Antisocial Personality Disorder

Personality denotes characteristic ways of thinking, feeling, behaving, and reacting to the environment. A personality disorder is said to exist when a person chronically uses mechanisms of coping in an inappropriate, stereotyped, and maladaptive fashion. Personality disorders are enduring and persistent styles of behavior and thought, not atypical episodes.

Several alcohol and other drug (AOD)-induced states can mimic personality disorders. If a personality disorder coexists with AOD use, only the personality disorder will remain during abstinence. AOD use may trigger or worsen personality disorders. The course and severity of personality disorders can be worsened by the presence of other psychiatric problems such as mood, anxiety, and psychotic disorders.

Diagnostic criteria for antisocial personality include a pervasive pattern of disregard for and violation of the rights of others and inability or unwillingness to conform to what are considered to be the norms of society.

The disorder involves a history of chronic antisocial behavior that begins before the age of 15 and continues into adulthood. The disorder is manifested by a pattern of irresponsible and antisocial behavior as indicated by academic failure, poor job performance, illegal activities, recklessness, and impulsive behavior. Symptoms may include dysphoria, an inability to tolerate boredom, feeling victimized, and a diminished capacity for intimacy.

Antisocial personality disorder, also known as psychopathic personality or sociopathic personality often brings a person into conflict with society as a consequence of a pattern of behavior that is amoral and unethical. Complications that might arise from having this disorder include: frequent imprisonment for unlawful behavior, alcoholism and drug abuse.

People with this disorder may appear charming on the surface, but they are likely to be aggressive and irritable as well as irresponsible across all areas. They may have numerous somatic complaints and possibly attempt suicide but due to their use of manipulative behavior, it is difficult to separate what is true and what is not.

• Disregard for society’s expectations and laws
• Unlawful behavior
• Violate rights of others (property, physical, sexual, legal, emotional)
• Physical aggression
• Lack of stability in job, home life
• Lack of remorse
• Superficial charm and wit
• Impulsiveness

People with a personality disorder often use alcohol and other drugs (AODs) for purposes that relate to the personality disorder: to diminish symptoms of the disorder, to enhance low self-esteem, to decrease feelings of guilt, and to amplify diminished feelings of individuality.

Many people with antisocial personality disorder use AODs in a polydrug pattern involving alcohol, marijuana, heroin, cocaine, and methamphetamine. The illegal drug culture corresponds with their view of the world as fast-paced and dramatic, which supports their need for a heightened self-image. Consequently, they may be involved in crime and other sensation-seeking, high-risk behavior. Some may have extreme antisocial symptoms. They tend to prefer stimulants such as cocaine and amphetamines. Rapists with severe antisocial personality disorder may use alcohol to justify conquests. People with less severe antisocial personality disorder may use heroin and alcohol to diminish feelings of depression and rage.



The cause of this disorder is unknown though genetic factors are thought to be involved since the incidence of antisocial behavior is higher in people who have an antisocial biological parent. However, environmental factors are also believed to contribute to a person developing antisocial personality disorder since people whose role model had antisocial tendencies is more likely to develop the disorder. About 3% of men and about 1% of women have antisocial personality disorder with percentages much higher among the prison population.



Diagnosis is reserved for those over 18 years of age, though often there is a history of similar behaviors before age 15, such as repetitive lying, truancy, delinquency, and substance abuse. Antisocial personality is indicated by a psychological evaluation. As this is a serious diagnosis without any known effective treatment, other disorders should be ruled out first.



People affected with the disorder rarely seek therapy, but might be forced into it because of a "run in" with the law. So far, there has been little success in treating antisocial behavior and personality. In-patient programs have met with success when progress is what determines privileges, and more privileges result in the development of improved self-esteem. Some evidence suggests the disorder decreases with age; after turning 30 or older, many antisocial patients’ symptoms fade somewhat and they may become ’only’ substance abusers. Homicide or suicide is highly common with people with this diagnosis.



Medications have not proved helpful in treating the disorder. Often they are not taken regularly or are abused, so are not effective in improving symptoms.



Group psychotherapy has been shown to be helpful if the patient feels comfortable in the group setting. Individual psychotherapy or cognitive behavior therapy may be helpful if the patient develops a sense of trust since often the person is afraid of forming close relationships with others and is resentful of authority figures. Family therapy may be warranted to help them understand their own feelings of confusion, guilt and frustration with the person who will not seek treatment. In one study with patients with mixed personality disorders, one group received brief therapy while the other group received no therapy. The group that received therapy was reported to have better general adjustment and a reduction in complaints and maintained these gains when they were tested 1.5 years later. Thus, while prognosis is thought to be poor, studies to develop effective treatment for this disorder continue to be conducted.

