Treatment for Antisocial Personality Disorder
There is no evidence-based pharmacological or psychological treatment specifically recommended for antisocial personality disorder (ASPD), as the available evidence is insufficient to support any intervention. The most promising approach based on emerging research is mentalization-based treatment (MBT) delivered in a group format, though this lacks high-quality guideline support 1, 2.
Current State of Evidence
The evidence base for ASPD treatment is severely limited and methodologically flawed:
A 2020 Cochrane systematic review found insufficient evidence to recommend any pharmacological intervention for ASPD, with only 11 studies involving 416 participants, most of whom were recruited for substance abuse problems rather than ASPD itself 3.
A 2010 Cochrane review of psychological interventions similarly concluded there is insufficient trial evidence to justify using any psychological intervention for adults with ASPD, with only 5 of 11 included studies providing usable data on 276 participants 2.
The available studies have critical methodological flaws: they recruited participants primarily for substance abuse rather than ASPD, used older medications, had high attrition bias, and rarely measured clinically relevant outcomes like aggression, reconviction, or social functioning 3, 2.
Psychotherapy: The Only Reasonable First-Line Approach
Mentalization-Based Treatment for ASPD (MBT-ASPD)
If any treatment should be attempted, MBT-ASPD delivered as group psychotherapy is the most theoretically sound and emerging option, though it lacks guideline-level evidence:
MBT-ASPD targets the core mentalizing vulnerabilities and attachment dysfunction central to ASPD, focusing on affect regulation and relational reactivity rather than anger management alone 1.
The group format establishes shared values, promotes learning from peers, and generates "we-ness" through semi-structured processes focused on personal formulation 1.
Therapists report that MBT-ASPD can be delivered safely with appropriate boundaries, non-judgmental stance, and attention to countertransference, though burnout risk is significant 4.
Cognitive Behavioral Therapy (Limited Evidence)
CBT combined with standard maintenance showed superiority over control conditions in one study of outpatients with cocaine dependence, but failed to show benefit in male outpatients with recent violence 2.
The improvements were confined to substance misuse outcomes, not antisocial behavior itself 2.
Pharmacotherapy: No Recommended Agents
No medication can be recommended for ASPD based on current evidence:
Antiepileptics (Phenytoin)
- One study (60 male prisoners) suggested phenytoin 300 mg/day may reduce aggressive acts compared to placebo, but this is very low-certainty evidence from a single, unreplicated trial 3.
Antidepressants (Desipramine, Nortriptyline)
- No evidence of benefit for social functioning or global state in ASPD participants 3.
Dopamine Agonists (Bromocriptine, Amantadine)
- No evidence of benefit, with bromocriptine causing severe side effects (nausea, flu-like symptoms) leading to dropout in 5 of 12 participants 3.
Critical Limitation
- All available pharmacological data come from unreplicated, single reports with very low-certainty evidence, and most participants were recruited for substance abuse rather than ASPD 3.
Treatment of Comorbid Conditions
The only evidence-based pharmacological approach is treating discrete comorbid conditions, not ASPD itself:
For comorbid major depression or anxiety disorders: Start escitalopram 5-10 mg daily or sertraline 25-50 mg daily, titrating gradually 5.
For substance use disorders: Contingency management combined with standard maintenance showed superiority in two studies, though results were inconsistent 2.
Avoid benzodiazepines due to risks of tolerance, addiction, and paradoxical agitation in approximately 10% of patients 5.
Clinical Algorithm for ASPD
Confirm ASPD diagnosis and rule out that antisocial behavior is better explained by substance use, bipolar disorder, or schizophrenia 6.
Assess for comorbid conditions (substance use, depression, anxiety, ADHD) as these are present in approximately one-third of ASPD patients and should be treated with evidence-based interventions for those specific conditions 7.
Consider referral to MBT-ASPD group therapy if available, recognizing this is based on emerging rather than established evidence 1.
If substance use is prominent, prioritize contingency management combined with standard maintenance, as this showed the most consistent benefit in ASPD populations 2.
Do not initiate pharmacotherapy specifically for ASPD, as no medication has demonstrated efficacy for core antisocial behaviors 3.
Monitor for therapist burnout and negative countertransference, as these are significant challenges in treating ASPD and require team support and supervision 4.
Critical Pitfalls to Avoid
Do not prescribe antipsychotics, mood stabilizers, or antidepressants for ASPD itself, as there is no evidence they reduce antisocial behavior, aggression, or reconviction 3.
Do not assume treatment will reduce criminality or violence, as no psychological or pharmacological intervention has demonstrated this outcome in controlled trials 2.
Do not recruit patients into treatment studies based on substance abuse alone, as this has contaminated the existing evidence base and prevented understanding of ASPD-specific treatment effects 3, 2.
Recognize that ASPD may not be a homogeneous condition, and different pathways to antisocial behavior may require different therapeutic approaches, though this framework requires further validation 6.