Antisocial Personality Disorder

Essentials

• Antisocial personality disorder means severely disturbed personality development characterized by maladjustment to social rules, disregard for other people's rights, impulsiveness and lack of remorse.
• The term ‘antisocial personality disorder' may sometimes be understood as a low level of sociality but as a diagnosis it means deep-rooted disregard for social rules and other people's rights, i.e. being antisocial.
• Its treatment should be started as early as possible, preferably in childhood.
• Antisocial personality disorder must not prevent someone from receiving health care and social services. It is important to recognize risks associated with the disorder, such as the risk of violence.

Prevalence and aetiology

• Antisocial personality is underdiagnosed. Its prevalence in the adult population is 2-3%.
  • The prevalence is more than 3 times higher in men than in women.
  • Antisocial personality is more common in urban than in rural areas.
  • About half of male prisoners have antisocial personality disorder.
• The development of antisocial personality depends on genetic and environmental factors. A biopsychosocial explanatory model is considered essential.
  • About 40% of boys and 25% of girls with conduct disorder develop antisocial personality disorder.
  • The risk is higher in children whose parents have a background of intoxicant abuse and crime, severe psychiatric disorders or institutional care.
  • Boys growing up without their fathers and born to very young mothers run an increased risk of antisocial development.
  • Insecure and difficult childhood circumstances and inadequate parenting may lead to poor choices in relationships and in seeking a place in society.
  • Concomitant attention deficit disorder will increase the risk of antisocial development.

Symptoms

• People with the disorder are often selfish, irresponsible and negligent.
  • Lying, foul play and criminal behaviour, impulsiveness and lack of remorse are often also present.
  • These people may cause malicious damage, steal or become involved in many kinds of illegal activity. The social and financial burden on society is high.
• Antisocial features can usually be detected by the 15th year of age.
• Antisocial personality disorder is often associated with other problems.
  • People with the disorder are often also dependent on intoxicants.
  • Affective syndromes, anxiety disorders, paraphilic disorders and compulsive gambling may be involved.
  • The socioeconomic position is often poor.
  • The person is susceptible to various traumas, accidents and communicable diseases and runs a high risk of falling victim to homicide or dying in an accident or through suicide.

Diagnosis

• Antisocial personality disorder is a broadly defined concept concentrating more on behaviour than on assessing the person's personality.
  • People who resort to impulsively violent action when drunk and antisocial people who carry out coldly premeditated violent deeds when sober may have very different personalities.
• In the ICD-10 classification of disorders used in many countries and the DSM-5 classification of disorders used in the USA, antisocial personality disorder has the same meaning.
  • According to ICD-10, the condition is called dissocial personality disorder and it also includes antisocial, sociopathic and psychopathic personality.
  • ICD-11 provides the possibility for determining the severity of personality disorder as mild, moderately severe or severe.
• The diagnosis of antisocial personality is made by a psychiatrist based on a careful interview and other available data.
  • The diagnosis can be made from the age of 18 years but antisocial personality usually develops through conduct disorder, and features of emotional coldness can be detected as early as in childhood.
  • Conduct disorder in childhood complements the clinical picture but is not required for the diagnosis.
  • Criminal behaviour as such without permanent antisocial features is not sufficient to make the diagnosis.
• In addition to fulfilling the general criteria for personality disorder Personality Disorders, at least 3 of the following are required to make the diagnosis.
  • Callous disregard for other people's feelings
  • Constant, grave irresponsibility and disregard for social norms, rules and obligations
  • Difficulty maintaining enduring relationships even though there are no problems forming relationships
  • Poor tolerance of frustration and low threshold for aggressive and violent behaviour
  • Inability to feel guilt or to learn from unpleasant experiences, punishment in particular
  • Tendency to blame others or to use embellishment and rationalization to defend their own behaviour that led to a conflict with society

Treatment

• A psychiatrist should be consulted if antisocial personality disorder is suspected.
• The treatment of antisocial personality disorder may be challenging. Involuntary psychiatric treatment has been tried in some countries but with modest results.
• It is usually sensible to begin with the treatment of any concomitant substance use disorder.
• There is no effective medication available but antidepressant and antipsychotic drugs may be helpful in the treatment of other concomitant disorders.
• Psychotherapeutic methods such as cognitive therapy or mentalization-based therapy are used primarily to address behaviour, to control impulsiveness and to reduce criminal activity.
  • Learning to identify and manage environmental risk factors may help.
  • Prisons provide anger management courses and support for withdrawal from organized crime.

Prognosis

• Antisocial personality disorder is a challenge for young people, with a chronic course and poor prognosis.
  • Criminal behaviour beginning at a very young age predicts a severe course of disorder.
• Measures increasing social cohesion and a sense of community appear to have some preventive effect, and the prevalence of antisocial personality decreases during war, for example.
• It is important to recognize vulnerable families, and if conduct disorder appears in a child, child welfare support should be offered as early as possible with child psychiatric help, as necessary Conduct Disorders in Children and Adolescents.
  • Positive feedback from success is more helpful than blame and punishment.
• The risk of antisocial development may be high if an adolescent ends up in the company of criminals and experiences criminal benefit. The police provide multiprofessional support to halt antisocial development that has already begun.
• Impulsiveness and criminal behaviour usually begin to calm down in middle age. A capacity for empathy may not develop but management of behaviour may improve and the person may begin to make responsible choices.
• Forming a couple relationship and employment may improve the situation.