Antisocial Personality Disorder (ASPD)
YURENA FEBLES ARTEAGA
464375
Autumn 2016
PSX_006 Psychotherapy
PhDr. Pavel Humpolíček Ph.D.

Definition
uIndividuals who habitually violate the rights of others without remorse.
vHabitual criminals à behaviours which could lead them to be arrested and prosecuted.
vManipulation
vHurt others in non-criminal but non-moral.
Dissocial personality disorder (DPD)
Confusing term
ØAntisocial ≠ loner
ØAntisocial = against society
Øpsychopathy = sociopathy ?

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CRITERIA
uDSM-5 (American Psychiatric Association, 2013)
uAntisocial Personality Disorder (301.7)
A.Disregard for and violation of the rights of others. Since 15 years old. Indicated by 3 or more:
1)Failure to conform to social norm
2)Deceitfulness
3)Impulsivity or failure to plan ahead
4)Irritability and aggressiveness
5)Reckless disregard for safety of self or others
6)Consistent irresponsibility
7)Lack of remorse
B.The individual is at least age 18 years.
C.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.

CRITERIA
•ICD-10 (World Health Organization, 1992)
uDissocial personality disorder (F60.2)
At least 3 of the following:
1.Callous unconcern for the feelings of others
2.Irresponsibility and disregard for social norms and obligations
3.Incapacity to maintain enduring relationships, but no difficulty in establishing them
4.Low tolerance to frustration and low threshold for discharge of aggression
5.Incapacity to experience guilt or to profit from experience
6.Blame others or offer plausible rationalizations for their behaviour
Associated feature à persistent irritability

A clockwork orange
uhttps://www.youtube.com/watch?v=MatuFuEm38c
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 'Is it better for a man to have chosen evil than to have good imposed upon him?'
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Development and Course
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Impact on functioning
uStrong impacts on most areas of functioning
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Incarceration
Premature death
Loss or seizure of assets
Furthermore, antisocials usually cause great harm to those around them, including
Study of Goldstein, Dawson, Smith, & Grant (2012)
Higher rates in divorce, separation, unemployment, financial dependency on state relief sources,
homelessness, anxiety, depression and suicide.
Family
Friends
Neighbours
Colleagues
Complete strangers
through financial exploitation, theft, emotional abuse, assault, sexual assault,
 homicide and so on.

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Prevalence
uAnnual prevalence between 0.2% and 3.3% (American Psychiatric Association, 2013)
uHighest prevalence of ASPD (>70%) à males with alcohol and substance abuse
uMales > Females. ¿Are females underdiagnosed? Emphasis in aggressive items
uHigher prevalence in samples affected by adverse socioeconomic (i.e., poverty) or sociocultural
(i.e., migration) factors. Diagnosis can be misapplied in settings in which apparently antisocial
behaviour may be part of a protective survival strategy.

Diagnostic
According to the DSM-5, ASPD can’t be diagnosed before age 18. If diagnostic criteria are met
before 18, the appropriate diagnosis would be Conduct Disorder.
Comorbidity
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(American Psychiatric Asociation, 2013)
Narcissistic personality disorder
Histrionic personality disorder

Comorbidity
•ASPD = Psychopathy ?  à ≠ personality pathology, behaviour characteristics, etiology and,
especially, the affective and interpersonal features.
•Anxiety in ASPD but not in Psychopathy (Goodwin and Hamilton, 2003; Verona et al., 2001)
•ASPD ≠ Criminal behaviour undertaken for gain
The presence of comorbid disorders can impact the characterization and treatment of
(Widiger, 2006)
Antisocial personality
Psychopathy
ØMost of prisoners with psychopathy meet the criteria for ASPD.
ØLess than half of ASPD meet the criteria for psychopathy (Hare, 2003)
Interactions between Antisocial personality or Psychopathy and Comorbid disorders may lead to
personality types that do not fit in completely in current theories.

Etiology
Uncoupled connections in areas of the frontal and parietal lobes (associated with self control and
regulation, attention and conflict solving).
It can account for the chronic low arousal, high impulsivity, lack of conscience, callousness, and
decision-making problem.
Between 40% and 80%
No clear associations between single genes and antisocial aggressive behaviours across studies
(Vassos et al., 2014)
Risk Factors (DSM-5)
First degree biological relative with ASPD
•Also risk for somatic symptom disorder and substance use disorders
•Adoption studies indicate that both genetic and environmental factors contribute (>genetic)
Heritability
(Glenn and Raine, 2014; Viding and McCrory, 2012)
Rs-Fmri study(resting state functional Magnetic Resonance Imaging)(Tang, Jiang, Liao, Wang, & Luo,
2013)

History
Failing to consider the differences between antisocials has a major impact on treatments, as
therapeutic interventions are more likely to succeed if they match the patient’s needs (Andrews et
al., 1990).

