Antisocial Personality Disorder (ASPD)

Key takeaways

• People with antisocial personality disorder frequently break rules and engage in behavior that causes harm. They show little regret or remorse for their actions.

• ASPD affects around 3% of the global population, making it the second most common personality disorder.^[1]It can only be diagnosed in people aged 18 or older.

• ASPD can be difficult to treat, but the symptoms often decrease as people become older, especially after the age of 40.^[2]

Understanding antisocial personality disorder

Antisocial personality disorder is a Cluster B personality disorder. This means that it is a long-term mental health condition affecting someone’s beliefs, values, traits, and behaviors. Impulsive behavior, unstable emotions, and difficulty in interpersonal relationships characterize cluster B personality disorders.^[3]

People with ASPD consistently break rules and laws, causing harm to themselves and the people around them. They have little regard for the welfare of others and will rarely express regret or remorse for the harm their actions have caused.^[4]

ASPD affects around 3% of the population and is 3 times more common in men than in women.^[1][5]

The first symptoms of ASPD typically appear early in life, although it is the only disorder with a minimum age for diagnosis, and cannot be diagnosed in people under the age of 18.^[6]One study found that almost 80% of people with ASPD had already displayed symptoms at age 11.^[7]Children under 18 who show signs of ASPD are diagnosed with conduct disorder (CD) rather than antisocial personality disorder.^[8]

Personality disorders are often understood on the dimensions of harm avoidance, novelty seeking, reward dependence, and persistence. People with ASPD show low harm avoidance, rarely appearing anxious or afraid, but score highly on novelty-seeking, taking part in risky behavior. They have low levels of reward dependence, not seeking social approval, and persistence, becoming easily frustrated when tasks are difficult.^[4]

Is antisocial personality disorder the same as sociopathy or psychopathy?

Psychopathy and sociopathy are not currently recognized disorders according to either DSM-5 or ICD-11. Antisocial personality disorder was known as sociopathic personality disturbance from its first appearance in 1952 until the name was changed to ASPD in 1968.

Psychopathy is included in DSM-5, but not as a disorder. Instead, there are a series of personality traits that are considered psychopathic traits. These include insincere charm, compulsive lying, shallow emotions, and an inflated sense of importance. When someone fulfills all of the criteria for ASPD and also shows these traits, they can be diagnosed with ASPD with psychopathic features.^[9]

Most people with psychopathy have ASPD, but only 25-30% of people with ASPD meet criteria for psychopathy.^[10]Research suggests that people with ASPD without psychopathic traits are significantly different from those with those traits. For example, those without psychopathic traits are less likely to commit crimes while in prison.^[11]

Causes of antisocial personality disorder

Mental illness rarely has a single cause, and this is especially true for personality disorders. ASPD is caused by a combination of genetic, biological, environmental, and psychological factors.

Biological and genetic factors

Current evidence suggests that ASPD is 50% heritable.^[11]. This heritability derives from an interaction between several genes, rather than coming from a single gene. Researchers are still exploring exactly which genes are involved, but have found some that have a significant impact.^[5]

Those genes, and possibly environmental factors, create differences in how the brain is structured, neurotransmitter levels, and patterns of brain activity in people with ASPD. These changes are complex and not yet fully understood, but a pattern is slowly emerging.

Genes associated with ASPD affect the serotonin system in the brain.^[5]Other genes change how oxytocin works in the amygdala (a brain region associated with emotions such as fear) in men, although it doesn’t have this effect in women.^[12]This may help explain some of the gender disparity in ASPD.

