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Day # 132: Antisocial Personality Disorder

Today we will continue our current theme of personality disorders as we begin to discuss the cluster B personality disorders. Today's topic is antisocial personality disorder.

Introduction 1

  • Individuals with antisocial personality disorder (ASPD) have a long-standing pattern of rule-breaking, exploiting others without remorse, and disregarding the rights and safety of others.

  • They may also be skilled at interpreting social cues and can appear charming to those who meet them for the first time and do not know their history.

  • Common traits/symptoms may include being -> impulsive, deceitful, dishonest, rule-breakers, manipulative, selfish, antagonistic, lack remorse, impulsive, irritable, angry, aggressive, reckless, hostile, irresponsible, and unlawful.

Diagnostic Criteria 2

  • The diagnosis of ASPD requires a pattern of disregard for and violation of the rights of others since age 15. Patients must be ≥ 18 years old for this diagnosis with a history of behavior consistent with conduct disorder during childhood/adolescence.

  • ≥ 3 of the following must also be present: Mnemonic "CORRUPT"

  • Crime - Failure to conform to social norms by committing unlawful acts

  • Obligations - Irresponsibility/failure to sustain work or honor financial obligations

  • Reckless - Recklessness and disregard for safety of self or others

  • Remorseless - Lack of remorse for actions

  • Underhanded - Deceitfulness/repeated lying/manipulating others for personal gain

  • Planning - Impulsivity/failure to plan ahead

  • Temper - Irritability and aggressiveness / repeated fights or assaults

Epidemiology/Pathogenesis 3, 4, 5

  • Prevalence is estimated to be 0.2 - 4% of the general population and is much more common in men.

  • As with all personality disorders, the dominant theory suggest ASPD develops from a combination of genetic vulnerability and environmental stressors.

  • Higher prevalence among the prison population and poor urban areas. Some estimate the prevalence of ASPD in prison populations may be as high as 75-80%. Other risk factors include early childhood trauma (with some evidence to suggest that physical abuse particularly predisposes to ASPD) and excessive parental rigidity surrounding rules.

  • Relatives of patients with ASPD show a higher incidence than among control participants. The disorder is five times more common among first-degree relatives and twin studies estimate a heritability of 67%.

  • Prognosis: Symptoms and behaviors first appear in childhood (see "history" below). Usually has a chronic course but some reports indicate that symptoms may improve as the individual ages. Many patients have somatization disorder and multiple physical complaints. There is increased morbidity from substance abuse, incarcerations, trauma, suicide, or homicide.

Clinical Pearls 4, 5, 6

  • History: Antisocial PD begins in childhood as conduct disorder. Individuals have a persistent pattern of violating rules or social norms and may have a history of aggression to people or animals, destruction of property, deceitfulness or theft, or other serious violation of rules. Lying, running away from home, truancy, thefts, fights, substance abuse, and illegal activities are typical experiences that begin in childhood. Consider the diagnosis of ASPD in patients who malinger, have a history of arrests, physically/sexually abuse others, and those with a lifelong pattern of substance use.

  • Mental status exam: Individuals may initially appear normal, composed, or even charming during an interview and can fool experienced clinicians. Alternatively, they may come off as manipulative, threatening, demanding, irritable, hostile, or full of rage. Some experts suggest that a "stress interview", in which individuals are vigorously confronted with inconsistencies in their histories, may be necessary to unmasks this tension. Another notable finding is a lack of remorse for destructive or unlawful behaviors in their life.

  • Optional personality questionnaires: Personality Assessment Inventory (PAI), Minnesota Multiphasic Personality Inventory (MMPI), Psychopathy Checklist (PCL-22), Antisocial Personality Disorder Test.

  • Differential diagnosis: Consider and rule out substance use disorders, mania, schizophrenia, and other personality disorders. A comorbid substance use disorder is present in 75% of individuals with ASPD. Consequences of substance abuse (theft to obtain money for drugs, illegal selling of drugs, aggressive behavior while intoxicated) may mirror certain behaviors seen in ASPD. Attempt to ascertain whether the substance abuse or antisocial behavior came first, however this is not always possible. If both began in childhood and continued into adulthood both diagnoses should be made. If the antisocial behavior is clearly secondary to premorbid drug abuse then a diagnosis of ASPD is not warranted. Also consider other personality disorders in the differential diagnosis, particularly other cluster B disorders (narcissistic, histrionic, borderline). To diagnose ASPD in someone with illegal behavior they must also display the maladaptive and persistent personality traits described in this post otherwise it is classified as "criminal behavior not associated with a personality disorder".

Treatment 7, 8, 9

  • General approach to personality disorders: In general, the first-line treatment of all personality disorders is psychotherapy, however, the data is not robust and depending on the personality disorder, patients rarely seek treatment themselves unless they have other comorbid behavioral health conditions. Patients with personality disorders may be highly symptomatic and are often prescribed multiple medications in a manner unsupported by evidence.

  • Psychotherapy: There is no clear evidence that any form of psychotherapy is effective at reducing antisocial behavior in individuals with ASPD. Cognitive behavioral therapy (CBT), dialectal behavioral therapy (DBT), impulsive lifestyle counseling (ILC), and other forms of therapy have been studied but there is no compelling evidence for an improvement of physical aggression, incarceration, social functioning, or other parameters. According to the authors of Pocket Psychiatry "evolving psychoanalytic conceptions of ASPD place it on a spectrum of severity with narcissistic personality disorder (ie, NPD —> malignant narcissim —> ASPD —> psychopathy) and the presence of more narcissistic features is hypothesized to make therapy more viable, though not empirically validated".

  • Pharmacotherapy: There are no FDA approved medications for ASPD. No trials demonstrate efficacy of any medication for ASPD. Clinical practice is largely based on expert opinion and case studies which suggest ASPD aggression could be treated with second-generation antipsychotics, mood stabilizers, or adrenergic receptor antagonists. Comorbid anxiety and depressive disorders should be treated accordingly (see treatment of depression; treatment of anxiety), but caution should be used when selecting medications due to the high addictive potential of these patients. Expectations for treatment response should be attenuated and the potentially limited benefits must outweigh the risks associated with medication treatment.



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