Despite the absence of a body of controlled outcome data, certain treatment modalities are more effective than others in patients with antisocial personality disorder who are not severely psychopathic. The effectiveness of a modality will depend on the treatment goals, which should be conservative at best.

Pharmacotherapy
Although as yet there are no data showing that antisocial personality disorder can be altered with medication, certain symptoms and behaviors in the patient with antisocial personality disorder may respond to pharmacological intervention if medication compliance is heightened through institutional or community supervision. Schizophrenic patients with antisocial personality disorder are most effectively treated with decanoate medications if there is a clinical choice. In hospital settings, the antisocial personality disorder patient who has anxiety or depression, a contraindication of severe psychopathy, may show prognostic improvement if medically treated for these symptoms.

By far the most troublesome symptom of antisocial personality disorder is violence, which is significantly more frequent and severe in psychopathic patients with antisocial personality disorder. Eichelman delineated a rational pharmacotherapy for aggression and violence based on four biological systems (

Table 82-4).

Reis labeled, and Eichelman and Meloy elaborated on, the physiological, pharmacological, and forensic distinction between “affective” and “predatory” aggression. These psychobiologically different modes of violence are most relevant to antisocial personality disorder and psychopathy, although they are not inclusive and should not be considered a standardized clinical nosology for aggression. Affective aggression is a mode of violence that is accompanied by high levels of sympathetic arousal and emotion (usually anger or fear) and is a reaction to an imminent threat. Predatory aggression is a mode of violence that is accompanied by minimal or no sympathetic arousal and is emotionless, planned, and purposeful. Research has shown that psychopathic criminals are more likely than nonpsychopathic criminals to engage in predatory violence toward strangers.

Appropriate pharmacological intervention with antisocial personality disorder patients or psychopathic patients involves an analysis of the mode of violence in which the patient has engaged and the selection of medications that have been shown to inhibit the relevant mode of violence. Anticonvulsants, such as phenytoin, may inhibit only affective aggression. The serotonin agonists appear to inhibit both types of aggression. Serotonergic dysfunction may account for prominent symptomatology in both psychopathic and nonpsychopathic patients with antisocial personality disorder, particularly their decreased ability to inhibit learned responses in the face of punishment; impulsivity; emotional dysregulation; assaultiveness; and dysphoria. Eichelman and others have proposed that psychiatrists who pharmacologically treat violent patients address the primary illness first, initially use the most benign interventions, quantify the efficacy of their treatment (such as nursing observation scales), and institute each drug as a single variable into treatment if at all possible.

Family Therapy
Both parent management training and structured family therapy have been shown to be effective in children with conduct disorder. There is no published research on family therapy with adult patients who have antisocial personality disorder, whether psychopathic or not. The use of family therapy when one of the participating adults is a severely psychopathic patient with antisocial personality disorder or a severely psychopathic individual who does not meet the criteria for antisocial personality disorder is not advised. Information learned by the individual from both the therapist and other family members is likely to be used to hurt and control in the service of sadism and omnipotent fantasy. Treatment efforts should focus on the physical, economic, and emotional safety of the other family members, whether spouse, children, or elderly parents.

Nonpsychopathic adults with antisocial personality disorder may benefit from family therapy and are most likely to be seen when the child with conduct disorder is the identified patient. Such work may have a positive effect on the intergenerational transmission of the disorder, a likely combination of both early social learning and psychobiology. Reductions in criminal recidivism as a result of family therapy have been reported. A genuine capacity to bond to the other family members, attempts to be a responsible spouse or parent, and clinical expressions of anxiety, dysphoria, or genuine affection during the treatment are positive prognostic indicators for the adults with antisocial personality disorder in family therapy. Continuous acting-out, however, should be expected and monitored through collateral contacts.

Milieu and Residential Therapy
Reviews of treatment programs to reduce recidivism of convicted offenders, of whom 60%-75% will meet the criteria for antisocial personality disorder, identify three guiding principles: 1) programs are most effective when they target moderately high-risk individuals; 2) treatment is most effective when criminogenic issues are addressed, such as antisocial values and attitudes, peer relationships with other criminals, chemical dependencies, and vocational-educational deficits; and 3) treatment should teach and strengthen interpersonal skills and model prosocial attitudes. The term milieu is used to describe any treatment method in which control of the environment surrounding the antisocial individual is the primary agent for change. Human behavior is strongly influenced by its consequences, and this occurs regardless of whether the results are intended or the influence is deliberate. The clinician chooses to leave this to chance, or to purposefully control the environment, if he or she can, as a therapeutic tool. Three milieu or residential approaches are promising for the treatment of antisocial personality disorder.

