- Treatment of Antisocial Personality Disorder
- Treating Other Medical Needs
- The use of medication to treat people with antisocial personality disorder
- What should be done with antisocial personality disorder in the new edition of the diagnostic and statistical manual of mental disorders (DSM-V)?
- Antisocial Personality Disorder
- What Is It?
- Antisocial Personality Disorder: Management and Treatment
- Treatment for Antisocial Personality Disorder
- What to Know About Antisocial Personality Disorder Treatment
Treating Other Medical Needs
Even if antisocial personality disorder itself cannot be treated, people with the condition can seek treatment for other mental health problems. Psychiatric conditions in general are much more common in this population than in the general population. (3)
In one study, 90 percent of people with antisocial personality disorder had another mental illness. The most common coexisting diagnosis is a substance dependence disorder. Women with antisocial personality disorder are at higher risk for substance use disorders than men with the disorder. (3)
Substance dependence can be treated with medication in some cases depending on the specific addiction a person has. For example, a person with an opioid addiction may be prescribed Subutex (buprenorphine), methadone, or extended-release naltrexone. (7) Similarly, Vivitrol (naltrexone), acamprosate, and Antabuse (disulfiram) can be used to treat alcohol dependence in a person with (or without) antisocial personality disorder. (8)
People with an antisocial personality disorder diagnosis are also at higher risk for anxiety and depression. About half of all people with antisocial personality disorder have an anxiety disorder, and about one-quarter of them have depression. (3) These conditions are treated similarly in those with and without antisocial personality disorder. But there is not much research on whether those treatments are as effective in people with antisocial personality disorder.
The most common first-line treatment for anxiety and depression disorder is a class of drugs called selective serotonin reuptake inhibitors (SSRIs). These drugs work by altering the amount of serotonin, a brain chemical called a neurotransmitter, in the brain. Serotonin plays a role in a person’s mood.
Several other groups of drugs also alter the concentration of certain neurotransmitters in the brain and can be used to treat depression, some anxiety disorders, or attention deficit hyperactivity disorder (ADHD). These include the following:
- Serotonin-norepinephrine reuptake inhibitors (SNRIs)
- Serotonin-norepinephrine-dopamine reuptake inhibitors (SNDRIs)
- Norepinephrine-dopamine reuptake inhibitors (NDRIs)
- Norepinephrine reuptake inhibitors (NRIs)
Someone with both bipolar disorder and antisocial personality disorder may be prescribed mood stabilizers, possibly including anti-epileptics like those discussed above. Someone with bipolar disorder or schizophrenia-like disorders may be prescribed an antipsychotic drug as well. None of these drugs are specifically approved to treat antisocial personality disorder, but if they successfully treat another condition in a person with antisocial personality disorder, that may reduce the person’s antisocial tendencies as well. (3)
Antisocial personality disorder is a condition characterised by persistent social rule-breaking, deceitfulness, offending behaviour, irresponsibility, lack of remorse and failure to plan ahead. People with antisocial personality disorder often present with a range of other problems including alcohol and illicit drug misuse, anxiety, depression, unemployment, homelessness and relationship difficulties. The condition causes a great deal of distress for the individual concerned and to the people around them including family members and friends. Also, it puts a huge financial burden on the society in terms of health and social care expenditure. This review sets out to assess the evidence for the effectiveness of medication used to treat antisocial personality disorder.
We considered eight studies, but none of them recruited participants solely on the basis of having antisocial personality disorder. While most studies included in this review looked at treatments to reduce drug or alcohol misuse in people with antisocial personality disorder, no study focused on treating the disorder itself. Studies varied in terms of choice of outcomes. While some studies reported outcome measures that were originally defined in the review protocol as being of particular importance in this disorder (for example, aggression, social functioning and adverse effects resulting from the use of medication), no study reported on reconviction.
In summary, we were unable to draw any firm conclusions from the existing literature. Nonetheless, there was some evidence that nortriptyline (a drug used to treat depression) could help people with antisocial personality disorder to reduce their misuse of alcohol. There was also some evidence that phenytoin (a drug used to treat epilepsy) could help to reduce the intensity of impulsive aggressive acts in people with antisocial personality disorder. Further research is required to clarify which medications are effective for treating the core features of this disorder. This research is best carried out using carefully designed clinical trials. Such trials should recruit sufficient numbers of people on the basis of having the disorder and use outcome measures that are of particular relevance to this disorder. They should also focus on recently marketed drugs where these have largely replaced older medications (for example, nortriptyline and phenytoin) which are no longer widely used.
