What is antisocial personality disorder?

A personality disorder is a mental illness associated with an unhealthy pattern of thinking, functioning and relating to others. There are many types of personality disorders, each of which has its own range of signs and symptoms.

A person with a personality disorder has difficulty understanding and relating to people and situations, and can experience significant problems coping with work, school, social and intimate relationships. Because their way of thinking and acting seems natural to them, many people with personality disorders may not realise they have a disorder and may blame those around them for the challenges they encounter in life.

Antisocial personality disorder (ASPD) is one of the most challenging and difficult-to-treat personality disorders. People with ASPD can show a pattern of guiltless, exploitative and socially irresponsible behaviour.

ASPD is usually a lifelong condition that may first become apparent in childhood or early adolescence and increases in severity during adulthood, peaking in a person's late 20s or early 30s.

People with ASPD typically struggle to conform to cultural norms and may engage in criminal activity, have difficulty maintaining ongoing employment, manipulate others for their own gain and struggle to form and sustain social relationships.

People with ASPD lack empathy for others and may not be capable of feeling remorse, or learning from negative outcomes they experience.

The severity of symptoms associated with ASPD can vary widely between individuals. Psychopathy is the most severe type of ASPD, but not all people with ASPD are psychopathic.

ASPD is diagnosed more often in men (70%) than in women (30%). The disorder is estimated to affect between 2-3% of the general population. [1]

Psychopathy

A personality disorder characterised by antisocial behaviour comprising lack of remorse, lack of empathy and general disregard for others.

1. Gask, L., Evans, M. and Kessler, D. (2013) Personality disorder. BMJ 347:f5276–f5276. doi:10.1136/bmj.f5276.

Causes

There is no single factor responsible for the development of ASPD. The disorder is likely to be caused by a complex interplay between biological, genetic, social and psychological factors.

Some people may inherit genes that make them more vulnerable to developing ASPD; the condition may then be triggered by particular life situations. One theory proposes that being exposed to physical or emotional abuse during childhood disrupts normal brain development by triggering an abnormal release of messenger molecules to the brain. There may be a link between levels of serotonin in the brain and ASPD. [2] A genetic dysfunction in serotonin regulation may predispose some people to the impulsive and aggressive behaviour associated with antisocial personality disorder.

Genes

A unit of inheritance (heredity) of a living organism. A segment of genetic material, typically DNA, that specifies the structure of a protein or related molecules. Genes are passed on to offspring so that traits are inherited, making you who you are and what you look like.

Genetic

Related to genes, the body's units of inheritance or origin.

Psychological

Relating to, arising in, or affecting the mind.

Serotonin

A chemical messenger within the brain that is thought to play a role in mood and behaviour. Many antidepressant medications act by increasing the amount of serotonin in the brain.

2. Scarpa, A., and Raine, A. (1997) Psychophysiology of anger and violent behavior. The Psychiatric Clinics of North America 20:375–394.

Risk factors

Although the cause of antisocial personality disorder remains to be fully understood, there are some factors that may make it more likely to develop antisocial personality disorder.

Risk factors may include:

  • Having a first-degree relative with the disorder;
  • A family history of substance abuse;
  • Low socio-economic status;
  • Being subjected to verbal, physical or sexual abuse during childhood;
  • Losing parents through a traumatic divorce or seperation during childhood, and;
  • Having an unstable family life during childhood.

Substance abuse

The behaviour of consuming unhealthy levels of alcohol and/or using recreational drugs.

2. Scarpa, A., and Raine, A. (1997) Psychophysiology of anger and violent behavior. The Psychiatric Clinics of North America 20:375–394.

Signs and symptoms

The behavioural patterns associated with ASPD can begin early in childhood and become increasingly apparent as a child reaches adolescence.

Some of the more typical childhood symptoms include:

  • Stealing;
  • Vandalism;
  • Lighting fires;
  • Fights with other children;
  • Cruelty to animals or other children;
  • School-related behavioural problems;
  • Poor academic performance, and;
  • Running away from home.

As the child matures into adolescence and adulthood, other problems may develop as their responsibilities grow.

Some of the more typical adolescent/adulthood symptoms may include:

  • Sexual promiscuity and engaging in sexual activity earlier than peers;
  • Pathological lying;
  • Risk-taking;
  • Substance abuse;
  • A reckless disregard for the safety of themselves and others;
  • Impulsiveness or failure to plan ahead;
  • Recurring difficulties with the law;
  • Lack of remorse - indifference to hurting others;
  • Using charm to manipulate others for personal gain;
  • Poor job performance - losing jobs, frequent job changes and proving to be an unreliable employee, and;
  • Unstable relationships, with physical or emotional abuse of partners, leading to a high rate of separation and divorce.

The behavioural patterns of ASPD tend to decrease with age; most of the symptoms will ease by the time someone is in their 40s or 50s. However, it is unclear whether this is because of ageing itself, or due to a person's improved self-awareness of the poor outcomes of their negative behaviour.

Pathological

Refers to a condition that is caused by a physical or mental disease.

Substance abuse

The behaviour of consuming unhealthy levels of alcohol and/or using recreational drugs.

2. Scarpa, A., and Raine, A. (1997) Psychophysiology of anger and violent behavior. The Psychiatric Clinics of North America 20:375–394.

Methods for diagnosis

An initial evaluation of a person will involve taking their medical history, performing a physical examination and, in some cases, ordering relevant laboratory tests. In particular, a neurological examination will be done to identify underlying conditions that may be causing the symptoms.

