychopa-thy Checklist – Revised (PCL-R, Hare, 1991). The PCL-R is commonly used within forensic and prison settings and is par-ticularly well suited for the assessment of this disorder within settings that are heavily populated by persons with a criminal history. The PCL-R includes the assessment of psychopathic traits that are relatively more specific to ASPD within prison settings, such as lack of empathy, glib charm and arrogance. However, as suggested by its title, it is perhaps better described as a checklist than as a semistructured interview. Many of its items are scored primarily (if not solely) on the basis of a per-son’s legal, criminal record rather than on the basis of inter-view questions. The availability of a detailed criminal history within prison settings has contributed to the PCL-R’s excellent interrater reliability and predictive validity, but an application of the PCL-R within most other clinical settings will need to rely more heavily on PCL-R interview questions, the adminis-tration and scoring of which will be unclear for some PCL-R items.


ASPD will at times be difficult to differentiate from a sub-stance dependence disorder in young adults because many per-sons with ASPD develop a substance-related disorder and many persons with a substance dependence engage in antisocial acts. The requirement that the ASPD features be evident prior to the age of 15 years will usually assure the onset of ASPD prior to the onset of a substance-related disorder. If both are evident prior to the age of 15 years, then it is likely that both disorders are in fact present and both diagnoses should then be made. ASPD and substance dependence will often interact, exacerbating and esca-lating each other’s development.


Antisocial acts will also be evident in the histrionic and borderline personality disorders, as persons with these disorders will display impulsivity, sensation-seeking, self-centeredness, manipulativeness and a low frustration tolerance. Females with antisocial PD are often misdiagnosed with histrionic personality disorder. Prototypic cases of ASPD might be distinguished from other personality disorders by the presence of the childhood his-tory of conduct disorder and the cold, calculated exploitation, abuse and aggression. Persons with narcissistic personality dis-order are also characterized by a lack of empathy and may often exploit and use others. In fact, many of the traits of narcissistic per-sonality disorder are evident in psychopathy, including a lack of empathy, glib and superficial charm and arrogant self-appraisal.


Epidemiology and Comorbidity


The National Institute of Mental Health Epidemiologic Catchment Area (ECA) study indicated that approximately 3% of males and 1% of females have ASPD (Robins et al., 1991). This rate has been replicated in subsequent studies, but it has also been suggested that the ECA finding may have underestimated the prevalence in males due to the failure to consider the full range of ASPD fea-tures. Other estimates have been as high as 6% in males (Kessler et al., 1994; Robins et al., 1991). The rate of ASPD within prison and forensic settings has been estimated at 50% but the ASPD criteria may exaggerate the rate within such settings due to the emphasis given to overt acts of criminality, delinquency and irre-sponsibility that are common to the persons within these settings. More specific criteria for psychopathy provide a more conserva-tive estimate of 20 to 30% of male prisoners with ASPD.


ASPD is much more common in males than in females. A sociobiological explanation for the differential sex prevalence is the presence of a genetic advantage for social irresponsibility, infidelity, superficial charm and deceit in males that contributes to a higher likelihood of developing features of ASPD. It has also been suggested that ASPD and histrionic personality disorder share a biogenetic disposition (perhaps towards impulsivity or sensation-seeking) that is mediated by gender-specific biogenetic and sociological factors toward respective gender variants.


Persons with ASPD are at a high risk for developing substance-related and impulse dyscontrol disorders. They are also likely to display borderline, narcissistic and paranoid per-sonality traits. Females with ASPD will also display histrionic personality traits.




ASPD is evident in childhood in the form of a conduct disorder. Evidence of a conduct disorder prior to the age of 15 years is in fact required for a DSM-IV ASPD diagnosis (American Psy-chiatric Association, 2000). The continuation into adulthood is particularly likely to occur if multiple delinquent behaviors are evident prior to the age of 10 years. As adults, persons with ASPD are unlikely to maintain steady employment and they may even become impoverished, homeless, or spend years within penal institutions. However, some persons with ASPD characterized by high rather than low levels of conscientiousness may express their psychopathic tendencies within a socially acceptable or at least legitimate profession. They may in fact be quite successful as long as their tendency to bend or violate the norms or rules of their profession and exploit, deceive and manipulate others, con-tribute to a career advancement. Their success, however, may at some point unravel when their psychopathic behaviors become problematic or evident to others. The same pattern may also occur within sexual and marital relationships. They may at first appear to be charming, engaging and sincere, but most relationships will end due to a lack of empathy, responsibility and fidelity.


There does tend to be a gradual remission of antisocial behaviors, particularly overt criminal acts, as the person ages. Persons with ASPD, however, are more likely than the general population to have died prematurely by violent means (e.g., ac-cidents or homicides) and to engage in quite dangerous, high-risk behavior.




The presence of ASPD is important to recognize in the treat-ment of any Axis I disorder, as their tendency to be manipulative. dishonest, exploitative, aggressive and irresponsible will often disrupt and sabotage treatment. It is also very easy to be seduced by psychopathic charm. Persons with ASPD can be seductive in their engaging friendliness, expressions of remorse, avowed commitment to change, and apparent response to or even fascina-tion with the success, skills, and talents of the therapist, none of which will be sincere or reliable.


The extent to which ASPD is untreatable has at times been overstated and exaggerated. Nevertheless, ASPD is the most difficult personality disorder to treat. Persons with ASPD will often lack a motivation or commitment to change. They might see only the advantages of their antisocial traits and not the costs (e.g., risks of arrest and failure to sustain last-ing or meaningful relationships). They are prone to manipulate, abuse, or exploit their fellow patients and the staff. The imme-diate motivation for treatment is often provided by an external source, such as a court order or the demands of an employer or relative. Motivation may last only as long as an external pres-sure remains.


The most effective treatment is likely to be prevention through an identification and intervention early in childhood. In adulthood, the most effective treatment may at times be simply some form of sustained incarceration (e.g., imprisonment), as many antisocial behaviors do tend to dissipate (or burnout) with time. The tendency to rationalize irresponsibility, minimize the consequences of acts, and manipulate others needs to be con-fronted on a daily and immediate basis. Community residential or wilderness programs that provide a firm structure, close supervi-sion and intense confrontation by peers have been recommended. The involvement of family members in the treatment has been shown to be helpful, but there are also data to suggest that inter-ventions with little professional input are less successful and are times counterproductive.


There is some research to suggest that the ability to form a therapeutic alliance is an important indicator of treatment success. Factors to consider are the demographic similarity of the therapist and patient, the quality of the patient’s past relationships and the therapist’s positive regard for the pa-tient. Many psychiatrists may also experience strong feelings of animosity and distaste for antisocial persons who have a history of abusive and exploitative acts. Rational, utilitarian approaches that help the person consider the long-term con-sequences of behavior can be useful. This approach does not attempt to develop a sense of conscience, guilt, or even regret for past actions, but focuses instead on the material value and future advantages to be gained by a more prosocial behavior pattern. There are data to suggest the use of pharmacother-apy in the treatment of impulsive aggression but it is unclear whether these findings would generalize to the full spectrum of ASPD psychopathology.


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