Antisocial Personality Disorder Introduction

Antisocial personality disorder is the most reliably diagnosed condition among the personality disorders, yet treatment efforts are notoriously difficult. Therapeutic hope has not vanished, however, and one study indicated that almost two-thirds of psychiatrists think that “psychopathic disorder” is sometimes a treatable condition. A similar finding was reported nearly 40 years ago. Diagnostic refinement is critical before any treatment efforts are undertaken, especially the determination of the degree of psychopathy in the patient with antisocial personality disorder.

Psychodiagnostic Refinements

The DSM-IV (American Psychiatric Association 1994) diagnosis of antisocial personality disorder continues the relatively young “social deviancy” tradition of defining chronic antisocial behavior that began with DSM-II (American Psychiatric Association 1968). The National Comorbidity Survey, which used DSM-III-R criteria, found that 5.8% of males and 1.2% of females showed evidence of a lifetime risk for the disorder. Robins and Regier (1991) determined that antisocial personality disorder, as defined by DSM-III (American Psychiatric Association 1980), had an average duration of 19 years from first to last symptom. This latter finding strongly suggests that in most individuals with antisocial personality disorder, remission will occur in time, an important prognostic factor. DSM-IV criteria for antisocial personality disorder are presented in

Table 82-1.

The older, “clinical” tradition for understanding antisocial personality disorder refers to the term psychopathy or psychopathic personality and was most thoughtfully delineated by Cleckley. It is distinguished by attending to both manifest antisocial behavior and personality traits, the latter described as the callous and remorseless disregard for the rights and feelings of others or aggressive narcissism. Hare and his colleagues developed a reliable and valid clinical instrument for the assessment of psychopathy. The 20 criteria composing the Psychopathy Checklist - Revised (PCL-R) are shown in

Table 82-2. This is a unidimensional scale that quantifies clinical interview and historical data on the patient.

After antisocial personality disorder has been diagnosed, or when antisocial traits or behaviors are shown by history that do not meet the DSM-IV threshold for the diagnosis, the severity of psychopathy should be determined by using the PCL-R or its corollary screening version (SV), the PCL-SV. A substantial body of research has shown that only a minority of patients with antisocial personality disorder have severe psychopathy, and this latter group has a significantly poorer treatment prognosis than do patients with nonpsychopathic antisocial personality disorder. Axis I conditions are also likely to accompany antisocial personality disorder, but psychopathy as a discrete entity, or taxon, appears to be independent of most Axis I conditions. The exception is alcohol and other substance abuse and dependence. Most self-report psychological tests are inherently unreliable in diagnosing antisocial personality disorder because of the propensity for these patients to deceive the clinician, but there are exceptions. The Minnesota Multiphasic Personality Inventory-2, the Millon Clinical Multiaxial Inventory-III, and the Rorschach test are very helpful in understanding the current psychodynamics, personality structure, and treatability of the patient.

Given the action-oriented nature of these patients and the likelihood of Head injury, neurological and neuropsychological impairments also must be ruled out. Such impairments may exacerbate clinical expressions, such as the physical violence of this character pathology. Measurable intelligence is independent of psychopathy but will influence the expression of chronic antisocial behavior.

General Treatment Findings

There is as yet no body of controlled empirical research concerning the treatment of antisocial personality disorder or severe psychopathy. Also, no demonstrably effective treatment is available, although this finding does not prove the null hypothesis that no treatment will ever exist for these troublesome conditions.

Meta-analytic studies of the effectiveness of treatment in juvenile delinquents, however, have consistently found an overall positive effect. The most useful treatments are skill-based and behavioral, targeting higher-risk offenders in the community. Research on effective treatments for adult offenders is very sparse, methodological problems are significant, and effect sizes are consistently small - the difference in standard deviation units between the means of the treatment and control groups. The effect sizes are typically one-half of the overall effects in meta-analyses of psychological interventions in general.

A review of the research on the treatment of antisocial personality disorder indicates that these patients have a poor response to hospitalization. The prognosis may be improved, however, if a treatable anxiety or depression is present. Patients with antisocial personality disorder also show a worse response to alcohol and other drug rehabilitation programs than do patients without antisocial personality disorder. An early positive assessment of the helping alliance by both the patient with antisocial personality disorder and the psychotherapist is significantly related to overall treatment outcome. Evidence also indicates that serotonin metabolism and low platelet monoamine oxidase activity have important roles in the expression of chronic antisocial behavior.

A review of the treatment research concerning criminal psychopathic patients, who have the most severe form of antisocial personality disorder according to the criteria of Hare (

see Table 82-2), indicates that these individuals are generally viewed as untreatable by clinical and legal professionals but are frequently segregated and referred for treatment. In a “therapeutic community”, they show less motivation and less clinical improvement and are discharged earlier than nonpsychopathic criminals. In a 10-year controlled outcome study, psychopathic individuals treated in a prison therapeutic community showed significantly more recurrences of violent offenses than did untreated psychopathic individuals.

Treatment Planning

Once the severity of psychopathy has been assessed in the patient with antisocial personality disorder and any other Axis I or III treatable conditions have been identified, four clinical questions should guide further psychiatric involvement with the patient:

1. Is the treatment setting secure enough to contain the relative severity of the psychopathic disturbance in the patient with antisocial personality disorder? If it is, therefore ensuring the safety of both patient and staff, treatment planning can begin, depending on the available resources. If it is not, staff may be put physically at risk by a decision to commence treatment. Political and bureaucratic pressures may be brought to bear on clinicians to “treat” currently untreatable patients with antisocial personality disorder and severe psychopathy, and a “not to treat” decision may entail a variety of personal dilemmas. A general clinical maxim with this personality disorder is that severity of psychopathy should be inversely related to treatment efforts and directly related to community safety and intensive supervision concerns. Patients scoring 30 or higher on the PCL-R, for instance, are generally not treatable, and risk management should focus only on ensuring institutional and community safety.
2. What personality characteristics, gleaned from clinical research on patients with antisocial personality disorder or psychopathy, are relevant to the treatment planning for this particular patient?
3. What are the emotional reactions that the clinician can expect in him- or herself when attempting to clinically treat or help risk manage (if no treatment is being attempted) this patient?
4. What specific treatment approaches, if any, should be applied to this patient, given the resources available and the degree of containment necessary to effectively intervene?

Each of the latter three questions is addressed in turn in the sections that follow.