Low levels of MAO-A, which breaks down neurotransmitters in the brain, are also associated with ASPD, and high testosterone levels are associated with antisocial personality traits in both men and women.^[13][14]

The prefrontal cortex (PFC) is an area of the brain responsible for impulse control and good decision-making. This is smaller in people with ASPD, although this could be a result of the disorder rather than the cause.^[15][16]People with ASPD also show less activity in this brain area during brain scanning tasks, although this may only apply to people with ASPD with psychopathic traits.^[11]. ASPD is also associated with problems in the limbic system, which helps process emotions.^[17]

The autonomic nervous system, which controls involuntary processes such as heart rate and breathing, may be less responsive in people with ASPD.^[13]This could result in them experiencing less intense physical signs of their emotions and contribute to symptoms.

Social, environmental, and psychological factors

Conduct disorder in children is thought to become ASPD in some adults.^[18]Only 25% of girls and 40% of boys with CD go on to develop ASPD, however, suggesting that they are different disorders.^[7]

Both ASPD and CD are closely associated with childhood neglect and other adverse childhood experiences. ASPD is more common in children with insecure attachment styles, particularly disorganized attachment.^[19]Some researchers suggest that ASPD develops from this insecure attachment, where children don’t learn to interact with other people on an emotional level, despite being able to understand those interactions cognitively.^[20][21]

Parenting styles may play a role in the development of ASPD. Parental training can help reduce the likelihood of children with CD developing ASPD when they become adults.

Other mental health conditions, such as ADHD, may increase the risk of someone developing ASPD.^[2]ASPD may develop differently in people who also have an anxiety disorder.^[11]

ASPD is an extremely complicated disorder, with many factors playing a role. Some studies have even suggested that watching TV makes a noticeable difference to the risk of ASPD.^[23]With so many risk factors and co-occurring conditions, it’s very difficult to identify which factors might cause ASPD, which are the result of ASPD, and which simply occur more often in people with ASPD due to other issues.

Other disorders commonly found with antisocial personality disorder

ASPD is often found alongside other disorders. Conduct disorder is considered a precursor for antisocial personality disorder, but other disorders are also more common in people with ASPD. These include

• Substance use disorder (SUD): 80-85% of people with ASPD also have a SUD, commonly alcohol addiction.^[24]

• PTSD: People who experience PTSD during childhood or adolescence are at increased risk of developing ASPD.^[25]In one study, approximately 21% of people with ASPD also had PTSD.^[26]

• ADHD: One study found that around 65% of people with ASPD also have ADHD.^[27]ADHD is also considered a risk factor for children later developing ASPD.^[22]

• Major depressive disorder (MDD): Adults with ASPD are 2.7 times more likely to be diagnosed with MDD.^[5]

• Borderline personality disorder (BPD): BPD has high rates of comorbidity with ASPD, and there is significant overlap between their symptoms.^[11]

• Anxiety disorders. Approximately two-thirds of patients diagnosed with ASPD also receive a diagnosis of an anxiety disorder, for example, social anxiety disorder.^[28]

There is some evidence that symptoms of ASPD can interact with those of other conditions, leading to worse outcomes. For example, those with impulsivity from bipolar disorder and impulsivity from ASPD are more impulsive than people who only have one condition. This suggests that different mechanisms cause this impulsivity, and having both conditions prevents them from compensating for this trait.^[11]

Prevention of antisocial personality disorder

In general, personality disorders have historically not been considered preventable, but antisocial personality disorder may be an exception. Because ASPD is closely associated with conduct disorder, it’s possible to identify children who are at risk of developing ASPD and offer support and treatment early.

Research to identify which children with CD are most at risk could help prevent ASPD. There may be a difference between children who have both CD and ADHD and those who only have CD, and those who have both disorders usually experience worse outcomes.^[29]

Some studies suggest that training aimed at parents can help reduce the likelihood that children with CD will go on to develop ASPD, but more high-quality research is needed to be sure.^[30]Other researchers highlight that peer relationships may be a significant risk factor in developing ASPD from CD, but these are rarely studied.^[6]

Other treatments that may help children with CD avoid developing ASPD include trauma-focused interventions and attempts to improve mentalization.^[30]

Symptoms of antisocial personality disorder

Antisocial personality disorder is associated with a wide range of symptoms, many of which relate to how the person interacts with others and their behavior. People with this disorder also experience thoughts and feelings that are different from most people.^[4]

Behavioral symptoms of ASPD

People with ASPD behave in ways that are frequently harmful to the people around them. Their actions can be impulsive and are often driven by their strong emotions.

