Abstract / Summary

Antisocial personality disorder (ASPD) is a serious condition which affects 1-4% of the population. In a typical family practice, one will encounter patients who have had a diagnosis of ASPD, as well as patients who have not yet been diagnosed. With patients who have not yet been diagnosed, it is important to trust your intuition, and watch for red flags suggestive of ASPD, which may permit you to refer to specialized mental health services for a diagnosis. And whether or not a patient has a diagnosis of ASPD, helpful strategies include ensuring appropriate physical and emotional boundaries to keep safe, as well as setting appropriate expectations and limits.

Case: Adult

You are seeing a 40-yo male new to your practice. He presents for a routine physical checkup. He has a history of problems with the law. Physical exam shows numerous tattoos. You can’t quite place it, but you do not feel comfortable around him. Your family medicine resident says bluntly, “I do not know what it is, but I feel creeped out by him…”

How are you going to manage this patient?

Epidemiology

It is believed that 80% of those in prison meet criteria for ASPD. 

Age of onset:

• By definition according to the DSM-5, Antisocial Personality Disorder cannot be diagnosed before age 18.
• However, an adolescent may display antisocial features, prior to age 18; for those under age 18 with antisocial feature, the diagnosis Conduct Disorder may apply

Etiology

Exact cause is unknown, though there is a strong genetic component.

Abbreviations

ASPD, antisocial personality disorder; CD, conduct disorder. 

Terms

Related terms include:

• In some contexts, sociopathy and psychopathy are used interchangeably.
• In other contexts, there is a difference in that sociopathy is rooted in environmental causes, while psychopathy is genetically based.
• “Antisocial”, to the general public, generally means someone who is socially isolated or a loner, and may not necessarily mean the same as antisocial PD

Note that in the DSM-5, while there are criteria for ASPD, there is not a distinction made for psychopathy.

Clinical Features

Individuals with ASPD (and psychopathy) may show the following traits:

• Self-confident
• Cold-hearted
• Manipulative
• Fearless
• Charming
• Cool under pressure
• Egocentric
• Carefree

There are both strengths and advantages to having traits of psychopathy.

There are certain professions, where having traits of psychopathy may be helpful. According to the Great British Psychopath Survey, the following are the top 10 professions with the most psychopaths:

• Chief executive officer (CEO)
• Lawyer
• Media (TV/Radio)
• Salesperson
• Surgeons (and there have been notable cases of emergency physicians as well)
• Journalist
• Police Officer
• Clergy person
• Chef
• Civil Servant

One can appreciate that for certain settings, it is good to not be too compassionate or empathetic. As remarked by an emergency physician with self-diagnosed psychopathic traits, ‘when I’m dealing with a complex trauma from a motor vehicle crash, it is good not to be distracted and burdened by feelings and emotions, unlike some of my other colleagues.’

And here are the professions with the least psychopaths:

• Health Care Aide
• Nurse
• Therapist
• Craftsperson / Trades
• Beautician/Stylist
• Charity worker
• Teacher
• Creative artist
• Physicians (with the exception of surgical specialties)
• Accountant

These are all professions where a high level of compassion and caring is required. While it is good to be compassionate and caring, some data suggest that being too compassionate can contribute to burnout, stress and mental health issues.

DSM-5 Criteria for Antisocial Personality Disorder (ASPD)

There are four criteria under DSM-5:

A. Disregard for and violation of others rights since age 15, as indicated by one of the seven sub features:

1. Failure to obey laws and norms by engaging in behavior which results in criminal arrest, or would warrant criminal arrest
2. Lying, deception, and manipulation, for profit for self-amusement,
3. Impulsive behavior
4. Irritability and aggression, manifested as frequently assaults others, or engages in fighting
5. Blatantly disregards safety of self and others,
6. A pattern of irresponsibility and
7. Lack of remorse for actions (American Psychiatric Association, 2013)

B. The person is at least age 18,

C. Conduct disorder was present by history before age 15

D. The antisocial behavior does not occur in the context of schizophrenia or bipolar disorder

Reference: DSM-5, American Psychiatric Association, 2013

Assessment / History

Sample screening questions based on DSM-5 criteria would be the following:

Are there any of the following risk factors for violence?  (Juhnke, 2010):

DANGERTOME

• D)elusions (or violent fantasies)
• A)ccess to weapons
• N)oted history of violence
• G)ang involvement
• E)xpressions of intent to harm others
• R)emorselessness about harm inflicted
• T)roublesome abuse of alcohol or drugs
• O)vert threats of harm to others
• M)yopic focus on harming others
• E)xclusion from others or increased isolation

Comorbidity

• Substance abuse disorder
• ADHD
• Learning problems
• Other personality disorders
• Mood disorders such as depression

Differential Diagnosis

• Schizophrenia
• Bipolar disorder
• Substance abuse disorders
• Autism spectrum disorder (ASD): Individuals with ASD have trouble seeing things from others’ perspectives, and as a result, may also appear uncaring. Nonetheless, there is an important difference -- those with ASPD understand others’ feelings well enough to be able to come across as charming and can be manipulative, whereas individuals with ASD do not.

