Antisocial personality disorder
(ASPD)
PSX_006 Psychotherapy – PhDr. Pavel Humpolíček, Ph.D
Autumn 2016
Yurena Febles Arteaga
UČO 464375
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CONTENTS
1 Definition................................................................................................................................. 2
2 Criteria ..................................................................................................................................... 2
3 Characteristics.......................................................................................................................... 4
3.1 Diagnostic Features.......................................................................................................... 4
3.2 Development and Course ................................................................................................. 5
3.3 Impact on functioning ...................................................................................................... 6
3.4 Prevalence ........................................................................................................................ 6
4 Diagnostic ................................................................................................................................ 6
4.1 Comorbidity ..................................................................................................................... 7
5 Etiology.................................................................................................................................... 8
6 History ..................................................................................................................................... 8
7 Treatment............................................................................................................................... 10
7.1 Medication...................................................................................................................... 11
7.2 Cognitive Behavioral Theraphy (CBT).......................................................................... 12
7.2.1 Cognitive Self Change (CSC)................................................................................. 12
7.2.2 Moral reconation therapy (MRT)............................................................................ 13
7.2.3 Milieu therapy......................................................................................................... 14
7.3 Contingency Management (CM).................................................................................... 14
7.4 Comparison and combination of cbt and cm and conclussion....................................... 15
7.5 Other approaches............................................................................................................ 15
8 References.............................................................................................................................. 17
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1 DEFINITION
ASPD (Antisocial Personality Disorder), also known as dissocial personality
disorder (DPD) is a DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, fifth edition),
diagnosis assigned to individuals who habitually violate the rights of others without remorse.
People with Antisocial Personality Disorder may be habitual criminals, engaging in behaviours
which could lead them to be arrested and prosecuted. They also may manipulate and hurt others in
non-criminal ways but that are regarded in society as irresponsible or in violation of social norms
and expectations.
The term antisocial may be confusing to the lay public since the most common definition is
an individual who is a loner or socially isolated. But, indeed, the literal meaning the term antisocial
is to be against society, to be against rules and acceptable behavior. Moreover, the terms
psychopathy and sociopathy are used in some contexts synonymously but, in others, they are
differentiated in that sociopathy is rooted in environmental causes, while psychopathy is
genetically based.
2 CRITERIA
According to the DSM-5 (American Psychiatric Association, 2013), Antisocial Personality
Disorder (ASPD) (301.7) falls under the dramatic/erratic cluster of personality disorders, the socalled
"Cluster B". There are four diagnostic criterion, of which Criterion A has seven sub-features:
A. A pervasive pattern of disregard for and violation of the rights of others, occurring since
age 15 years, as indicated by three (or more) of the following:
1) Failure to conform to social norms with respect to lawful behaviors, as indicated
by repeatedly performing acts that are grounds for arrest.
2) Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for
personal profit or pleasure.
3) Impulsivity or failure to plan ahead.
4) Irritability and aggressiveness, as indicated by repeated physical fights or assaults.
5) Reckless disregard for safety of self or others.
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6) Consistent irresponsibility, as indicated by repeated failure to sustain consistent
work behavior or honor financial obligations.
7) Lack of remorse, as indicated by being indifferent to or rationalizing having hurt,
mistreated, or stolen from another.
B. The individual is at least age 18 years.
C. There is evidence of conduct disorder with onset before age 15 years.
D. The occurrence of antisocial behavior is not exclusively during the course of schizophrenia
or bipolar disorder.
On the other hand, the World Health Organization's International Statistical Classification of
Diseases and Related Health Problems, tenth edition (ICD-10) (World Health Organization,
1992), has a diagnosis called dissocial personality disorder (F60.2), which is characterized by at
least 3 of the following:
1. Callous unconcern for the feelings of others.
2. Gross and persistent attitude of irresponsibility and disregard for social norms, rules, and
obligations.
3. Incapacity to maintain enduring relationships, though having no difficulty in establishing
them.
4. Very low tolerance to frustration and a low threshold for discharge of aggression, including
violence.
5. Incapacity to experience guilt or to profit from experience, particularly punishment;
6. Marked readiness to blame others or to offer plausible rationalizations for the behavior that
has brought the person into conflict with society.
There may also be persistent irritability as an associated feature. The ICD states that this
diagnosis includes "amoral, antisocial, asocial, psychopathic, and sociopathic personality".