Behavioral symptoms of ASPD include

• Criminality, especially assaults and arson.

• Drug use.

• Risky sexual behavior.

• Violent behavior.

• Failure to conform to social norms.

• Impulsive or reckless behavior.

• Difficulty not acting on their emotions.

• Lying and manipulating others.

• Difficulty holding down a job.

Cognitive symptoms of ASPD

People with ASPD rarely think about the rights, needs, or well-being of others. They also fail to fully consider the consequences of their actions, especially if those consequences will harm others. Importantly, they usually see nothing wrong with their actions and will justify the harm they cause.

Common cognitive symptoms of ASPD include

• Inability to distinguish between right and wrong.

• Justifying or rationalizing harmful behavior.

• Easily bored.

• Refusal to accept responsibility for their choices or actions.

• Disinterest in the safety of others.

• Failure to consider consequences.

• Difficulty understanding other people’s mental and emotional states (mentalizing).

• Difficulty recognizing and naming their own emotions.

Emotional symptoms of ASPD

People with ASPD often experience strong negative emotions, which can drive some of their harmful behaviors. They can also struggle to feel emotionally attached to others or empathize.

Common emotional symptoms of ASPD include

• Frequently feeling aggressive or irritable.

• Emotional detachment.

• Absence of remorse.

• Frequent mood swings.

• Difficulty controlling emotions.

• Smaller range of emotions, particularly prosocial emotions.

• Easily frustrated or provoked.

Diagnosing antisocial personality disorder

Because antisocial personality disorder is a complex disorder, it needs to be diagnosed by a trained healthcare professional, usually a psychologist or psychiatrist. ASPD is predominantly diagnosed through a clinical interview, in which the clinician attempts to understand the patient’s thoughts, feelings, and behaviors.

As part of this clinical interview, clinicians are comparing their patients’ behavior and experiences to the criteria listed in DSM-V. To diagnose someone with ASPD, they need to be sure that they meet all of the necessary criteria.^[8]

These include showing signs of conduct disorder before the age of 15, and they must currently be at least 18 years old.

The person must also display at least 3 of the following behaviors or traits

1. Failure to conform to social norms and laws, indicated by repeatedly engaging in criminal behavior.

2. Deceitfulness, indicated by continuously lying, using aliases, or conning others for personal gain and pleasure.

3. Exhibiting impulsivity or failing to plan ahead.

4. Irritability and aggressiveness, indicated by repeated violence.

5. Reckless and unsafe behavior.

6. Irresponsibility, for example, by repeatedly failing to consistently work or honor financial obligations.

7. Lack of remorse after hurting or mistreating another person.

Those behaviors must not only occur as a consequence of schizophrenia or during manic episodes.

This is the most common approach to diagnosing ASPD, but DSM-V does offer an alternative approach known as Section III. This approach prioritizes personality traits over behaviors and may incorporate more aspects of psychopathy, but it is rarely used outside of research studies.^[31]

What assessments and tests are used

Antisocial personality disorder can be extremely difficult to diagnose, and there are no laboratory tests, such as blood tests or scans, available to help clinicians form this diagnosis.^[32]There are currently no validated assessment tools to screen for ASPD either. Instead, healthcare professionals refer directly to the diagnostic criteria in DSM-5.

