Antisocial Personality Disorder: Diagnostic Criteria and Treatment
Diagnostic Criteria
Antisocial Personality Disorder (ASPD) is diagnosed based on a pervasive pattern of socially irresponsible, exploitative, and guiltless behavior that begins in childhood or early adolescence and continues into adulthood. 1, 2
Core Diagnostic Features
Age requirement: The diagnosis requires the individual to be at least 18 years old, with evidence of conduct disorder symptoms beginning before age 15 1, 3
Pattern of antisocial behavior: Documented history of irresponsible and antisocial conduct including deception, manipulation, disregard for the rights of others, and lack of remorse for harmful behaviors 1, 4
Childhood precursor: The disorder typically manifests as conduct disorder in childhood (usually by age 8), which converts to ASPD at age 18 if antisocial behaviors persist 1, 3
DSM-5 Alternative Model Considerations
The DSM-5 Section III Alternative Model proposes a dimensional-categorical hybrid approach that assesses impairments in personality functioning and pathological personality traits, though critics note the lack of evidence for improved outcomes with this model 5, 3
Neurobiological Markers
Brain imaging studies have identified cortical dysfunction in crucial brain regions, particularly frontal lobe abnormalities 4, 3
Cognitive characteristics include inflexibility, attention deficits, and inappropriate processing of contextual environmental cues leading to poor behavioral choices 4
Differences in autonomic nervous system functioning have been documented 4
Clinical Assessment Approach
Assessment must rely entirely on the individual's behavioral history, as there are no diagnostic laboratory tests or biomarkers. 3
Gather information from multiple sources due to the patient's propensity for pathologic lying and masquerade 2, 5
Perform mental status examination specifically evaluating thought processes, suicidal intent, and homicidal intent 2
Document pattern of behavior beginning in childhood with specific examples of irresponsible and antisocial conduct 1, 2
Differential Diagnosis
Rule out the following conditions that may mimic ASPD:
- Substance use disorders (which frequently co-occur but are distinct) 2
- Adult antisocial behavior without childhood onset 2
- Psychotic disorders 2
- Organic brain disorders 2
- Other personality disorders, particularly borderline personality disorder 2, 5
Common Pitfalls
The most critical diagnostic error is failing to establish the childhood onset of conduct problems before age 15. 1, 3 Without this developmental history, the diagnosis cannot be made, and the presentation may represent adult antisocial behavior rather than ASPD.
Treatment Options
Treatment of ASPD is extremely challenging, with little to no evidence of consistently effective interventions, primarily because these patients are often excluded from mental healthcare and research studies. 6
Psychotherapeutic Approaches
Cognitive-behavioral therapy (CBT): Has been developed for ASPD and shows some promise in structured settings 3, 5
Mentalization-based therapy: A newer model specifically developed for ASPD that shows early promise in helping patients understand their own and others' mental states 3
Dialectical Behavior Therapy (DBT): May be beneficial for targeting specific symptoms, though originally developed for borderline personality disorder 5
Organizational Preconditions for Treatment
Effective treatment requires specific organizational structures that most standard outpatient settings cannot provide. 6
Rapidly establish firm behavioral limits at the outset of treatment 2
Ensure healthcare workers have specialized training in managing antisocial behaviors 6
Implement systematic monitoring and consequences for treatment non-adherence 6
Pharmacological Management
There are no medications approved for treating ASPD itself; pharmacotherapy should target specific symptoms or co-occurring disorders only. 3
For aggression and irritability: Consider mood stabilizers or atypical antipsychotics, though evidence is limited 3
For comorbid conditions: Treat co-occurring depression, anxiety disorders, or substance use disorders with standard evidence-based medications 3, 2
SSRIs (such as escitalopram, paroxetine, or fluvoxamine) may be used for comorbid anxiety or depression 7, 8
Treatment Algorithm
Initial assessment phase: Document behavioral history, establish diagnosis, evaluate for comorbid psychiatric and substance use disorders 2, 3
Safety evaluation: Assess suicidal and homicidal intent immediately 2
Establish treatment framework: Set clear behavioral expectations and consequences before initiating therapy 2, 6
Target comorbidities first: Address substance use disorders, mood disorders, or anxiety disorders with evidence-based treatments 3, 2
Initiate psychotherapy: Begin mentalization-based therapy or CBT in a structured setting with trained clinicians 3, 6
Consider adjunctive medication: Only for specific target symptoms (aggression, irritability) or comorbid conditions 3
Prognostic Factors
The disorder tends to improve with advancing age, though it remains chronic and lifelong for most individuals. 1, 3
Earlier onset (before age 8) is associated with poorer prognosis 1
Positive moderating factors include stable marriage, consistent employment, and early intervention during childhood 1
Early incarceration or adjudication during childhood may paradoxically improve outcomes by providing structure 1
Critical Caveats
ASPD is associated with excessive rates of natural and unnatural death, including suicide, homicide, and accidents. 1 This mortality risk must be continuously assessed throughout treatment.
The disorder predicts poor treatment response across all psychiatric interventions, so realistic expectations should be set with patients, families, and treatment teams 1, 6
Co-occurring mental health disorders, addictive disorders, and medical comorbidities are extremely common and complicate treatment 1, 3