Although the disorder excludes conduct disorders, presence of conduct disorder during childhood
or adolescence may further support the diagnosis.
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3 CHARACTERISTICS
3.1 DIAGNOSTIC FEATURES
According to the DSM-5 (American Psychiatric Association, 2013), the essential feature of
antisocial personality disorder is a pervasive pattern of disregard for, and violation of, the rights
of others that begins in childhood or early adolescence and continues into adulthood. This people
usually have behavioural problems during childhood such as agressions, intimidations, run away
(e.g. from home or school), animal harming and so on. The prognosis is worse when the disorder
begins in childhood. Since deceit and manipulation are central features of ASPD, it’s good to
integrate information collected from systematic clinical assessment with information from
collateral sources.
Individuals with ASPD fail to conform to social norms with respect to lawful behavior
(Criterion Al). Their repeatedly criminal acts (such as destroying property, harassing others,
stealing, or pursuing illegal occupations) and their contempt towards law enforcement officers are
normally grounds for arrest (whether they are arrested or not).
Persons with this disorder disregard the wishes, rights, or feelings of others. They are
frequently deceitful and manipulative in order to gain personal profit or pleasure (e.g., to obtain
money, sex, or power) (Criterion A2). They may repeatedly lie, use an alias, con others or
malinger. Those with good verbal skills can often deceit their victims, including untrained and
unwary therapist. They tend to be charismatic, attractive, and very good at obtaining sympathy
from others, by describing themselves as the victim of injustice. Some studies suggest that the
average intelligence of antisocials is higher than the norm, though this has been disputed.
A pattern of impulsivity may be manifested by a failure to plan ahead (Criterion A3).
Decisions are made on the spur of the moment, without forethought and without consideration for
the consequences to self or others; this may lead to sudden changes of jobs, residences, or
relationships. This incapacity to plan their acts led therapist in the beginning to think that teaching
them problem solving strategies would be helpful, but what they obtained was making them even
more offenders because they learnt how to plan their crimes.
Individuals with ASPD tend to be irritable and aggressive, repeatedly getting into physical
fights or commiting acts of physical assault (including spouse beating or child beating) (Criterion
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A4). (Aggressive acts that are required to defend oneself or someone else are not considered to be
evidence for this item.)
These individuals also display a reckless disregard for the safety of themselves or others
(Criterion A5). This may be evidenced in their driving behavior (i.e., recurrent speeding, driving
while intoxicated, multiple accidents, etc.). Besides, they may engage in sexual behavior or
substance use that has a high risk for harmful consequences and neglect their children, putting
them in danger.
Individuals with ASPD also tend to be consistently and extremely irresponsible (Criterion
A6). Irresponsible work behavior may be indicated by significant periods of unemployment despite
available job opportunities, or by abandonment of several jobs without a plan for getting another
job. There may also be a pattern of repeated absences from work that are not explained by illness
either in themselves or in their family. Financial irresponsibility is indicated by acts such as
defaulting on debts, failing to provide child support or support to other dependents.
These individuals show little remorse for the consequences of their acts (Criterion A7).
They can be indifferent to, or provide a superficial rationalization for, having hurt, mistreated, or
stolen from someone (e.g., 'life's unfair," "losers deserve to lose"). These individuals may blame
the victims for being foolish, helpless, or deserving their fate (e.g., "he had it coming anyway");
they may minimize the harmful consequences of their actions; or they may simply indicate
complete indifference. They generally fail to compensate or make amends for their behavior. They
usually believe that everyone is out to "help number one" and that no one should avoid being
pushed around by them. It is widely thought that antisocials are without empathy, but this can be
disputed since sadistic antisocials use empathy to experience their victim's suffering, obtaining
pleasure from it (Turvey, 1995).
The specific behaviors characteristic of conduct disorder fall into one of four categories:
aggression to people and animals, destruction of property, deceitfulness or theft, or serious
violation of rules.
3.2 DEVELOPMENT AND COURSE
Antisocial personality disorder has a chronic course but may become less evident or remit
as the individual grows older, particularly by the fourth decade of life. Although this remission
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tends to be particularly evident with respect to engaging in criminal behavior, there is likely to be
a decrease in the full spectrum of antisocial behaviors and substance use.