Treatment
Still no really effective treatment programs
Very difficult to treat as to be next to untreatable, especially high levels of psychopathy (e.g.,
Harris and Rice, 2006)
They hardly ever search for help (egosyntonic)
DSM-5 does not specify treatment options
Kept from committing crime by the criminal justice system but incarceration may not deter these
individuals
Appart from the harm to themselves and others, severe financial consequences that affect society
(e.g. $400 billion financial damage in USA)
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Medication
uPharmachological treatment has been used to treat, especially, the aggressive behaviours of
antisocial individuals.
uStill no direct evidence that pharmacotherapy is a viable approach for treating them.
Hirose (2001): Risperidone (antipsychotic) à reduction in aggressive
Walker et al. (2003):
Quetiapine (antipsychotic) to highly aggressive individuals with psychopathy & ASPD diagnosis �
Reduction in aggression, impulsivity & irritability
Sheard et al. (1976):
Lithium in incarcerated offenders à positive impact on the reduction of violent behavior during
detention.
Barratt et al. (1997): Phenytoin (antiepileptic) à effective way for treating aggressive behaviour
in incarcerated populations

Medication
Mattes (2012):
Oxcarbazepine (modern antiepileptic) à suitable for treating aggression in offender populations.
Glenn and Raine (2014):
Selective serotonin reuptake inhibitors à increase glucose metabolism in the orbitofrontal cortex
(potential method for improving functioning in criminals deficient region).
NO STUDIES IN ANTISOCIAL OR PSYCHOPATIC INDIV.
Drug abuse or non-compliance with treatment guidelines make impossible the widespread use of these
medicaments.

Cognitive Behavioural Therapy (CBT)
uEmotions, cognitions and behaviours are connected. Maladaptive tendencies are tackled through
treatment of unwanted behaviors and/or disturbed thought processes
No or very limited treatment efficacy, especially in individuals with high levels of psychopathy.
Hitchcock (1995):
- 20 psychopathic offenders
- 20 non-psychopathic inmates
Little effect in either sample
Hughes et al. (1997): Psychopathy correlated negatively with improvements in forensic patients
Group or Individual CBT
Olver et al. (2013); Seto and Barbaree (1999):
Offenders high levels of psychopathy more likely to reoffend despite showing improvements
Olver and Wong (2009):
Sexual offenders high levels of psychopathy more likely to quit the program & recidivate than L.L.
of psychopathy

Cognitive Self Change (CSC)
uSpecific form of CBT. It brings thinking habits and patterns under the conscious and deliberate
control. uSuccess at modifying the behaviour of violent offenders, both antisocial and otherwise
(Barbour, 2013). Recidivism rate diminishes. uGroups meet twice a week for 3 hours during the
period that they are imprisoned.
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Journaling
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Role plays

Moral reconation therapy (MRT)
uIt slightly decreases the risk of further offending (Ferguson and Wormith, 2013).
uGenerally implemented in a group format. Correctional or outpatient settings.
Kohlberg’s (1976) theory of moral development
Preconventional level
Conventional level
Postconventional level
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.
In groups of 10 to 15 offenders, each one is given a workbook with exercises and lessons.
Focusing areas: confrontation of beliefs, attitudes & behaviors, assessment of current
relationships, reinforcement of positive behavior & habits, positive identity formation,
development of frustration tolerance, and development of higher stages of moral reasoning.
12-16 sessions (usually 2 per week). 1-2 hours each.

Milieu therapy
uIt uses therapeutic communities to effect behavior change.
uIt clusters integrative forms of the CBT approach.
uTechniques that support self-examination, the development of accountability and the enhancement of
interpersonal engagement.
Effective in ASPD
(Messina et al., 1999)
Lower rates of recidivism, less drugs use and completion of program in individuals with substance
abuse with and without ASPD
Non-effective in Psychopathy
(Rice et al., 1992)
Efficacy evaluation 10.5 years after theraphy:
- Participants with psychopathy à higher rate of violent recividism.
- Offenders without psychopathy à lower rate of reoffense.

Contingency Management
vIt seems to have positive effects in antisocial populations with comorbid substance use disorders.
Based on the principles of instrumental learning
Use of negative and positive reinforcers to modify behavior
Silverman et al. (1998):
Reinforce cocaine abstinence in methadone abusers with and without ASPD.
Likelihood of abstinence was increased in the treatment conditions.

Comparison and combination
CBT & CM
Messina et al. (2003):
Study in substance abusers with and without ASPD.
•ASPD group treatment responsivity: CM>CBT CM>CBT&CM
•ASPD participants higher reduction in the use of cocaine (T. responsivity)
•Group without ASPD did not show reduced use of cocaine in this period.

Brief Conclussion
uIn general, there is evidence that psychological and behavioural interventions are effective for
antisocial individuals. uIndividuals with ASPD seem resistant to some forms of CBT, but are more
responsive to behavioural interventions that focus on reward and contingency learning. uOn the
contrary, psychopathic individuals seem to be unresponsive to individual, group, and community CBT.
Too early to conclude treatment doesn’t work with high levels of psychopathy?
Flawed designs, relatively small sample sizes, inappropriate characterization of the target
populations,... (D’silva et al., 2004; Harris and Rice, 2006).

Other approaches
vAttempt to redefine psychopathology using multimodal latent variables. Search for:
•multimodal neuroimaging,
•cognitive endophenotypes
•computional psychiatry.
•Goal: re-characterize antisocial personality and psychopathy using statistical regularities in
biology and cognition
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•How? Using large databases which include many types of biological and cognitive measures obtained
in these populations
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•The classification of the individual provides a specific body of candidate target areas for
treatment (Brazil et al., 2016).

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