What are the DSM‑5 criteria for diagnosing Antisocial Personality Disorder in an adult (≥18 years) with a history of conduct disorder before age 15?

DSM-5 Diagnostic Criteria for Antisocial Personality Disorder

Antisocial Personality Disorder (ASPD) requires three core components: a pervasive pattern of violating others' rights beginning by age 15 (documented as conduct disorder), the individual must be at least 18 years old at diagnosis, and specific adult antisocial behaviors must be present. 1, 2

Essential Criterion A: Evidence of Conduct Disorder Before Age 15

The diagnosis absolutely requires documented evidence of conduct disorder with onset before age 15 years. 1, 3 This childhood pattern must include behaviors such as:

• Aggression toward people or animals
• Destruction of property
• Deceitfulness or theft
• Serious rule violations 3

Earlier onset of conduct disorder (before age 10) predicts more severe ASPD with greater total symptoms, worse substance use disorders, higher criminality rates, and increased homelessness compared to later-onset conduct disorder. 4 The 15-year age cutoff remains controversial, as individuals with adult antisocial behaviors but later-onset conduct disorder show similar numbers of adult symptoms, though the earlier-onset group demonstrates worse psychosocial outcomes. 4

Essential Criterion B: Current Age Must Be At Least 18 Years

The ASPD diagnosis cannot be applied to anyone under 18 years of age. 1, 3 Before age 18, the appropriate diagnosis remains conduct disorder, even if the pattern clearly suggests future ASPD. 3

Essential Criterion C: Adult Antisocial Behavior Pattern

After age 18, the individual must demonstrate a pervasive pattern of irresponsible and antisocial behavior characterized by at least three of the following: 5, 2

• Failure to conform to social norms and lawful behaviors, evidenced by repeatedly performing acts that are grounds for arrest
• Deceitfulness, including repeated lying, use of aliases, or conning others for personal profit or pleasure
• Impulsivity or failure to plan ahead
• Irritability and aggressiveness, shown by repeated physical fights or assaults
• Reckless disregard for safety of self or others
• Consistent irresponsibility, demonstrated by repeated failure to sustain work or honor financial obligations
• Lack of remorse, shown by being indifferent to or rationalizing having hurt, mistreated, or stolen from another 5, 2

Critical Diagnostic Considerations

Assessment Requires Multiple Informants

Gather information from multiple sources including family members, legal records, employment history, and medical records—never rely solely on patient self-report. 6 Individuals with ASPD characteristically engage in pathological lying and manipulation, making their self-reports unreliable for diagnosis. 5 Collateral information from criminal justice records, prior psychiatric evaluations, and family interviews provides essential corroboration. 6

Temporal Pattern: Chronic and Lifelong

ASPD represents a stable, chronic pattern beginning in childhood or early adolescence and continuing into adulthood. 1, 5 Unlike episodic mood disorders, the antisocial pattern persists continuously without distinct periods of remission, though severity typically lessens with advancing age (usually after age 40). 2, 3

Differential Diagnosis Pitfalls

Rule out substance-induced antisocial behavior—the antisocial pattern must be present independent of active substance use. 5 Many individuals with substance use disorders engage in antisocial acts only to obtain drugs, which does not constitute ASPD. 5

Distinguish ASPD from adult antisocial behavior without the childhood conduct disorder component. 5 Criminal behavior beginning in adulthood without childhood conduct problems represents adult antisocial behavior, not ASPD. 4

Differentiate from Borderline Personality Disorder, which involves unstable mood, relationships, and self-image with fear of abandonment and self-harm, rather than the consistent rule-breaking and exploitation characteristic of ASPD. 6

Family History and Risk Factors

Family history of suicidal behavior, substance abuse, or physical/sexual abuse significantly increases ASPD risk. 6 The disorder develops from complex interactions between genetic predisposition (high heritability) and environmental factors, particularly adverse childhood experiences. 6, 2

DSM-5 Specifier for Youth

DSM-5 includes the specifier "with limited prosocial emotions" for adolescents with conduct disorder, characterizing those with higher developmental vulnerability to progress to ASPD. 1 This specifier identifies youth with callous-unemotional traits who show particularly poor treatment response. 1