3.3 IMPACT ON FUNCTIONING
Antisocial Personality Disorder has strong impacts on most areas of functioning such as
incarceration as a result of their criminal actions, premature death from violence or accidents or
loss or seizure of assets from reckless spending. According to the study of Goldstein, Dawson,
Smith, & Grant (2012), the rates in ASPD individuals with divorce, separation, unemployment,
financial dependency on state relief sources, homelessness, anxiety, depression, and suicide are
elevated when compared to the general population. Furthermore, antisocials usually cause great
harm to those around them, including family, friends, neighbours, colleagues and complete
strangers through financial exploitation, theft, emotional abuse, assault, sexual assault, homicide
and so on.
3.4 PREVALENCE
According to the DSM-5 (American Psychiatric Association, 2013), the annual prevalence
of Antisocial Personality Disorder is between 0.2% and 3.3% when the criteria from prior DSM
editions are applied. The highest prevalence of antisocial personality disorder (greater than 70%)
is among most severe samples of males with alcohol use disorder and from substance abuse clinics,
prisons, or other forensic settings. Prevalence is higher in samples affected by adverse
socioeconomic (i.e., poverty) or sociocultural (i.e., migration) factors. The diagnosis can at times
be misapplied to individuals in settings in which apparently antisocial behavior may be part of a
protective survival strategy. That is why the clinicians must consider the social and economic
context in which the behaviours occur.
Moreover, ASPD is much more common in males than in females. There has been some
concern that antisocial personality disorder may be underdiagnosed in females, particularly
because of the emphasis on aggressive items in the definition of conduct disorder.
4 DIAGNOSTIC
The DSM-5 notes that Antisocial Personality Disorder cannot be diagnosed before age 18,
so while an adolescent may display antisocial features, prior to age 18, if diagnostic criteria are
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met, the appropriate diagnosis would be Conduct Disorder (American Psychiatric Association,
2013). Anyway, to be diagnosed with ASPD after age 18, there must be a history of some
symptoms of conduct disorder before age 15.
4.1 COMORBIDITY
According to the DSM-5 (American Psychiatric Asociation, 2013), Antisocial
Personality Disorder may coexist with other disorders such as substance use disorder,
schizophrenia and bipolar disorders and to a lesser extent other disorders such as narcissistic
personality disorder and histrionic personality disorder. In the case that antisocial behavior
occurs exclusively during the course of schizophrenia or a bipolar disorder, it shouldn’t be
diagnosed as ASPD. Clinicians must be very careful and distinguish among disorders looking
at the differences in their distinctive features, especially in the cases of narcissistic and
histrionic personality disorder.
It is also important to distinguish ASPD from criminal behavior undertaken for gain
because the last one is not accompanied by the characteristic personality features of this
disorder. Only when antisocial personality traits are inflexible, maladaptive, persistent and
cause significant functional impairment or subjective distress do they constitute ASPD.
The presence of comorbid disorders is an additional factor that can impact the
characterization and treatment of antisocial personality and psychopathy (Widiger, 2006). A
significant portion of prisoners with psychopathy will meet the criteria for ASPD. However,
less than half of the inmates diagnosed with ASPD will meet the criteria for psychopathy (Hare,
2003). Despite a large superposition in behavioural tendencies, psychopathy and ASPD differ
in personality pathology, behavior characteristics, etiology and, especially, the affective and
interpersonal features.
There are also reports of increased prevalence of anxiety disorders (Goodwin and
Hamilton, 2003; Verona et al., 2001) but this does not seem to be the case for psychopathy and
it has even been suggested that psychopathy ‘protects’ against the development of anxiety and
mood disorders (Blair, 2012). It seems like interactions between antisocial personality or
psychopathy and comorbid disorders may lead to personality types that do not fit in completely
in current theories.
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5 ETIOLOGY
Various studies state that both genetic and enviromental factors affect in ASPD development.
Across several studies, the estimated heritability of antisocial behaviour varies between 40% and
80%, indicating that there is a very strong genetic basis for these behaviours (Glenn and Raine,
2014; Viding and McCrory, 2012). However, a recent meta-analysis showed that there are no clear
associations between single genes and antisocial aggressive behaviours across studies (Vassos et
al., 2014). Therefore, the solely studying of genetic factors is not enough to explain pathological
behaviours.