Overall, mental illness should primarily be diagnosed so that patients can obtain optimal treatment. A secondary aim should be to safeguard society against dangerous individuals. For a disorder such as antisocial personality disorder, both aims are highly relevant. If patients diagnosed as having an antisocial personality disorder do not receive treatment, it may simply be because there is no way to help such patients, or because such patients are all ‘treatment rejecting’ .
Do we know for a fact that people with antisocial personality disorder cannot be treated? Experience with other types of psychiatric illness suggests that there are barriers to treatment, not all of which are intrinsic to the disorder itself. For example, the stigma attached to mental illness, the belief that available treatments will not be helpful, and the basic level of public awareness of the nature of mental illness, may all have an impact on the behaviour of both the patients and their family members, and also the behaviour of service providers (see, for example, ).
Few treatments have been tested for antisocial or psychopathic personality disorder. A review of psychosocial treatments for antisocial personality disorder found 11 studies in total . However, only two of these studies can be considered to tailor specifically for antisocial personality disorder . Nevertheless, findings reviewed across a range of areas revealed that patients with antisocial personality disorder are able to respond to treatment options designed to target a number of the symptoms associated with this condition . These symptoms include substance abuse, driving under the influence, as well as anger and violence. Simultaneously developers of mentalisation-based treatment for borderline personality disorder are working to develop their treatment to be appropriate for patients with comorbid borderline and antisocial personality disorder .
Similarly, psychoeducational, group-based prison programmes have helped patients change their criminal ways of thinking, reducing the risk of recidivism in turn and in general, correctional rehabilitation is showing effects of practical significance for criminal recidivism and offender functioning . Therefore, while it is true that the antisocial personality disorder diagnosis can sometimes be used to refuse treatment to patients, clinical research is becoming progressively more interested in viewing this diagnosis as a target for treatment.
What’s in a name?
As mentioned above, one change in the proposed criteria is the introduction of the term ‘psychopathic’. Another notable change is a higher focus on issues pertaining to interpersonal and emotional aspects of the psychopathology.
When it comes to the concept of psychopathy, the main focus of this concept has been on its utility in forensic settings, and very little has been concerned with the effective treatment of patients.
The concept of psychopathy is strongly related to predicting the risk of recidivism in criminal behaviour; 7 years ago, a meta-analysis of the single most important instrument used in psychopathy, the PCL-R, found 16 studies that had assessed the PCL-R as a predictor of institutional adjustment, and 34 studies that had assessed the PCL-R as a predictor of criminal recidivism . In contrast, research addressing psychopathy as a target for treatment is far more limited.
Thus, while it has been claimed that psychological treatments for psychopathy are ineffective or may even worsen the outcome in patients, the evidence supporting this claim is limited . Where is the evidence that suggests that psychopathic and antisocial patients cannot be treated? The evidence rests mainly on findings that indicate that psychopathy and, to a much lesser extent, antisocial personality, represent a negative prognostic factor in many contexts . Conversely, although it has been noted that higher severity predicts poorer outcome, this does not mean that treatment cannot be of some benefit; as mentioned above, many of the problems characteristic of individuals with psychopathy and antisocial personality respond to such treatment. This leads to the question: what would happen in this line of research if the concept of psychopathy were to replace the concept of antisocial personality disorder? Would researchers and clinicians continue to refine tools for evaluating dangerousness, and would the focus on treatment and counselling slip out of focus?
A search on the PubMed database (conducted 15 August 2010) revealed that out of 1,678 hits on ‘psychopathic personality’ or ‘psychopathy’, a total of 393 articles contained words such as ‘psychotherapy’, ‘counselling’, or ‘treatment’ (23% of the articles). In comparison, 2,761 of a total of 7,299 hits (38%) on ‘antisocial personality’ contained the same words. While certainly not all of the 2,761 articles containing the word with ‘antisocial personality’ and mention of ‘psychotherapy’ or ‘counselling’ can be considered as representing important works that drive a treatment agenda forward, it seems to imply that the emerging interest in actually treating patients with antisocial disorder is borne by the label of ‘antisocial’, rather than the label of ‘psychopathy’.
