Antisocial personality disorder is characterized by a pervasive pattern of disregard for consequences and for the rights of others. Diagnosis is by clinical criteria. Treatment may include cognitive-behavioral therapy, antipsychotic medications, and antidepressants.
People with antisocial personality disorder commit unlawful, deceitful, exploitative, reckless acts for personal profit or pleasure and without remorse; they may do the following:
Estimates of the lifetime prevalence of antisocial personality disorder range from 2 to 5% based on several large epidemiologic surveys from the United States and the United Kingdom ( 1, 2 ). Antisocial personality disorder is more common among males than among females (3:1) ( 3 ), and there is a strong heritable component. Prevalence decreases with age ( 4 ), suggesting that patients can learn over time to change their maladaptive behavior.
Comorbidities are common. Most patients also have a substance use disorder (and about half of those with a substance use disorder meet criteria for antisocial personality disorder) ( 3 ). Patients with antisocial personality disorder often also have an impulse control disorder , mood disorders , anxiety disorders , gambling disorder, attention-deficit/hyperactivity disorder , or borderline personality disorder .
Both genetic and environmental factors (eg, abuse during childhood ) contribute to the development of antisocial personality disorder. A possible mechanism is impulsive rather than planned aggression, related to abnormal serotonin transporter functioning. Disregard for the pain of others during early childhood has been linked to antisocial behavior during late adolescence.
Antisocial personality disorder is more common among 1st-degree relatives of patients with the disorder than among the general population ( 1 ). Risk of developing this disorder is increased in both adopted and biologic children of parents with the disorder.
If conduct disorder accompanied by attention-deficit/hyperactivity disorder develops before age 10 years, risk of developing antisocial personality disorder during adulthood is increased ( 2 ). Risk of conduct disorder evolving into antisocial personality disorder may be increased when parents abuse or neglect the child or are inconsistent in discipline or in parenting style (eg, switching from warm and supportive to cold and critical [ 3 ]).
Patients with antisocial personality disorder may express their disregard for others and for the law by destroying property, harassing others, or stealing. They may deceive, exploit, con, or manipulate people to get what they want (eg, money, power, sex). They may use an alias.
These patients are impulsive; they do not plan ahead or consider the consequences for or the safety of self or others. As a result, they may suddenly change jobs, homes, or relationships. They may speed and drive while intoxicated, sometimes leading to crashes. They may consume excessive amounts of alcohol or take illicit drugs.
Patients with antisocial personality disorder are socially and financially irresponsible. They may change jobs with no plan for getting another. They may not seek employment when opportunities are available. They may not pay their bills, default on loans, or not pay child support.
These patients are often easily provoked and physically aggressive; they may start fights or abuse their spouse or partner. In sexual relationships, they may be irresponsible and exploit their partner and be unable to remain monogamous.
Remorse for actions is lacking. Patients with antisocial personality disorder may rationalize their actions by blaming those they hurt (eg, they deserved it) or the way life is (eg, unfair). They are determined not to be pushed around and to do what they think is best for themselves at any cost.
These patients lack empathy for others and may be contemptuous of or indifferent to the feelings, rights, and suffering of others.
Patients with antisocial personality disorder may be very opinionated, self-assured, or arrogant. They may be charming, voluble, and verbally facile in their efforts to get what they want.
For a diagnosis of antisocial personality disorder ( 1 ), patients must have
This disregard is shown by the presence of ≥ 3 of the following:
Also, patients must have evidence that a conduct disorder has been present before age 15 years. Antisocial personality disorder is diagnosed only in people ≥ 18 years.
Antisocial personality disorder should be distinguished from the following:
There is no evidence that any particular treatment leads to long-term improvement. Thus, treatment aims to reach some other short-term goal, such as avoiding legal consequences, rather than changing the patient. Contingency management (ie, giving or withholding what patients want depending on their behavior) may be of limited benefit ( 1 ). Comorbid disorders (eg, mood disorders , substance use disorders ) should also be treated according to their preferred approach.