On the other hand, a rs-fMRI (resting state functional Magnetic Resonance Imaging) study
indicated uncoupled connections in areas of the frontal and parietal lobes which are associated
with self control and regulation, attention and conflict solving. It was stated that physiological and
anatomical deficits observed in the frontal/parietal areas, as well as the cerebellum, can account
for the chronic low arousal, high impulsivity, lack of conscience, callousness, and decision-making
problems commonly seen in individuals with APD (Tang, Jiang, Liao, Wang, & Luo, 2013).
According to DSM-5 (American Psychiatric Association, 2013), having a first degree
biological relative with ASPD is a risk factor. Biological relatives of individuals with this disorder
are also at increased risk for somatic symptom disorder and substance use disorders. Adoption
studies indicate that both genetic and environmental factors contribute to the risk of developing
antisocial personality disorder, somatic symptom disorder and substance abuse disorder. Adoptedaway
children resemble their biological parents more than their adoptive parents, but the adoptive
family environment influences the risk of developing a personality disorder and related
psychopathology.
6 HISTORY
Around the 19th century, the high prevalence of antisocial behavior in some psychiatric
populations caught the attention of psychiatrists who began to attribute that behavior to deviant
mental functioning. For instance, Pinel (1806) described psychiatric patients that didn’t show
incapacities in rational thinking yet exhibited antisocial behavior.He attributed the antisocial
behaviour to uncontrollable impulses and instinctive fury.
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A century later, Cleckley (1941) proposed sixteen specific diagnostic criteria for the condition
that included disruptive traits (e.g., lack of anxiety, superficial relationships with others and impulsive
behavioral deviance) and traits that promoted psychological stability (e.g., social selfassurance
and persuasiveness). While Cleckley highlighted both maladaptive and adaptive features
of psychopathy, other clinicians placed greater emphasis on callousness and a predatory
aggressive style in their operationalization of psychopathy (e.g., McCord and McCord, 1964). The
tension between the presence of maladaptive and adaptive traits of psychopathy make evident the
complex nature of this disorder and the difficulty to distinguish psychopathy from antisocial
personality.
Nonetheless, with the introduction of the Diagnostic Statistical Manual of Mental Disorders
(DSM), discussions about the definition of psychopathy and its differentiation from other
antisocial disorders got complicated. The first edition of the DSM included the construct
Sociopathic Personality Disturbance, in which the individual’s social and cultural background
played a fundamental role. This classification disappeared in the third edition of the DSM
(American Psychiatric Association, 1980), when the current diagnosis of Antisocial Personality
Disorder (ASPD) was included. This evolution progressively placed an emphasis on observable
behavioral criteria for the diagnosis (Arrigo and Shipley, 2001). As a consequence, the DSM
discarded the fact that there were multiple types of antisocial individuals (e.g., psychopathic vs.
non-psychopathic) that differed in many ways, and cluster them into a single group based on
similarities in behaviour.
Nevertheless, the International Statistical Classification of Diseases and Related Health
Problems (ICD) developed by the World Health Organization (1992), introduced a diagnostic
category that acknowledges the existence of antisocial personality types (e.g., amoral, psychopathic,
antisocial), although this tool has not been popular in research on antisocial behavior.
However, in the same way that the DSM, the ICD does not provide enough guidelines for how to
differentiate between the clinical subtypes, collapsing them into a single category.
The evolution of the conceptualizations of antisocial personality and psychopathy has guided
the development of assessment instruments and treatment. Failing to consider the differences that
exist across types of antisocial individuals has a major impact on treatment outcomes, as
therapeutic interventions are more likely to succeed if they matchthe patient’s needs (Andrews et
al., 1990).
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7 TREATMENT
Several attempts have been made to treat ASPD using a variety of clinical approaches. Despite
that, there are still no really effective treatment programs available for these individuals. Many
clinicians and researchers advocate that antisocial individuals, particularly those with high levels
of psychopathy, are very difficult to treat as to be next to untreatable (e.g., Harris and Rice, 2006).
This issue is increased by the fact that these individuals hardly ever search for help, as usually they
do not admit that they have a problem (egosyntonics). If they do search voluntarily for treatment
is mostly to alleviate other diseases such as depression or emotional distress. The DSM-5
(American Psychiatric Association, 2013) does not specify treatment options for ASPD either.
So, as we see, the consensus is very little in the way of effective treatment for ASPD.
