Antisocial Personality Disorder

Antisocial personality disorder (APD) is a psychiatric disorder characterized by chronic and pervasive patterns of behavior that disregard and violate the rights of others. These patterns of behavior begin in childhood or early adolescence and continue into adulthood.

Individuals with APD exhibit signs of antisocial behavior such as unlawful behavior, deceitfulness, consistent irresponsibility, physical fighting, disregard for the safety of self and others, and lack of guilt or remorse. The diagnosis requires that the individual be at least 18 years of age and have had a history of some symptoms of conduct disorder before the age of 15.

Individuals with antisocial personalty disorder frequently lack empathy and tend to show contempt for the feelings and suffering of others. They may have an inflated self-opinion and can display superficial charm to gain money, sex, or power.

People with APD often use faulty rationalizations to justify their behavior. Examples include excuse making, blaming someone or something else for causing the behavior, lying, thinking that they're special and that the rules don't apply to them, victim playing, grandiosity, and using power plays to get their way.

More men than women are diagnosed with APD, although some women with APD may be misdiagnosed as borderline personality disorder (BPD). Determining the type and extent of antisocial symptoms for women is not easy ( Rutherford et al. 1999), but it is important because of the high prevalence of neglectful parenting in women with substance use disorders and APD ( Goldstein et al. 1999).

Substance Use Among People with Antisocial Personality Disorder

Many people with APD use substances in a polydrug pattern involving alcohol, marijuana, heroin, cocaine, and methamphetamine. The illicit drug culture can correspond with their view of the world as fast-paced and dramatic, which supports their need for a heightened self-image. Consequently, they may be involved in crime and other sensation-seeking, high-risk behavior.

APD appears to be a failure to attach. The people with this diagnosis appear deficient in their ability to experience shared or reciprocal emotions such as guilt or love. Individuals with APD disdain society's rules; they know right from wrong but they do not care. They may be excited by the illicit drug culture and may have considerable pride in their ability to thrive in the face of the dangers of that culture. They are often in trouble with the law. If they are more effective, they may limit themselves to exploitive or manipulative behavior that does not make them so vulnerable to spending time in jail.
Treatment

Antisocial personality disorder is difficult to treat. Individual treatment for the disorder is often mandated by a court.

Clients with APD are often said to "act out" tension or conflict. Behaviors that interfere with treatment, which might even result in a client being sent immediately to jail, are seen by therapists as a form of resistance to whatever happens to be the focus of therapy at the time. Substance abuse treatment counselors working with clients with APD often sense resistance to substance abuse treatment and its goals.

In addition to an objective psychosocial and criminal history, the following steps may be useful in assessing the antisocial client:

  • Taking a thorough family history.
  • Finding out whether the client set fires as a child, abused animals, or was a bed-wetter.
  • Taking a thorough sexual history that includes questions about animals and objects. Asking about any unusual or out-of-the-ordinary sexual experiences may serve as a lead-in and as a means to gauge how the client responds to questions about such personal areas.
  • Taking a history of the client's ability to bond with others. Counselors can ask, "Who was your first best friend?" "When was the last time you saw him or her?" "Do you know how he or she is?" "Is there any authority figure who has ever been helpful to you?"
  • Asking questions to find out about possible parasitic relationships and taking a history of exploitation of self and others. In this context, parasitic refers to a relationship in which one person uses and manipulates another until the first has gotten everything he or she wants, then abandons the relationship.
  • Taking a history of head injuries, fighting, and being hit. It may be useful to refer for neuropsychological testing.
  • Testing urine for recent substance use.
  • HIV testing.

The assessment should consider criminal thinking patterns, such as rationalization and justification for maladaptive behaviors. There is a special need to establish collateral contacts and to assess for criminal history and the relationship of substance use to behavior.

References:

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Hare RD. The Hare PCL-R: Some issues concerning its use and misuse. Legal and Criminological Psychology. 3((Part 1)):99-119; 1998.

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Raine, A., Lencz, T., Bihrle, S., LaCasse, L., and Colletti, P. Reduced prefrontal gray matter volume and reduced autonomic activity in antisocial personality disorder. Archives of General Psychiatry 57(2):119-127; discussion 128-129, 2000.

Rutherford MJ, Cacciola JS, Alterman AI. Antisocial personality disorder and psychopathy in cocaine-dependent women. American Journal of Psychiatry. 156((6)):849-856; 1999. (PubMed)

Seivewright N, Daly C. Personality disorder and drug use: A review. Drug & Alcohol Review. 16((3)):235-250; 1997. (PubMed)

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Adapted from Substance Abuse Treatment for Persons with Co-Occurring Disorders:
Treatment Improvement Protocol 42
DHHS Publication No. (SMA) 05-3922

Page last modified or reviewed by athealth on January 29, 2014