Antisocial Personality Disorder Study Guide

Antisocial Personality Disorder

Introduction

The Diagnostic and Statistical Manual of Mental Disorders (DSM 5) classifies the ten personality disorders into three clusters: A, B and C. Antisocial personality disorder lies within cluster B, besides histrionic, narcissistic and borderline personality disorders (American Psychiatric Association, 2013). Class B disorders are characterized by unpredictable, emotional and dramatic interactions between the individual and other persons. The clinical features include a pervasive pattern of disregard for and violation of the rights of other persons, beginning from above the age of fifteen years. The individual performs acts that serve as grounds for arrest by resisting social norms pertaining to expected lawful behavior. They may also engage in repeated lying, acts of deception and using aliases or conning others for monetary gain or pleasure. Other features include impulsivity/failure to plan, aggressiveness and irritability, often involving assaults and physical fights and consistent irresponsibility marked by failure to maintain reliable work behavior or honest monetary obligations. The person may also exhibit lack of remorse, indifference or rationalize hurting or mistreating other individuals. The person should be at least eighteen years old and the disorder’s onset should be before fifteen years whereas the antisocial behavior ought not to be exclusively within schizophrenia or bipolar disorder.

Figure 1: DSM 5 Criteria for Classifying Personality Disorders

Differential Diagnoses

Paraphilias, Posttraumatic Stress Disorder, Schizophrenia, Schizoaffective disorder, Schizophreniform disorder, Social phobia, Alcoholism, Anxiety Disorders, Brief Psychotic Disorder, Bulimia Nervosa, Depression, Dissociative Disorders, Ganser Syndrome, Illness Anxiety Disorder (also known as hypochondriasis), Marrow Failure Syndromes.

Figure 2: Differential Diagnoses of Antisocial Personality Disorder

Epidemiology

The lifetime prevalence of ASPD is estimated at 1 to 4 % within the general population. Males have a likelihood of thrice to five times of being diagnosed with ASPD than females, having incidences of 6 % and 2 % respectively. Reliable studies reveal decreasing prevalence rates with increasing age, attributable to personality trait changes with age and increasing mortality with individuals having the antisocial personality disorder. Cultural considerations for personality disorders are founded on the social-historical concepts of personality, developmental processes and neurobiology.  Western cultures encouraging individualism and independence may be reflected in self-reported psychological stress among persons endeavoring to establish a “goodness of fit” between their style and the immediate society.

Psychotherapy is the mainstream treatment for antisocial personality disorder. The therapist focuses on changing the patient’s thinking process (cognitive therapy) and encouraging socially acceptable behavior (behavioral therapy). Family therapy increases the understanding among family members of the person with the condition whereas group therapy should be coutured to meet the needs of individuals with the disorder. Group therapy encourages the person to share his/her experience with other persons having the disorder. Medication is helpful in stabilizing mood swings or treating the distressing symptoms such as impulsivity and violent aggressiveness. Alcohol dependence is managed with nortriptyline whereas bromocriptine and nortriptyline manage anxiety. Phenytoin may decrease the frequency and intensity of impulsive acts. Figure 2: Therapy modalities for ASPD

The prognosis for ASPD is often poor. Persons with antisocial personality disorder have higher risk for substance abuse, besides higher likelihood of being imprisoned for criminal acts. They also have higher likelihood to die via violence. Since they rarely seek medical attention independently, the legal system is the main body availing treatment to them.

The diagnosis of ASPD depends primarily on complete medical history and physical evaluation. No specific laboratory tests may diagnose any personality disorder, although the doctor may use blood tests, X-rays of the chest and abdomen; and CT-scan of the head to rule out physical illnesses that could have caused the symptoms.

Co morbidities of ASPD include other mental disorders, particularly schizophrenia. ASPD manifests symptoms suggestive of psychosis and propensity for violence. Nonetheless the violence is to lesser extremes than in schizophrenia and occurs only during a manic episode, marked with agitated behavior.

The ethical and legal considerations pertaining to ASPD arises first from the fact that  the DSM criteria centers on the criminal and antisocial behavior instead of the underlying interpersonal deficits and personality structure. The conflict centers on whether the persons have medical conditions or intentionally engage in social rule breaking without remorse (Yakeley and Williams, 2018). The medical and legal disciplines are often in dilemma whether the individuals ought to be punished for their criminal acts or treated with moral re-education.

Patient education should include increasing awareness of the condition to the individual. The person should also be directed to see the detrimental effects of their irresponsible acts. Also the therapist should direct them to envisage the benefits of socially acceptable behavior (Skodol, 2020). They could be encouraged to seek employment opportunities, pay bills and loans on time and provide child support.

References

  • American Psychiatric Association (2013). DSM 5. American Psychiatric Association, 70.
  • Fisher KA, Hany M. Antisocial Personality Disorder. [Updated 2020 Dec 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK546673/
  • Khalifa, N., Duggan, C., Stoffers, J., Huband, N., Völlm, B. A., Ferriter, M., & Lieb, K. (2010). Pharmacological interventions for antisocial personality disorder. The Cochrane database of systematic reviews, (8), CD007667. https://doi.org/10.1002/14651858.CD007667.pub2
  • Mulder, R. (2017) Cultural Aspects of Personality Disorder. The Oxford Handbook of Personality Disorders. Retrieved from doi 10.1093/oxfordhb/9780199735013.013.0013
  • Skodol, A. (2020) Antisocial Personality Disorder. University of Arizona College of Medicine. Retrieved from https://www.msdmanuals.com/home/mental-health-disorders/personality-disorders/antisocial-personality-disorder
  • Yakeley, J., & Williams, A. (2018). Antisocial personality disorder: New directions. Advances in Psychiatric Treatment, 20(2), 132-143. doi:10.1192/apt.bp.113.011205