Occasionally, these individuals are more or less kept from committing crime as many of them are
contained by the criminal justice system through some combination of incapacitation such as
incarceration, or supervision and monitoring such as parole or house arrest. But incarceration may
not deter these individuals, as they have difficulties to learn from mistakes, are rigid in decision
making, are unresponsive to punishment and make poor decisions (De Brito, Viding, Kumari,
Blackwood, and Sheilagh, 2013).
The DSM- 5, as well as other sources, indicate that these individuals normally cease
behavioral expression of their antisocial belief system in their 40's (American Psychiatric
Association, 2013) although this is inconclusive. Other sources argue that they become no longer
physically capable of acting in aggressive way or engaging in criminal activity because they turn
too emotional battered by resisting society and accumulate physical injuries from a lifestyle of
neglect of medical care, untended injuries, drugs and alcohol abuse.They still have an antisocial
belief system in their day to day dealings with others, but may hide their behaviour through practice
effects. This would lead them to be more subtle and not draw attention, avoiding the risk of being
arrested.
Appart from the above mentioned harm to themselves and others, the behaviors of antisocial
individuals lead to severe financial consequences that affect society. For instance, in the USA
alone the financial damage resulting from this behavior is estimated at $400 billion (Kiehl and
Buckholtz, 2010). In summary, the emotional and financial costs oft this disorder create a real need
for identifying and developing treatment programs that will target these disorders.
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7.1 MEDICATION
Pharmachological treatment has been used to treat, especially, the aggressive behaviours of
antisocial individuals.There is still no direct evidence that pharmacotherapy is a viable approach
for treating these individuals and, given the complex nature of antisocial personality and
psychopathy, at the moment pharmacotherapy does not seem to be a strong treatment approach for
these populations. Some of the casereports using pharmacotherapy are detailed next.
Hirose (2001) described the case of a patient diagnosed with ASPD, who had a long history
of aggressive and disruptive behavior. Risperidone (an antipsychotic), was administered at
different time points and he observed a reduction in aggressive behavior in the periods that
followed. Walker et al. (2003) described the cases of 4 highly aggressive, impulsive and irritable
individuals with psychopathy and a diagnosis of ASPD who were admitted to a maximum-security
forensic psychiatric institute. They were treated with quetiapine (another antipsychotic). All of the
patients showed a reduction in aggression, impulsivity, and irritability, which led to the conclusion
that quetiapine seems effective in treating severe antisocial behavior.
There are also studies in offender samples such as the one of Sheard et al. (1976), which
assessed the effect of lithium on impulsive aggression in incarcerated offenders using a doubleblind,
placebo-controlled study design. It was reported that lithium seems to have a positive impact
on the reduction of violent behavior during detention. In another study from Barratt et al. (1997),
incarcerated offenders participated in a study in which 30 inmates were treated with phenytoin (an
antiepileptic drug) while another 30 inmates from the control group were administered a placebo.
The results suggest that this anticonvulsant offers an effective way for treating aggressive
behaviour in incarcerated populations. Mattes (2012) has recently reviewed previous
pharmacological trials in both incarcerated and non-incarcerated populations and has argued that
oxcarbazepine, a modern antiepileptic, should be suitable for treating aggression in offender
populations.
Finally, treatment with selective serotonin reuptake inhibitors has been found to increase
glucose metabolism in the orbitofrontal cortex, suggesting a potential method for improving
functioning in regions that have been identified as deficient in criminal populations (Glenn and
Raine, 2014). However, no studies with antisocial or psychopatic individuals have been made
related to this (Olivier and van Oorschot, 2005).
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What is more, although there are effective pharmacological treatment for some of the
symptoms, drug abuse or non-compliance with treatment guidelines make impossible the
widespread use of these medicaments.
7.2 COGNITIVE BEHAVIORAL THERAPHY (CBT)
Many treatment studies in antisocial offender populations have employed Cognitive
Behavioral Therapy (CBT). In CBT, maladaptive tendencies are tackled through treatment of
unwanted behaviors and/or disturbed thought processes. This approach comes from a unitary
perspective in which emotions, cognitions and behaviors are interconnected. Thereby, CBT is able
to target multiple components of an experience and act accordingly.
