Continuing Education Activity

This activity reviews the evaluation and treatment of antisocial personality disorder (ASPD). ASPD is a deeply ingrained and dysfunctional thought process that focuses on social exploitive, delinquent, and criminal behavior most commonly known due to the affected individual's lack of remorse for these behaviors. ASPD falls into 1 of 4 cluster-B personality disorders within the DSM V, which also includes narcissistic, borderline, and histrionic personality disorders. This activity reviews the role of the an interprofessional team in evaluating, treating, and improving the care for patients with this condition.

Objectives:

• Identify the psychopathology of antisocial personality disorder
• Summarize the diagnostic criteria of Antisocial personality disorder.
• Outline the treatment and management options available for Antisocial personality disorder.
• Summarize interprofessional team strategies for improving care coordination and communication to advance the treatment of antisocial personality disorder and improve outcomes.

Introduction

Antisocial personality disorder (ASPD) is a deeply ingrained and rigid dysfunctional thought process that focuses on social irresponsibility with exploitive, delinquent, and criminal behavior with no remorse. Disregard for and the violation of others' rights are common manifestations of this personality disorder, which displays symptoms that include failure to conform to the law, inability to sustain consistent employment, deception, manipulation for personal gain, and incapacity to form stable relationships.[1]

The Diagnostic and Statistical Manual of Mental Disorders (DSM 5) classifies all ten personality disorders into three clusters (A, B, and C). Antisocial personality disorder falls into 1 of 4 cluster-B disorders, which also includes borderline, narcissistic, and histrionic. All of these disorders characteristically present with dramatic, emotional, and unpredictable interactions with others.[2] Antisocial personality disorder is the only personality disorder that is not diagnosable in childhood. Before the age of 18, the patient must have been previously diagnosed with conduct disorder (CD) by the age of 15 years old to justify diagnostic criteria for ASPD.[1]

Many researchers and clinicians argue this diagnosis, with concerns of significant overlap with other disorders, including psychopathy. However, others counter that psychopathy is simply a subtype of antisocial personality disorder, with a more severe presentation. Recent literature states that although a heterogeneous construct that can subdivide into multiple subtypes that share many similarities and are often comorbid but not synonymous, individuals with ASPD must be characterized biologically and cognitively to ensure more accurate categorization and appropriate treatment.[3]

Etiology

Although the precise etiology is unknown, both genetic and environmental factors have been found to play a role in the development of ASPD. Various studies in the past have shown differing estimations of heritability, ranging from 38% to 69%. Environmental factors that correlate to the development of antisocial personality disorder include adverse childhood experiences (both physical and sexual abuse, as well as neglect) along with childhood psychopathology (CD and ADHD).[4]

Other studies stress the importance of both shared and non-shared environmental factors, including both family dynamics and peer relations on the development of ASPD. Research has focused on establishing the exact gene contributing to ASPD, and much evidence is pointing toward the 2p12 region of chromosome 2 and variation within AVPR1A. Interactions of specific genes with the environment have been an area of study as well, with evidence of variation in the oxytocin receptor gene (OXTR) contributing to the broad ranges of behavior elicited in antisocial personality disorder due to its effect on the influence of deviant peer affiliation.[5]

Epidemiology

The estimated lifetime prevalence of ASPD amongst the general population falls within 1 to 4%.[6][7] Due to the predicting factor of the initial diagnosis of conduct disorder before the age of 15, this assumption can be quite broad as CD does not always get adequately evaluated.[8] Gender distribution tends to be skewed towards males, with 3 to 5 times more likelihood of being diagnosed with ASPD than females, with 6% men and 2% women within the general population.[9] Substance abuse has been found to show a significant correlation to the diagnosis of antisocial personality disorder,[10] while education and intelligence displays a negative correlation,[9][11] with a higher prevalence of ASPD amongst those with lower IQs and reading levels.[12] Research has shown reductions in the prevalence rate with increasing age in criminal populations,[13] as well as epidemiological samples.[9] Changes in personality traits with age and increased mortality with the behavior of antisocial personality disorder have been hypothesized to justify this age-dependent alteration.[14]

History and Physical

Before performing a comprehensive psychiatric assessment of the patient, a careful history and physical examination is necessary.   "The DSM-5 diagnostic criteria for Antisocial Personality Disorder

1. A pervasive pattern of disregard for and violation of the rights of others, since age 15 years, as indicated by three (or more) of the following:

   1. Failure to conform to social norms concerning lawful behaviors, such as performing acts that are grounds for arrest.

   2. Deceitfulness, repeated lying, use of aliases, or conning others for pleasure or personal profit.

   3. Impulsivity or failure to plan.

   4. Irritability and aggressiveness, often with physical fights or assaults.

   5. Reckless disregard for the safety of self or others.

   6. Consistent irresponsibility, failure to sustain consistent work behavior, or honor monetary obligations.

   7. Lack of remorse, being indifferent to or rationalizing having hurt, mistreated, or stolen from another person.

2. The individual is at least age 18 years.

3. Evidence of conduct disorder typically with onset before age 15 years.

4. The occurrence of antisocial behavior is not exclusively during schizophrenia or bipolar disorder."

Evaluation

No current diagnostic modalities, such as tests including serology, are currently accepted standards in diagnosing antisocial personality disorder. However, genetic testing and neuroimaging have been used to evaluate potential causes and patterns, respectively, with ASPD (see Etiology section above). Patients with antisocial personality disorder are at a higher risk of contracting certain viral infections and sexually transmitted diseases associated with high-risk behavior, including hepatitis C and human immunodeficiency virus, as well as increased mortality rates due to accidents, traumatic injuries, suicides, and homicides.[15][16][17]

Treatment / Management

Although there has been a multitude of interventions tested in the past, an appropriate algorithm fails to exist today. Literature suggests early treatment intervention with conduct disorder in children as the least costly and most effective with treating ASPD.[18] However, researchers have employed certain psychopharmacology and psychotherapy throughout literature, but due to the severity of potential harms in adulthood, intricate consideration are necessary when delineating a treatment course.[19]

Most of the needs of antisocial personality disorder are addressable in the outpatient setting. Hospitalization is not cost-effective as it provides little to no benefit to those with ASPD, and it is very costly. Also, the presence of those with ASPD in a psychiatric hospital disrupts the environment, thus affecting the treatment of other patients in need of therapeutic care. Hospitalization is reserved for treating co-occurring conditions or possible complications, such as substance intoxication/withdrawal or recent suicidal behavior.