Prognosis

On one hand, many of the traits of psychopaths can be helpful in certain areas and professions. 

On the other hand, human beings are a social species (as opposed to a solitary species such as reptiles), and as a result, this means that they generally do worse at the things most often associated with being successful in a social species, such as positive interpersonal relationships. As a result, they earn less money and do not generally attain high status (Stevens at al., 2012).

As people with ASPD age into their 40’s, their antisocial behaviours tend to stop (DSM-5, American Psychiatric Association, 2013). Perhaps with age, they have learned to be more subtle and less overtly aggressive in order to reduce their risk of getting into trouble.

Management and Treatment

There is no treatment per se for antisocial personality disorder (ASPD), though there are strategies and interventions to best help others cope with those with ASPD.

Do’s

• Trust your intuition. If something doesn’t feel right, it probably isn’t. Your intuition is your body’s innate (often unconscious) ability to evaluate which situations are safe if not. It has developed in mammals over millennia. Note that many individuals with antisocial are able to be charming and disarm your concerns, or put you on the defensive -- however, trust your own instincts!
• Ensure adequate boundaries, limits and consequences are set, including the justice system if necessary. This can be done at the clinic level by ensuring there are signs indicating that:
  • Expectations are for a safe environment, which means zero tolerance for threats, or intimidation.
  • Consequences include calling the police, security and being discharged from the clinic.
• Do accept you may also need to set additional boundaries. Because individuals with ASPD may tend to “push the boundaries”, there may be other boundaries not stated officially you may need to reinforce such as:
  • No comments about the clinic staff’s appearance, dress or race, etc.
  • No fraternization policies between clinic staff and patients, etc.
    
• Use concrete positive and negative reinforcements. Instead of asking someone with ASPD to respect the rules because “it’s the right thing to do”, try to show the person with ASPD the concrete benefits to them.
  For example, “if you respect the rules, you’ll get paid, and you won’t get in trouble with the law, etc.”
• Be wary if a patient is asking you to trust them. Individuals with ASPD will often be asking you to trust them -- this should be a warning sign. Normal trustworthy people don’t have to ask others to trust them. You have a right to expect that patients earn your trust first. 
• Be wary if you are feeling afraid of your patient.
  

Don’ts

• Don’t expect that punishment will be able to deter their behaviours. Individuals with ASPD often don’t seem to respond to punishment as well as others, likely related to their underlying wiring which makes them less fearful.
  
• Don’t depend on their sense of empathy. It’s understandable you might want to ask them to see if they can understand how their behaviours may have hurt someone, but don’t expect this to change their behaviour.

Medication Treatment

There is little evidence to support the use of medication for treating antisocial personality disorder.

However, certain antipsychotic and antidepressant medications may be helpful in some instances:

• May help with aggression/impulsivity
  • Carbamazepine
  • Lithium
• May possibly help with anger
  • Specific serotonin reuptake inhibitors (SSRIs)

Where to Refer

Consider referring to specialized mental health treatment such as

• Mental health services affiliated with justice and corrections, such as forensic mental health clinics.

Evidence-based treatments include:

• A specific form of cognitive behavioral therapy (CBT) called CSC (cognitive self Cchange) has some evidence of improving the behaviour of violent offenders (Barbour, 2013; Powell, & Sadler).

Practice Guidelines

National Institute for Health Care Excellence (NICE) Guideline for Antisocial personality disorder: prevention and management

URL: https://www.nice.org.uk/guidance/cg77

URL: https://www.ncbi.nlm.nih.gov/books/NBK55333/

References

Stevens G: Successful Psychopaths: Are They Unethical Decision-Makers and Why? Journal of Business Ethics. Jan 2012, Volume 105, Issue 2, pp139-149.

“Thirteen Rules for Dealing with Sociopaths in Everyday Life” found on pages 156-162 of The Sociopath Next Door by Dr. Martha Stout.

Juhnke G: The DANGERTOME Personal Risk Threat Assessment Scale: An Instrument to Help Aid Immediate Threat Assessment for Counselors, Faculty, and Teachers, J. Creativity in Mental Health, 2010, Vol 5(2), 177-191.
https://www.tandfonline.com/doi/abs/10.1080/15401383.2010.485095?journalCode=wcmh20