The pattern of findings in studies using CBT in offender populations suggests no or very
limited treatment efficacy, especially in individuals with high levels of psychopathy. For instance,
Hitchcock (1995) compared the effects of cognitive therapy in 20 psychopathic offenders and 20
non-psychopathic inmates and found that this form of treatment had little effect in either sample.
Other studies using some form of group or individual CBT have reported that psychopathy
correlated negatively with clinical improvements in forensic patients (Hughes et al., 1997),
offenders with elevated levels of psychopathy compared to low levels of psychopathy were more
likely to reoffend despite showing improvements due to treatment (Olver et al., 2013; Seto and
Barbaree, 1999), sexual offenders with high levels of psychopathy compared to low levels of
psychopathy were more likely to quit the program and to recidivate (Olver and Wong, 2009) and
so on.
7.2.1 Cognitive Self Change (CSC)
A specific form of CBT (Cognitive Behavioral Therapy) called CSC (Cognitive Self
Change) seems to be one method which has success at modifying the behaviour of violent
offenders, both antisocial and otherwise (Barbour, 2013). CSC is designed to bring thinking
habits and patterns under the offender’s conscious and deliberate control. Participants learn
to objectively observe and report their thinking without justification. Then, they are aimed
to identify the linkages between their specific thinking patterns and their antisocial conduct.
They finally rehearse and practice alternative thinking patterns, using actual events in their
lives. Techniques such as journaling and role plays are very used. For this therapy, groups
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usually meet twice a week for 3 hours during the period that they are imprisoned. With this
therapy, recividism rate diminishes.
7.2.2 Moral reconation therapy (MRT)
Moral reconation therapy slightly decreases the risk of further offending (Ferguson
and Wormith, 2013). It is generally implemented in a group format because there is a risk
that one-on-one therapy reinforces narcissistic behavioural characteristic. Groups usually
meet weekly for two to six months and it can be used in correctional or outpatient settings.
MRT is grounded in the framework of cognitive behaviorism, and draws inspiration
from Kohlberg’s (1976) theory of moral development, which assumes that moral
development progresses through three main stages: the preconventional level (common to
children, persons judge the morality of an action by its direct consequences and have an
egocentric point of view), the conventional level (typical of adolescents and adults, who
judge the morality of actions compared with society’s views and expectations) and the
postconventional level (there is a growing realization that one’s own perspective may, on
occasion, take precedence over society’s views). Therefore, an individual in the last level
may disobey rules inconsistent with his or her own principles. Theorists suggest that many
people never reach this level of abstract moral reasoning (Cherry, 2011).
According to this theory, breaking the law would seem more acceptable to those at the
earlier, more selfcentered, stages of development. Little and Robinson (1988) affirm that
offenders “enter treatment with low levels of moral development, strong narcissism, low
ego/identity strength, poor self-concept, low self-esteem, inability to delay gratification,
relatively strong defense mechanisms, and relatively strong resistance to change and
treatment”. Consequently, MRT seeks to move offenders from a lower, hedonistic level of
moral reasoning (pleasure vs. pain) to a higher level where social rules and others become
important.
The program is designed to influence how offenders think about moral issues and make
moral judgments. It is a structured program that uses a manual describing exercises and
lessons directed at groups of 10 to 15 offenders. The therapy involves 12 to 16 sessions.
Each session lasts 1 to 2 hours, and there are usually two sessions per week. Each
participant is given a workbook that contains the mentioned exercises and lessons. It
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focuses on several areas, including confrontation of beliefs, attitudes and behaviors,
assessment of current relationships, reinforcement of positive behavior and habits, positive
identity formation, development of frustration tolerance, and development of higher stages
of moral reasoning.
Despite criticism, the advocates of MRT believe that they have developed an approach
that is superior to other cognitive-behavioral approaches.
7.2.3 Milieu therapy
Milieu therapy uses therapeutic communities to effect behavior change. It clusters
integrative forms of the CBT approach. Though there are some differences, this approach
generally implements techniques that support self-examination, the development of
accountability, and the enhancement of interpersonal engagement through CBT strategies.
Messina et al. (1999) used this approach in individuals with substance abuse with and
without ASPD to examine the likelihood of treatment completion, drug use, and recidivism.
The results were similar for patients with and without ASPD; both had lower rates of
recidivism, used less drugs, and were equally likely to complete the program.