The first approach, token economy programs, has been empirically found to shape patient and staff behavior within institutions. Although effective, such programs may be legally challenged by patients with antisocial personality disorder on the basis of an arguable constitutional right to avoid unwanted therapy. Despite their declining popularity, they have no serious competition as a system of behavioral management in hospitals. However, evidence also indicates that the more typically unstructured hospital ward may actually harm patients by promoting psychotic, aggressive, and dependent behaviors.

The second approach, the therapeutic community, was originally developed by Jones in England a half century ago. Members of the community care for one another, follow the rules, submit to the authority of the group, and are rewarded or disciplined by the group. The primary intervention in the therapeutic community is the daily group meeting, which functions both as a psychotherapeutic and as a policy-making body. Peer problem solving is encouraged, and staff are facilitators of this largely democratic group culture. Although few controlled studies of therapeutic communities have been done, they have shown modest positive effects.

When offenders within therapeutic communities are classified as either psychopathic or nonpsychopathic based on the criteria of the PCL-R (

Hare 1991; Table 82-2), the results are striking. Ogloff et al. found that the scores on the PCL-R were both postdictive and predictive of treatment outcome in a Canadian therapeutic community for adult male offenders. Individuals in the psychopathic group were less motivated to change their behavior and had a higher attrition rate. In contrast, individuals in the nonpsychopathic group became less angry, less hostile, less anxious, and less depressed and were more socially at ease and more assertive in interpersonal relationships.

Similarly, Ravndal and Vaglum found that antisocial aggressiveness was related to attrition among substance-abusing participants in a Norwegian therapeutic community. Rice et al. retrospectively evaluated the efficacy of a maximum-security therapeutic community in reducing both general and violent recidivism. They used a matched-group, quasi-experimental design and found that treatment was associated with lower recidivism, especially violent recidivism, for the nonpsychopathic patients and higher violent recidivism for the psychopathic patients, with an average follow-up of 10 years. Although the reasons for this finding are unknown, and the treatment program was highly unusual, it is the first comparative study to suggest that therapeutic communities may actually be detrimental to the safety of society when severely psychopathic patients are treated.

The third approach, wilderness programs, uses nature as the milieu both to reinforce individual responsibility and to stimulate group cohesion. Although there are no controlled outcome studies of their effectiveness in changing antisocial personality disorder or, for that matter, criminal recidivism, it is likely that the effect size would be modest. The capacity of the subject to form an attachment or bond with the group and the experience of anxiety or fear in the face of natural danger would be favorable prognostic indicators. The severity of psychopathy would probably predict treatment failure and an absence of generalization of the newly learned, prosocial behaviors once the individual returned to the community.

Although there have been many studies purportedly to evaluate the treatment efficacy with antisocial individuals, S. Wong and D. Elek (“The Treatment of Psychopathy: A Review,” unpublished manuscript, Department of Psychology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada, 1990) found that none met their six criteria for a good study: 1) a valid measure of psychopathy, 2) an assessment of diagnostic reliability, 3) a detailed description of the treatment program, 4) the use of reliable and objective measures of treatment outcome, 5) a follow-up period of at least 1 year, and 6) the use of an appropriate control group. A model treatment program for high-risk offenders was proposed by the Darkstone Research Group for the Correctional Service of Canada. It included a prosocial treatment environment, the neutralization of procriminal attitudes, the involvement of nonpsychopathic offenders as prosocial models without formal authority to run the program, interpersonal skills training, emotion management skills, the acceptance of personal responsibility, dissociation from criminal peers and lifestyle, and the cessation of substance abuse. Such a program has yet to be implemented but represents the best integration of realistic methods and goals to date.

Cognitive-Behavioral Therapy
Relapse prevention theory, a structured form of cognitive-behavioral therapy, has been associated with successful correctional treatment programs. The premise of the theory is that the targeted behavior, in this case antisocial behavior, is learned, motivated, and reinforced by internal factors within the patient and external factors within the environment. Internal motivators encompass thoughts, feelings, perceptions, and fantasies, whereas external motivators may include alcohol or stimulants, weapons, or an available pool of victims. Reinforcers may be either positive or negative and internal or external. For example, an internal positive reinforcer could be a heightened level of autonomic arousal that results from sensation-seeking behavior. A discrete antisocial behavior is preceded by a chain of events that, if not interrupted, leads to relapse. Various treatment methods arise from this model to teach the antisocial individual to implement new cognitive and behavioral strategies and to break this cognitive-behavioral chain.

