Antisocial Personality Disorder

Definition and classification

• Personality disorder signifies deeply rooted and persistent behavioural patterns that are inflexible and hinder adaptation in several life areas (emotional life, impulse control, human relations).
• Within the relevant class, ICD-10 does not group personality disorders, 10 of which are mentioned.
• In the DSM-5, personality disorders are classified into three main clusters; antisocial personality disorder is placed in the dramatic-emotional B cluster.
• The criteria used in ICD-10 and DSM-5 classifications are fairly convergent with each other.
  • ICD-10: disregard for others, irresponsibility, fragile human relationships, poor impulse control, inability to feel guilty, tendency to “sugar-coat” one's own behaviour.
  • DSM-5: illegal behaviour, dishonesty, impulsiveness, aggressiveness, irresponsibility, unrepentance

Description

• Extremes and prominent features are different: from explosive, impulsive behaviour to manipulative behaviour that characterizes social relationship.
• Disregard to truth and social responsibilities, indifference to other persons' feelings or rights and inability to put oneself into another person's position are characteristic to the disorder.
• Grave discrepancy between the person's behaviour and social norms is large.
• Behaviour is characterized by tendency of getting easily bored, poor tolerance of frustrations, low threshold of irritation, aggressiveness, and violent behaviour.
• The inner world of the patient is devoid of feelings and the patient lacks the ability to feel guilt or empathy, or the patient has very strong emotions, anxiety, and impulsiveness.
• Not all the patients are criminals, and even chronic offenders do not always fulfill the criteria of antisocial personality disorder.
• Psychopathic persons are usually diagnosed with antisocial personality disorder. On the other hand, all persons with antisocial personality disorder are not psychopaths.
• A person with psychopathic personality disorder type seeks power over others and will manipulate, exploit, deceive, con, or otherwise take advantage, in order to inflict harm or to achieve their goals.

Diagnosis

• According to both ICD-10 and DSM-5 classifications the diagnosis of antisocial personality disorder can be made if the individual is at least 18 years of age, and DSM-5 requires that the symptoms have started as conduct disorder before the age of 15. ICD-10 regards conduct disorder of childhood as complementary information. The typical disturbed behaviour has often started already before puberty and continues far into adulthood.
• Already before the age of 15 years the patient has repeatedly lied, stolen and deceived to gain personal profit, started physical fights, tortured animals, skipped school or been away from home without permission, been indifferent and reckless concerning other people's health or safety, etc.
• At adult age, neglect of adult responsibilities concerning e.g. studying, work life, care for the family or financial obligations is typical.
• Most patients have shown severe and permanent conduct disorders since the early childhood , independent of the atmosphere in the family or the social factors of the living environment.
• The situation is often complicated by simultaneous substance abuse or dependence.
• As more secondary benefit is obtained the situation becomes more complicated.
• Exclusion criterion: the antisocial behaviour is not only manifested during a schizophrenic or manic episode.
  • From the perspective of differential diagnosis, it is important to remember that the criteria of antisocial personality disorder may be fulfilled during e.g. the manic phase of a mood disorder, even though the patient would not have a personality disorder.

Epidemiology

• The cumulative lifetime prevalence in general population is 3% in men and 1% in women, among male prisoners up to 60%.
• Genetic factors play an important aetiological role. The functions of the prefrontal and limbic brain areas seem deviant in neuropsychological tests and in functional imaging.
• The functioning of the autonomic nervous system deviates from that of the general population. The findings suggest difference in the development of the central nervous system, which, together with environmental effects leads to e.g. lack of empathy and to difficulties in social learning.
• About 80% will be clearly improved from their problematic behaviour like criminality and promiscuity by the age of 30-45 years, although the old behaviour models easily reappear in stress situations. The prognosis in adult age is, however, often poor: premature violent deaths, criminality, problems in human relations, substance abuse, other mental disturbances, and excessive use of services are common.

Principles of treatment

• Aim at description of problems in concrete terms and suggest practical solutions.
• Cope with your own negative transference or behavioural patterns often evoked by the patient's aggression and antisocial behaviour.
• Results of pharmacotherapy depend also on the selection of outcomes, but very promising results have not been accumulated. It has been possible to reduce aggressiveness by phenytoin and use of alcohol by nortriptyline. These products, however, are no longer suitable in the pharmacotherapy due to e.g. their adverse effects.
• SSRIs or valproic acid may be helpful in treating impulsivity and aggressivity. In single cases, second generation antipsychotics have clearly been beneficial.
• Some patients may benefit from long-term structured cognitive-behavioural or psychodynamic psychotherapy, but research evidence is insufficient to back up any psychological intervention.
• Childhood interventions are being studied to improve the prognosis of children at risk.
• Early interventions targeted at the group with the most multiple problems are most cost-effective according to current understanding.

During the consultation

• Although there is no scientific evidence of the benefit of any particular intervention, pessimism should not be allowed to prevail.
• When the disorder is present concomitantly with psychosis, the patient should still be treated, even if he/she would have undesired features or properties due to the personality disorder, and even if he/she would seem to deliberately sabotage his/her own treatment.
• Due to their behaviour, antisocial patients often encounter other people's loss of temper and blame. Therefore, attempts at tuition are not helpful.
• The most important means are empathetic calmness, flexibility, and a practical approach.
• It is useful to be aware of one's own countertransference. Professional counselling may be helpful in this.
• Try to define the patient's problem as clearly as possible: always ask the following five questions:
  • What made you come?
  • Why did you come right now?
  • What do you wish me (the doctor) or the hospital to do to help you?
  • What do you think is the cause of your problems?
  • If you had not come to me now, what do you think would have happened?
• Is the presenting symptom an excuse for contact that reveals something more essential (so that unnecessary examinations can be avoided)?
• Treating and excluding somatic diseases may have a crucial role in alleviating irritability and impulsiveness.
• The prevalence of concurrent mental disorders is above average (impulse control disorders, alcoholism and drug addiction, gambling addiction, mood disorders, anxiety and somatization disorders). Treatment of these disorders may be of great help in behavioural problems.
• Normal life crises, problems with human relationships or unemployment may be the cause of changes in mood. The feeling that somebody understands is as important to these patients as to anybody else.
• The opportunity to share the problems in an emphatic (but professional) human relationship is often the best means of reducing self-destructive impulsiveness and of allowing time for gradual spontaneous cure of the behavioural disorder.
• Another reason for the physician to remain within clear professional boundaries is to avoid becoming manipulated oneself.
• Especially remember to avoid prescription of benzodiazepines. Preferably prescribe melatonin for insomnia.