Clinicians may use a test, such as the Hare Psychopathy Checklist-Revised (PCL-R), to screen for psychopathic traits in someone who is being assessed for ASPD, but these traits are not required for a diagnosis of ASPD.^[33]

Risks and complications from antisocial personality disorder

Antisocial personality disorder carries significant risks. As well as being vulnerable to other mental health diagnoses, people with ASPD experience higher rates of accidents, injuries, suicide attempts, and infections such as hepatitis C and HIV.^[34]

Because of the connection with criminal behavior, people with ASPD have a higher probability of being imprisoned, and 50-80% of convicted offenders have the disorder.^[35]Similarly, people with ASPD are more likely to experience homelessness.^[36]

Risks to others

Antisocial personality disorder is associated with significant risks to others because of the harmful behaviors people with this disorder show and their lack of remorse. Criminal behavior, especially violent acts, harms individuals and the community.

Children of people with ASPD can be at increased risk of adverse childhood experiences, which in turn increases their vulnerability to mental health issues in the future. While most people with ASPD do not abuse children, it is more common in people with ASPD who have experienced abuse themselves.^[6]

Treatment options for antisocial personality disorder

Treatment of ASPD can be especially difficult because, not only do patients lack insight into their condition in the same way as other personality disorders, they are also less inclined to care about the harm done to others as a result of their PD. The lack of empathy and remorse makes people with ASPD unlikely to be motivated to change.

Symptoms of ASPD often reduce naturally as the patient becomes older, particularly after the age of 40.^[2]

Therapy

The main form of treatment for people with ASPD is psychotherapy, also known as talking therapy. Which type of therapy should be used depends on the patient, what therapy is trying to achieve, and potentially whether psychopathic traits are also present.^[21]

Common treatment modalities for people with ASPD include

• Dialectical behavior therapy (DBT): Originally developed to treat people with BPD, DBT aims to teach mindfulness, distress tolerance, emotional regulation, and interpersonal skills to people with ASPD.

• Cognitive behavioral therapy (CBT): CBT is a form of therapy designed to help people recognize, challenge, and change any thoughts, feelings, and behaviors that are causing problems in their lives. CBT can be effective for some patients with ASPD, but many people with ASPD do not see benefits for themselves in making these changes.

• Schema therapy: Schema therapy aims to identify beliefs and thought patterns that people with ASPD developed early in life, which support their current behavior. Patients are encouraged to explore alternative thoughts and beliefs that may be more helpful.^[37]

• Multisystemic therapy: Multisystemic therapy is often used with adolescents who have ASPD and works with schools, families, and other important figures in the patient’s life, as well as with the patient themselves.^[38]

• Mentalization-based therapy (MBT): MBT helps people with ASPD to understand their own thoughts and feelings. Therapists will then use this understanding to help patients recognize other people’s internal mental world.

Often, treatment for ASPD aims to minimize some of the most difficult behaviors, typically criminality, even where it is unable to address the underlying thoughts and emotions. This is reinforced by court-mandated treatment for people with ASPD who have committed serious crimes, despite limited evidence for the effectiveness of psychotherapy in that context.^[39]

While psychotherapy can be effective in helping some people with ASPD to minimize their symptoms, ASPD remains difficult to treat. Therapists can struggle to form a therapeutic alliance, which is essential to the success of psychotherapy, with this group of patients.^[11]Many people with ASPD will also end therapy prematurely.^[40]

Medication

There are no medications designed or licensed to treat ASPD. Many patients with ASPD will be offered medications either to minimize symptoms or to treat other mental health disorders they may have.

Antipsychotics, mood stabilizers, and antidepressants are all commonly offered to people with ASPD. In some cases, benzodiazepines can be used to help with emotional regulation, but given the high risk of substance abuse in this group, they are used with caution

Alternative

Virtual reality (VR) interventions may allow people with ASPD to explore social situations in a safe and controlled environment. There is some evidence that techniques using VR can help people with ASPD to better identify and understand other people’s emotions.^[37]

Final thoughts

Antisocial personality disorder is a difficult disorder, harming both the sufferer and the people around them. People with ASPD often find that their symptoms reduce significantly as they become older, but it is otherwise very difficult to treat. Current research may create opportunities to help prevent children with CD from developing ASPD.