Indeed, in an article concerning a recent trial of cognitive behaviour therapy for antisocial personality disorder and violence, the authors stated their surprise that the patients with antisocial personality disorder were actually willing to enter treatment that was targeted for this disorder . My colleagues and I have noted the same thing in an ongoing study taking place in substance abuse treatment settings in Denmark (unpublished results; Thylstrup and Hesse). Even in the absence of tangible rewards, it appears that a number of antisocial disorder patients are willing to try treatment and even attend sessions when they are presented with a careful description of their disorder and the problems that it causes, and offered a treatment that targets this disorder.
Like other socially disadvantaged patients, patients with antisocial personality disorder have problems with dropout rates and stability. However, psychiatric and substance abuse treatment services should not give up on the agenda of developing a range of treatments for antisocial behaviours. Psychotherapy will not turn serial killers or other extremely severe psychopaths into responsible citizens, and psychotherapy does not cure antisocial personality disorder. But many kinds of treatment can potentially be helpful for groups of patients whose behaviour is harming themselves and others.
The significance of subtypes for treatment
Research into subtypes of psychopathy generally suggests that significant subtypes do exist. This research suggests that subtypes exist within the group of patients that have characteristics of psychopathy . Some patients with high levels of psychopathy have a very low capacity for empathy, they experience low levels of anxiety and depression, score highly on traits such as callousness and narcissism and they have a strong tendency to use instrumental violence. Another group of patients with high levels of psychopathy experience high levels of symptoms such as anxiety and depression, as well as high comorbidity of conditions such as borderline personality disorder .
The latter group may be more responsive to treatment and it appears that they have the ability to form a working alliance with a therapist or counsellor . Once again, this does not mean that we should exclude the more severely affected patients from treatment, it suggests that the development of effective treatments for psychopathy may best be preceded by targeting the patients who are comparatively easier to help, before progressing onto the more severely affected patients.
What kind of treatment can be effective?
Wong and Hare have developed a set of guidelines listing potentially helpful treatments for psychopathy . These guidelines may also apply to antisocial behaviour more generally. These guidelines include employing moral reasoning as an active part of treatment, using a cognitive behavioural approach, applying a social information processing approach, and planning for relapse prevention . Additionally, one may add that treatment needs to structured, and that patients should not be required to address their emotional states. Asking the patients about ‘feeling states’ is unlikely to be helpful to those who have difficulty accessing such states, and who may act out aggressively when confronted with a potential personal shortcoming. And finally, a high level of external structure that may include supervision of the patient , as well as contingent reinforcement of specific prosocial behaviours , is likely to lead to improved outcomes in antisocial patients.
What could go wrong in clinical practice?
There is another issue aside from research resources. The change in diagnostic criteria may also have an impact on clinical practice. The shift to describing antisocial behaviours within the broader concept of psychopathy can lead clinicians to make mistakes in two ways: the first is by failing to diagnose clinically relevant, potentially treatable psychopathology, because a patient with serious antisocial behaviour lacks additional features of psychopathy, such as callousness or failure to experience remorse. The second is by wrongly attributing these additional psychopathological features to patients who do not have them, thus overdiagnosing the disorder, but consequently failing to provide treatment, based on the false belief that all patients with antisocial personality are equally difficult to treat.
Therefore, the DSM-V should stress the interventions that antisocial patients may respond to, as well as the aspects of antisocial behaviours that may respond to treatment. Also, given the considerable evidence supporting the existence of clinically significant subtypes, the text should mention these subtypes, and mention that research indicating a very chronic and severe course of the disorder may not apply equally to all subtypes. While this is not standard in diagnoses, antisocial/psychopathic personality disorder is not a standard psychiatric disorder.
What Is It?
Published: March, 2019
Antisocial personality disorder, like other personality disorders, is a longstanding pattern of behavior and experience that impairs functioning and causes distress.
