Antisocial Personality Disorder (ASPD)
Summary
Antisocial Personality Disorder (ASPD), also known as Dissocial Personality Disorder (ICD-10), is a Cluster B personality disorder characterised by a lifelong, pervasive pattern of disregard for the rights of others. Individuals often violate social norms, deceive others, and act impulsively with a profound lack of remorse. It is notoriously difficult to treat and is strongly associated with criminality, substance abuse, and early mortality. [1,2]
Key Facts
- Age Criterion: By definition, ASPD cannot be diagnosed before age 18. If the features are present before 18, the diagnosis is Conduct Disorder.
- Psychopathy: Often confused with ASPD. Psychopathy is a severe subgroup (measured by PCL-R) characterised by core affective deficits (glib charm, lack of empathy, grandiosity) in addition to the antisocial behaviours. Not all people with ASPD are psychopaths.
- Prevalence: High in prisons (50-75%) and homeless populations.
Clinical Pearls
The "Mask of Sanity": High-functioning individuals (Psychopaths) can appear superficially charming, intelligent, and articulate. They use this "mask" to manipulate clinicians and victims. Do not rely solely on the interview; Collateral History (records, family) is essential to uncover the history of lying and violence.
Macdonald Triad: The classic childhood precursors of violent sociopathy: 1. Enuresis (Bedwetting late into childhood), 2. Cruelty to Animals, 3. Pyromania (Fire-setting).
Counter-Transference: Clinicians often feel fear, anger, or a sense of being manipulated when dealing with ASPD patients. Recognise these feelings as a diagnostic clue.
Demographics
- Prevalence: 3% of men, 1% of women in general population.
- Gender: Male > Female (3:1).
- Environment: Strong association with low socioeconomic status, childhood abuse/neglect, and chaotic upbringing.
Aetiology (Bio-Psycho-Social)
- Genetic: Heritability ~50%. (MAO-A "Warrior Gene" variants in context of abuse).
- Neurobiology: Reduced volume in Prefrontal Cortex (Impulse control). Hypo-arousal hypothesis: They have low baseline heart rate/arousal, so they seek intense stimulation (sensation seeking) to feel normal.
- Environmental: Childhood trauma, harsh discipline, deviant peer groups.
DSM-5 Criteria
A pervasive pattern of disregard for rights of others occurring since age 15, as indicated by 3 or more of:
- Failure to conform to social norms with respect to lawful behaviours (Arrests).
- Deceitfulness: Repeated lying, use of aliases, conning others.
- Impulsivity: Failure to plan ahead.
- Irritability and Aggressiveness: Repeated fights/assaults.
- Reckless disregard for safety of self or others (Speeding, unprotected sex).
- Consistent Irresponsibility: Failure to sustain work or financial obligations.
- Lack of Remorse: Indifferent to having hurt/mistreated others.
Must be at least 18 years old, with evidence of Conduct Disorder less than 15 years.
- Mental State Exam (MSE):
- Appearance: Often normal (or tattoos/scars).
- Behaviour: Can be charming/seductive OR intimidating/hostile.
- Speech: Normal.
- Mood: Irritable or Euthymic.
- Insight: Poor (blame others/society).
Diagnostics
- PCL-R (Psychopathy Checklist Revised): The gold standard tool for assessing psychopathy (Forensic use).
- Urine Drug Screen: Substance use is a ubiquitous comorbidity.
- Criminal Records: Essential for accurate history.
Management Algorithm
SUSPECTED ASPD
(History of violence, arrests,
impulsivity, lying)
↓
EXCLUDE COMORBIDITIES
(Bipolar, ADHD, Substance Misuse)
Treating these reduces risk!
↓
RISK ASSESSMENT (Essential)
(Violence, Recidivism, Self-harm)
↓
PSYCHOSOCIAL INTERVENTION
(Focus on behaviour, not personality)
↓
┌─────────────┼─────────────┐
COMMUNITY PRISON SEVERE /
(Therapeutic DANGEROUS
Community) (Forensic)
1. Psychological
- CBT: Focuses on "Thinking Skills" - impulse control, recognising consequences, anger management.
- Therapeutic Communities (TC): Group-based living (usually in prison) where peer pressure is used to enforce social norms. Evidence is modest.
- Mentalization Based Therapy (MBT): Developing empathy.
2. Pharmacological
- No licensed Medication: There is no drug for personality.
- Treat Comorbidities:
- SSRI: For depression/anxiety.
- Antipsychotics: (e.g. Quetiapine) occasionally used for severe aggression/agitation (off-label).
- Lithium/Valproate: For impulsivity (weak evidence).
- Warning: Avoid Benzodiazepines (Disinhibition -> Increase violence) and Opioids (Misuse).
3. Social / Risk
- Probation services.
- MAPPA (Multi-Agency Public Protection Arrangements).
- Child Protection services.
- Legal: Incarceration.
- Social: Homelessness, divorce, unemployment.
- Medical: Trauma (injuries from fights), STIs, Substance dependence (Alcohol/Opioids).
- Mortality: High rate of suicide and homicide.
- Course: Chronic, but often "burns out" after age 40 (reduction in criminal activity).
- Treatment: Generally poor response. High dropout rates.
Key Guidelines
| Guideline | Organisation | Key Recommendations |
|---|---|---|
| Antisocial PD (CG77) | NICE (2009) | Do not use medication routinely. Focus on group-based cognitive and behavioural interventions. |
| Psychopathy | DoH | Criteria for admission to DSPD (Dangerous and Severe Personality Disorder) units. |
Landmark Studies
1. New Zealand Dunedin Study
- Followed 1000 children. Identified low MAO-A activity genotype + child maltreatment = High risk of antisocial behaviour. (Gene x Environment interaction).
What is ASPD?
It is a personality disorder, which means it is a deeply ingrained way of thinking and behaving. People with ASPD often act on impulse, struggle to follow rules, and find it hard to understand or care about the feelings of others.
Is he mad or bad?
This is an old debate. Medically, it is a recognised disorder of brain development and personality. However, legally, people with ASPD are considered responsible for their actions (they know right from wrong, they just don't care).
Can it be cured?
No. You cannot change a personality with a pill. However, as people get older, the aggressive behaviour often settles down. Treatment involves learning skills to manage anger and think before acting.
Primary Sources
- NICE Guideline [CG77]. Antisocial personality disorder: prevention and management. 2009.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
- Hare RD. The Hare Psychopathy Checklist-Revised. 2003.
Common Exam Questions
- Diagnosis: "Age requirement?"
- Answer: 18 years. (Childhood version is Conduct Disorder).
- Differential: "Narcissistic vs Antisocial?"
- Answer: Narcissists want status/admiration. Antisocials want material gain/power and violate rights.
- Management: "First line treatment?"
- Answer: Group-based cognitive/behavioural therapy (e.g. Thinking Skills). Not drugs.
- Pharmacology: "Drug to avoid?"
- Answer: Benzodiazepines (cause disinhibition).
Viva Points
- Cluster B: Antisocial, Borderline, Narcissistic, Histrionic. (The "Bad" / Dramatic / Emotional cluster).
- Insanity Defense: Does ASPD count? Generally NO. They do not lose touch with reality (Psychosis). They are fit to plead.
Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. Clinical decisions should account for individual patient circumstances. Always consult appropriate specialists.