Insufficient evidence exists to support any psychological intervention in adults with ASPD.[20] No pharmacological intervention has been shown to treat ASPD, but medications are highly recommended to treat co-occurring conditions. Aggressive behavior is treatable with second-generation antipsychotics as first-line therapy, including risperidone (2 to 4mg/day), quetiapine (100 to 300mg/day). Second and third-line therapies for aggression include selective serotonin reuptake inhibitors (SSRI), sertraline (100 to 200mg/day) or fluoxetine (20mg/day), and mood stabilizers; lithium and carbamazepine (dosed at recommended levels for bipolar disorder), respectively. Anticonvulsants, such as oxcarbazepine and carbamazepine, can be used to aid with impulsivity. Bupropion and atomoxetine are often used to treat associated ADHD due to their non-addictive nature. 

Differential Diagnosis

• Narcissistic personality disorder (cluster B personality disorder with overlap; exploitive and uncompassionate, but not aggressive or deceitful)
• Borderline personality disorder (cluster B personality disorder with overlap; manipulative, but for reassurance and nurture)
• Substance use disorder (Impulsivity and irresponsibility due to substance influence must be ruled out before diagnosing ASPD. ASPD can be diagnosed if substance use is co-occurring)

Prognosis

Of those children with conduct disorder, 25% of girls and 40% of boys will meet the diagnostic criteria for antisocial personality disorder. Boys exhibit symptoms earlier than girls, who often only elicit these symptoms in puberty. Children who do not develop conduct disorder and progress to the age of 15 without antisocial behaviors will not develop ASPD. Childhood conduct disorder is a reliable prognosticator of adulthood ASPD.[1] The small percentage of adults with antisocial personality disorder who never met the criteria or never received an assessment for conduct disorder, tend to have milder symptoms.[21]

Antisocial personality disorder, although a chronic condition with a lifelong presentation, has had moderations shown with advancing ages, with the mean remitted age of 35 years old. Those with less baseline symptomatology showed better-remitted rates. Studies in the past revealed remission rates of 12 to 27% and 27 to 31% rates of improvement, but not remitted. Crime rates and severity reflect this relation as well, with peak crime statistics in late teens and higher severity of crimes at younger ages. Those with later presentations of antisocial behavior showed less severe behavioral problems. Those who were either never imprisoned or imprisoned for longer periods displayed greater remission rates than those imprisoned for shorter periods. This finding indicated that short-term incarceration could be somewhat preventive for future antisocial behavior.[1]

Complications

Many individuals diagnosed with antisocial personality disorder remain a burden to their families, coworkers, and closely associated peers, such as neighbors, despite becoming less troublesome with age. Mental health comorbidities and associated addictive disorders, as well as higher mortality rates due to suicides and homicides, only add to this burden. Most of those who improve with age remain unable to re-claim their lost prospects, including education, domestication, and employment. Those patients who did show remission were more likely to have spousal or family ties, with better social support.[1]

Deterrence and Patient Education

• Antisocial personality disorder is one of the best-documented disorders in all of literature pertaining to psychiatry, including etiology, epidemiology, pathophysiology, neuroanatomy, heritability, and interventional treatment. However, an established treatment algorithm and specialized psychopharmacology currently fail to exist.
• Better preventative measures are necessary as many of those with ASPD may only have an evaluation upon incarceration after inflicting harm. One is not apt to seek help for ASPD symptomatology. Many only seek assistance for co-occurring mental disorders or only present for court-mandated assessments.  
• Even with the remission rates in advanced ages, antisocial personality disorder causes much turmoil to the patient and the patient’s surrounding community. The lives of those with ASPD remain negatively impacted even after remission.

Enhancing Healthcare Team Outcomes

The diagnosis, categorization, and management of ASPD is quite complex and multifaceted, often only presenting after harm has already taken place. Management of the disorder is best with an interprofessional team dedicated to the treatment of mental health disorders. People with antisocial personality disorder are at risk of incarceration due to the violent and deceitful nature of the behaviors elicited in ASPD. Hospitalization provides no benefit to a patient with ASPD and can actually create a disruptive hospital environment to others who truly need hospitalization for therapeutic purposes. The majority of these individuals are noncompliant with therapy and often fail to show up at clinics. Thus, management can be difficult.

The physician overseeing the case almost inevitably needs to be a psychological specialist; they can work collaboratively with the patient's family physician, but the complexity of this diagnosis requires specist-level care. Nursing staff should also have specialized psychological training, so they have received adequate training on ways to approach and cope with these individuals, as well as to be able to recognize therapeutically significant signs and behaviors that need to be brought to the treating physician's attention. They can also assess patient compliance as well as give their impressions of treatment effectiveness. A pharmacist should also provide consultation on the medications used, verifying dosing and checking carefully for drug interactions, and reporting to the nurse or physician if there are any concerns. Only with a collaborative interprofessional team approach patients with antisocial personality disorder receive optimal care leading to better outcomes. [Level 5]