By definition, people with antisocial personality disorder don’t follow society’s norms, are deceitful and intimidating in relationships, and are inconsiderate of the rights of others. People with this type of personality may take part in criminal activity. But if they do, they are not sorry for their hurtful deeds. They can be impulsive, reckless and sometimes violent. This disorder is far more common and more apparent in men than women.
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Psychotherapy is the treatment of choice for antisocial personality disorder. Psychotherapy is a type of individual counseling that focuses on changing a person’s thinking (cognitive therapy) and behavior (behavioral therapy). Group and family therapy might also be helpful. Family therapy can increase understanding among family members of people with antisocial personality disorder. Group therapy is most beneficial if it is tailored to people with antisocial personality disorder. A person with the disorder might be more comfortable discussing his or her feelings and behaviors with individuals who face similar problems and issues.
Although medication is not used to treat the antisocial personality disorder itself, it might be used to help stabilize mood swings or treat some of the distressing symptoms of the disorder, such as impulsivity and violent aggressiveness.
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The best-documented medication is lithium carbonate, which has been found to reduce anger, threatening behavior and combativeness among prisoners. More recently, the drug was shown to reduce behaviors such as bullying, fighting and temper outbursts in aggressive children.
Phenytoin (Dilantin), an anticonvulsant, has also been shown to reduce impulsive aggression in prison settings.
Other drugs have been used to treat aggression primarily in brain-injured or mentally retarded patients. These include carbamazepine, valproate, propranolol, buspirone and trazodone.
Antipsychotic medications also have been studied in similar populations. They may deter aggression, but potentially induce irreversible side effects. Tranquilizers from the benzodiazepine class should not be used to treat people with ASP because they are potentially addictive and may lead to loss of behavioral control.
Medication may help alleviate other psychiatric disorders that coexist with ASP, including major depression, anxiety disorder or attention-deficit/hyperactivity disorder, thus producing a ripple effect that can reduce antisocial behavior. Mood disorders are some of the most common conditions accompanying ASP and are among the more treatable. For reasons that remain unknown, depressed patients with personality disorders tend to not respond as well to antidepressant medication as depressed patients without personality disorders.
Antisocials with bipolar disorder may respond to lithium carbonate, carbamazepine or valproate, which can help stabilize moods and may lessen antisocial behavior as well. Stimulant medication can be used to reduce symptoms of attention deficit disorder, a condition that can compound the aggression and impulsivity that may accompany ASP. Stimulants must be considered judiciously because they can be addictive. Uncontrollable and dangerous forms of sexual behavior may be targeted by injections of medroxyprogesterone acetate, a synthetic hormone that reduces testosterone levels.
Addiction and Family Counseling
Alcohol and drug abuse present major barriers for treatment of a person with underlying ASP. Although abstinence from drugs and alcohol does not guarantee a reduction in antisocial behavior, people with ASP who stop abusing drugs are less likely to engage in antisocial or criminal behaviors and have fewer family conflicts and emotional problems. Following a treatment program, patients should be encouraged to attend meetings of Alcoholics Anonymous, Narcotics Anonymous or Cocaine Addicts Anonymous.
Pathological gambling (a separate disorder that is quite different from social or professional gambling) is another addictive behavior common to people with this condition. Although few formal treatment programs exist for people so preoccupied with gambling that nothing else matters, people with the disorder should be encouraged to attend Gamblers Anonymous.
People with antisocial personality disorder with spouses and families may benefit from marriage and family counseling. Bringing family members into the process may help antisocial patients realize the impact of their disorder. Therapists who specialize in family counseling may help address the antisocial person’s trouble maintaining an enduring attachment to his spouse or partner, his inability to be an effective parent, problems with honesty and responsibility, and the anger and hostility that can lead to domestic violence. Antisocials who were poorly parented may need help learning appropriate parenting skills.
Incarceration may be the best way to control the most severe and persistent cases of antisocial personality disorder. Keeping antisocial offenders behind bars during their most active criminal periods reduces their behaviors’ social impact.
Treatment for Antisocial Personality Disorder
A lot of people throw the word “sociopath” around pretty casually. But it’s not just a word reserved for serial killers. In fact, 7.6 million American adults (or 3.6% of the population) meet the standard diagnostic criteria for antisocial personality disorder, the actual name for sociopathy.