Patients with antisocial personality disorder are likely to respond to this method of treatment if they are motivated to change and it is used in a milieu or residential setting. This is most predictable in the nonpsychopathic patient with antisocial personality disorder who normatively responds to aversive consequences and has felt the emotional and practical pain of his or her antisocial acts. It is unlikely to have any effect on the severely psychopathic patient with antisocial personality disorder because of deficits in passive avoidance learning (inhibiting new behavior when faced with punishment), the inability to foresee the long-term consequences of his or her actions, and the lack of capacity to reflect on the past. The cognitive deficits of the psychopathic patient, such as moderate formal thought disorder and impairments in understanding the connotative meaning of words, would also attenuate the degree of success achieved with this mode of therapy.

Cognitive-behavioral and social learning techniques are the most frequently used methods for treating antisocial individuals. Gacono et al. recommended the following essentials for such treatment programs: clear and unambiguous rules and consequences are established and enforced, life skills and cognitive skills that are taught are congruent with the patients’ developmental levels, cognitive distortions and criminal lifestyle patterns are identified and modified, tolerance for affect and the effect of the patients’ behaviors on others are addressed, and treatment continuity is established on release into the community.

Psychodynamic Approaches
There is no clinical evidence that psychopathic patients with antisocial personality disorder will benefit from any form of psychodynamic psychotherapy, including the expressive or supportive psychotherapies , psychoanalysis, or various psychodynamically based group psychotherapies. However, psychodynamic treatment of antisocial personality disorder can be differentiated from psychodynamically understanding the patient with antisocial personality disorder, whether psychopathic or not, when other, more promising modes of treatment are applied, such as those noted earlier. Psychodynamic understanding of the patient with antisocial personality disorder assumes that unconscious determinants play a major role in behavior. It also embraces a “levels” approach to both understanding and treating personality disorder. In other words, treatment efforts target, or at least acknowledge, the multiple and simultaneous levels that influence observable, clinical behavior: psychobiology, unconscious psychodynamics, conscious thought, and the environment. In the case of a patient with antisocial personality disorder, this conceptualization could translate into psychopharmacological intervention to minimize affective violence (psychobiology), the process of thinking about and discussing with staff the aggressive narcissism of the patient and its countertransference effect (psychodynamics), active treatment of the patient with relapse prevention that focuses on the internal and external motivators for antisocial acts (conscious thought), and the choice of a maximum-security milieu treatment program within which the treatment occurs (environment). Approaches that ignore other “levels” or determinants of personality-disordered behavior are likely to fail and often are used because of the preferred treatment “philosophy” of the team leader, even in the absence of empirical data.

Conclusions

Treatment and management of antisocial personality disorder, with or without severe psychopathy, test the clinician’s mettle. Although these patients rarely seek medical care for their personality disorder - only one out of seven will ever discuss their symptoms with a doctor - concurrent problems will bring them into treatment, whether voluntary or not.

The comprehensive care of the patient with antisocial personality disorder involves six principles:

1. During the initial diagnostic workup, the severity of psychopathy of the patient with antisocial personality disorder should be determined, with a clinical focus on the capacity to form attachments and the severity of superego disturbance.
2. Any treatable conditions, such as Axis I mental or substance abuse disorders, should be identified.
3. Situational factors that may be aggravating or worsening the antisocial behaviors need to be delineated.
4. The mental health professional must recognize the likelihood of legal problems and potential legal entanglements, even if they are initially denied.
5. Most important, treatment should begin only if it is demonstrably safe and effective for both the patient and the clinician. This would generally rule out any attempts to psychiatrically treat the severely psychopathic antisocial patient. Medical treatment of such a patient’s major mental disorder, if present, will usually result in better organization of the psychopathy.
6. Careful attention should be paid to all countertransference reactions, because they provide important insights into the inner world of the patient with antisocial personality disorder and the severity of his or her psychopathy.

As an anonymous Australian psychiatrist wrote,

Basically it is symptomatic relief, clear guidelines about expected behavior, treatment of any major psychotic illness, realistically accepting them as they are and trying extremely hard not to be too frightened of them.