In contrast, though, it has not been effective in psychopathy. Rice et al. (1992)
evaluated the efficacy of a therapeutic community program and, after an evaluation
conducted approximately 10.5 years after treatment they found that participants with
psychopathy had a higher rate of violent recividism. In contrast, offenders without
psychopathy had a lower rate of reoffense. These results suggest that the therapeutic
community program promoted the further development of the disruptive interpersonalaffective
features typically seen in offenders with psychopathy, while those without
psychopathy were able to use the acquired skills to develop prosocial behaviours.
Thus, research indicates that therapeutic communities are useful for treating antisocial
personality in general, but not psychopathy. This has contributed to the pessimism
regarding treatment of psychopathy that is still dominant in some settings.
7.3 CONTINGENCY MANAGEMENT (CM)
Contingency Management (CM) is one treatment method that seems to have positive effects
in antisocial populations with comorbid substance use disorders. It is based on the principles of
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instrumental learning and involves the use of negative and positive reinforcers to modify behavior.
For instance, Silverman et al. (1998) used it to reinforce cocaine abstinence in methadone abusers
with and without adiagnosis of ASPD. Patients received vouchers that they could exchange for
services or goods after handing in drug-free urine samples. The use of vouchers as positive
reinforcement increased the likelihood of abstinence in the treatment conditions.
7.4 COMPARISON ANDCOMBINATION OF CBT AND CM AND CONCLUSSION
Messina et al. (2003) made a study in substance abusers with and without ASPD, in which
they systematically compared the effects of CM, CBT and the combination of CM and CBT. One
intriguing result was that participants with ASPD were more likely to show a reduction in the use
of cocaine (they had more treatment responsivity). Besides, treatment responsivity in the ASPD
group was higher in the CM condition relative to the CBT and combined CM and CBT conditions.
The group without ASPD did not show reduced use of cocaine in this period.
In general, there is evidence that psychological and behavioural interventions are effective
for antisocial individuals. Individuals with ASPD seem resistant to some forms of CBT, but are
more responsive to behavioural interventions that focus on reward and contingency learning. On
the contrary, psychopathic individuals seem to be unresponsive to individual, group, and
community CBT. It is important to note that most of the studies that included a psychopathic
sample had some issues like flawed designs, relatively small sample sizes, an inappropriate
characterization of the target populations, etc. (D’silva et al., 2004; Harris and Rice, 2006). That
is the reason why some have argued that it is too early to conclude that treatment does not work in
populations with elevated levels of psychopathy (D’silva et al., 2004; Salekin et al., 2010).
Nonetheless, it is clear that different types of antisocial individuals can differ considerably in the
response to treatments.
7.5 OTHER APPROACHES
Current treatment approaches do not match the needs of the patient, since there is a lack of
insight into the different biological and cognitive factors that can cause antisocial behavior which
has lead to cluster all antisocial individuals into the same group. Thus, those treatment approaches
have not been fully successful.
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Novel approaches which try to redefine psychopathology using multimodal latent variables
have been developed in response to these failures. They include the search for multimodal
neuroimaging, cognitive endophenotypes and computional psychiatry. The goal is to recharacterize
antisocial personality and psychopathy using statistical regularities in biology and
cognition as natural delineators rather than man-made psychological constructs, which are less
precise. This would be possible using large databases which include many types of biological and
cognitive measures obtained in these populations (one example is ENIGMA consortium, an
international collaboration between more than 500 scientists who have combined their genetic,
imaging and clinical data to study brain disorders). Thereby, once the individual has been classified,
the dimensions in the classification will provide a specific body of candidate target areas for
treatment (Brazil et al., 2016).
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8 REFERENCES
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American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental
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Andrews, D. A., Bonta, J., & Hoge, R. D. (1990). Classification for effective rehabilitation:
Rediscovering psychology. Criminal justice and Behavior.
Arrigo, B. A., & Shipley, S. (2001). The confusion over psychopathy (I): Historical
considerations. International Journal of Offender Therapy and Comparative
Criminology, 45(3), 325-344.
Barbour, P. (2013). Criminal Thinking: A cognitive-behavioral therapy approach. ATTC.
Retrieved March, 4, 2014 from
http://madcp.dreamhosters.com/sites/default/files/4F_Barbour_Criminal_Thinking.pdf
Barratt, E. S., Stanford, M. S., Felthous, A. R., & Kent, T. A. (1997). The effects of phenytoin on
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