“Antisocial personality disorder (APD) is not about being unsociable or unfriendly,” Susan Masterson, PhD, a psychologist based in Lexington, Kentucky, tells Health. Think about it this way: anti = against, social = society/people. “Someone with APD is ultimately concerned with his or her own needs. Social norms and laws are mere obstacles and challenges to their goals, not barriers,” she explains.
RELATED: Sociopath vs. Narcissist: Experts Explain the Difference
“Relationships are only addressed in the context of how treating others well will result in something pleasurable, or reduce something negative,” she adds. “And how their behavior impacts others is only of concern if it creates a problem for them.”
To be diagnosed with APD, according to the Diagnostic and Statistical Manual of Mental Disorders V (the bible of the mental health world), someone must show impairments in personality functioning—either in terms of identity, like egocentrism or self-esteem derived from from personal gain, power, or pleasure; or self-direction, like goal-setting based on personal gratification and lacking the internal standards to conform to lawful or culturally normative ethical behavior. They would also have issues with interpersonal functioning, like a lack of empathy or concern for feelings, needs, or suffering of others; a lack of remorse after hurting or mistreating another; and an incapacity for intimate relationships.
Someone with APD would also probably be antagonistic and deceitful, using manipulation and subterfuge to influence or control others; callousness and remorseless, with a lack of concern for the feelings or problems of others or the effects their actions might have on others; aggressive and hostile; and impulsive and irresponsible, failing to consider or disregarding the consequences of their actions. It’s no wonder the disorder is also known as sociopathy (not to be confused with psychopathy; that’s different).
RELATED: 9 Ways to Spot a Sociopath
As with most mental health disorders, nailing down the cause of APD is difficult—it at all possible, says Masterson. pinpointing any one cause is difficult, if at all possible. It has a lot to do with how you’re brought up. “It can run in families, but it’s unclear if it’s nature or nurture—a genetic disposition or learned behaviors and environmental influences—at play,” she says.
Treatment, unsurprisingly, is tough. “There’s no true cure for the mental and behavior issues that come with APD,” GinaMarie Guarino, a licensed mental health counselor based in New York, tells Health. “People with APD are not motivated to change their behavior; they don’t see a need to change,” she explains. “Instead, they feel that their behaviors are fine and that everyone else needs to change their own behaviors and expectations, and they’re more inclined to blame or redirect responsibility for their actions onto other figures of authority.”
Personality disorders aren’t a chemical issue, which is why there’s no medicinal answer for antisocial personality disorder (although a doctor may prescribe medication to treat overlapping mood issues). Rather, “it’s a mindset that someone carries everywhere they go and is the filter through which they base all their impressions and decisions on how to behave,” says Masterson.
RELATED: What It Means to Be a High-Functioning Sociopath—and How to Tell if You Know One
Treatment, then, revolves around managing the symptoms of the disorder and learning coping skills as well as how to deal with triggers and modify behavior.
But it’s rare that someone with APD would even seek help on their own (unless it would somehow eliminate or ameliorate a consequence, like a potential prison sentence or significant material loss, says Masterson). So the majority of people with APD remain undiagnosed and untreated. That’s why many of the APD cases you actually hear about have to do with people in the criminal justice system, says Guarino, as “therapy is often a condition of probation or parole for people with APD,” she explains.
For those who do seek help, one of the most common treatments for APD is CBT, or cognitive behavioral therapy. “CBT helps affected people learn how to slow down reaction times, reduce impulsive behavior, and incorporate consequential thinking into decision-making,” says Guarino. Any psychotherapy, though, would focus on improving conduct to reduce negative consequences in the person’s life, like “how to modify expectations to be more in line with reality, or use relaxation techniques to calm down the flare of an angry reaction when a sense of entitlement conflicts with what they’re getting out of a situation,” adds Masterson.
But there’s a major catch: Psychotherapy for APD only works if the affected person is actually motivated to change, Guarino says. “Like most mental health disorders, the desire for change must come from the person. They must have their own personal reasons for changing their behavior,” she explains. And that’s why it’s especially hard to treat someone with APD. “People with APD often do not see a problem with their behaviors, and so they don’t want to be cured,” she adds.
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