The medical history forms the most important part of diagnosis. Studies have shown that family members form a crucial part of establishing an accurate medical history. The medical history involves asking when the symptoms started, how much they affect daily life and whether the person has experienced thoughts of self-harm, suicide or harm to others.

Laboratory tests may include a full blood count, thyroid function, liver function and urine screening for alcohol and other drugs. Laboratory tests can help establish whether the symptoms are being caused by an underlying medical condition.

 ASPD is suspected in people who present to their healthcare provider with substance abuse, injury from reckless behaviour, drug-seeking behaviour, recurrent sexually-transmitted infections, or evidence of physical abuse.

ASPD is only diagnosed in people over 18 years of age. There are specific criteria that need to be met in order for the diagnosis to be made:

A diagnosis of ASPD may be made when someone over the age of 18 exhibits an ongoing pattern of disregard for, and violation of, the rights of others, which is accompanied by at least three of the following behaviours:

  • A failure to conform to social expectations of 'normal' and the constraints of the law;
  • Repeated lying and/or the use of aliases;
  • Impulsiveness and the inability to make and stick to plans;
  • Aggressiveness and irritability;
  • Reckless disregard for their own safety and of those around them;
  • Consistent irresponsibility, such as failure to maintain employment or to honour financial obligations, and;
  • An overt lack of remorse.

Full blood count

A blood test that examines the blood, either by using a microscope or an automated machine, to determine the number of red blood cells, white blood cells and platelets.

Neurological

Of the nervous system, including the brain.

Thyroid function

A blood test to test the levels of hormones produced by the thyroid and the levels of thyroid-stimulating hormone produced by the pituitary gland.

Sexually-transmitted infections

A viral or bacterial infection contracted through sexual intercourse or genital contact. Such an infection can lead to development of diseases such as chlamydia, gonorrhoea, genital herpes and AIDS.

Substance abuse

The behaviour of consuming unhealthy levels of alcohol and/or using recreational drugs.

Self-harm

The act of deliberating injuring oneself, such as cutting or burning one's skin.

Suicide

The act of intentionally killing oneself.

2. Scarpa, A., and Raine, A. (1997) Psychophysiology of anger and violent behavior. The Psychiatric Clinics of North America 20:375–394.

Types of treatment

ASPD is a challenging condition to treat. There is currently no effective treatment available.

Medication

No specific medication is recommended for treatment, as no particular medication has been shown to be effective. However, some people may experience relief from some of their symptoms with medication. In particular, people with severe aggression can potentially be treated with a range of medications that may include risperidone, quetiapine, sertraline or fluoxetine, lithium carbonate or carbamazepine. Such medications may have side effects including irregular jerky or rigid movements, tremors or spasms, weight gain and metabolic syndrome.

People with ASPD who also experience major depression, substance abuse or anxiety may also benefit from medication, but the effectiveness of such treatment is still not clearly understood.

In particular, antisocial people with substance abuse problems may benefit from joining an addiction support program, such as methadone maintenance, which has been shown to decrease criminal behaviours and improve interpersonal relationships.

Psychotherapy

People with ASPD often have traits that interfere with the process of cognitive behaviour therapy. It can prove too difficult to work with them despite the best efforts of the therapist. However, some people with mild forms of ASPD may benefit from such therapy. 

Coping skills for family members

Given the difficulties faced by people with ASPD, family members can learn effective coping strategies to learn how to set boundaries and help protect themselves from the aggression, anger and violence that are common in people with ASPD. 

Anxiety

A feeling of tension, nervousness and dread about future events. It can trigger physical symptoms such as a rapid pulse or breathing difficulties.

Cognitive behaviour therapy

A psychological or 'talking' therapy that focuses on changing unhelpful thoughts and behaviours that are causing a person distress.

Tremors

Unintentional trembling in one or more parts of the body.

Substance abuse

The behaviour of consuming unhealthy levels of alcohol and/or using recreational drugs.

2. Scarpa, A., and Raine, A. (1997) Psychophysiology of anger and violent behavior. The Psychiatric Clinics of North America 20:375–394.

Potential complications

  • Reckless behaviour;
  • Child abuse;
  • Gambling problems;
  • Premature death due to reckless behaviour;
  • Being in prison;
  • Anxiety;
  • Aggression leading to verbal or physical abuse;
  • Relationship difficulties;
  • School or work difficulties;
  • Homicidal or suicidal behaviours;
  • Self-harm or self-mutilation;
  • Low socio-economic status and homelessness, and;
  • Substance abuse.

Anxiety

A feeling of tension, nervousness and dread about future events. It can trigger physical symptoms such as a rapid pulse or breathing difficulties.

Substance abuse

The behaviour of consuming unhealthy levels of alcohol and/or using recreational drugs.

Self-harm

The act of deliberating injuring oneself, such as cutting or burning one's skin.

2. Scarpa, A., and Raine, A. (1997) Psychophysiology of anger and violent behavior. The Psychiatric Clinics of North America 20:375–394.

Prognosis

ASPD is usually a lifelong disorder that begins in childhood and is fully expressed by late 20s or early 30s. An earlier diagnosis can help to improve outcomes, help with family and community involvement, marital attachment and employment status. Most people's symptoms will ease with age. 

2. Scarpa, A., and Raine, A. (1997) Psychophysiology of anger and violent behavior. The Psychiatric Clinics of North America 20:375–394.