The following guidelines for therapists treating patients with Antisocial Personality Disorder, especially with alcohol and other drug (AOD) issues, may be useful for those who wish to understand treatment goals for ameliorating symptoms of this disorder.

Clinicians should be careful to avoid mislabeling patients. Although some women may have antisocial personality disorder, they receive this diagnosis less often than men. Instead, they may be misdiagnosed as having borderline personality disorder. Many AOD-using offenders in the prison system may not meet the criteria for antisocial personality disorder once they are abstinent.



In engaging the patient with antisocial personality disorder, it is useful to join with the patient’s worldview, which may include a need for control and a sense of entitlement. In this context, entitlement refers to people who believe their needs are more important than the needs of others. Entitlement may include rationalization of negative behavior (such as robbery or lying). People with antisocial personality disorder may evidence little empathy for their victims. If incarcerated, they may believe they should be released immediately. In an AOD treatment program, they may describe themselves as being unique and requiring special treatment.

The primary motivation of the patient with antisocial personality disorder is to be right and to be successful. It is useful to work with this motivation, not against it. Although this motivation may not reflect socially acceptable reasons for changing behavior, it does offer a point from which to begin treatment. Wanting to be clean and sober, to keep a job, to avoid jail, and to become the chair of an AA meeting are reasonable goals, despite a self-serving appearance. Therapists may help patients by working with patients’ worldview, rather than by trying to change their value system to match those of the therapist or of society.

Patients should understand their role in the process. In engaging patients, therapists may want to use contracts to establish rules for conduct during treatment. The contract should explicitly state all expectations and rules of conduct and should be honored by all parties. Such an approach can be useful with people with antisocial personality disorder, who often view relationships as unfair contracts in which one person attempts to take advantage of the other. Therapists may find that once a level of interpersonal respect has been established, working with antisocial patients can lead to important gains for the patient.



In addition to an objective psychosocial and criminal history, the following steps may be useful in assessing the antisocial patient:

The assessment should consider criminal thinking patterns, such as rationalization and justification for maladaptive behaviors. There is a special need to establish collateral contacts and to assess for criminal history and the relationship of AOD use to behavior.

Useful assessment instruments include the Minnesota Multiphasic Personality Inventory (MMPI), the Millon Clinical Multiaxial Inventory (MCMI), the PCL-R (Hare Psychopathy Checklist-Revised), and the CAGE questionnaire.



People with antisocial personality disorder may enter treatment profoundly depressed, feeling that all systems have failed them. Often, their scams and lofty ideas have failed and they feel exposed, feel like losers, and have no ego strength. They are at risk for suicide, especially during intoxication or acute withdrawal. They may require psychiatric hospitalization and detoxification.

They may become acutely paranoid. Containment in the form of a brief hospitalization may be indicated for patients experiencing acute paranoid reactions to avoid acting out against others. For less acute paranoid reactions, therapists should try to avoid cornering patients, disengage from any power struggle, offer lower stimulus levels, and create options, especially if those are supplied by the antisocial patient. During this phase, clarification without harsh confrontation is recommended.

When patients with antisocial personality disorder have crises, therapists should become cautious and careful. During crises, these patients may engage in dangerous physical behavior in order to avoid unpleasant situations or activities, and therapists should avoid angry confrontations.




It is helpful to view the process of working with antisocial patients as a process of adaptation of thinking rather than the restructuring of a patient into a person whose morals and values match those of the therapist or society. Therapists may benefit from modifying their own expectations of treatment outcomes, and realize that they may not help some patients to develop empathic and loving personalities. It is enough to guide patients to lead lives that follow society’s rules.

Individual therapy offers the therapist an opportunity to point out patients’ errors in thinking without causing them to feel humiliated in the presence of the therapy group. Other issues for individual therapy may include continued relapse management and identity of empathy. Three key words summarize a strategy for working with people with antisocial personality disorder: corral, confront, and consequences.

Corralling with regard to patients with antisocial personality disorder means coordinating treatment with other professionals, establishing a system of communications with other professionals and with the patient, contracting patients to be responsible for their AOD use in the recovery program, monitoring information about the patient, and working toward specific treatment goals. Patients may benefit by signing agreements to comply with the treatment plan and by receiving written clarification of what is being done and why. Interventions and interactions should be linked to original treatment goals.

One approach to treatment that adds to the notion of "corralling" is to "expand the system." Spouses, family members, friends, and treatment professionals may be invited to participate in counseling sessions as a way to provide collateral data. This is sometimes called "network therapy."

In confronting antisocial patients, therapists can be direct without being abusive. They can be clear in pointing out antisocial thinking patterns. They can remark on contradictions between what patients say and what patients do. Random AOD testing is essential for monitoring patients. Honest reporting of AOD use should be an active part of treatment.

Patients should bear the consequences of their behavior. For instance, violation of probation or rules should be recorded. Patients who are offenders should be encouraged to report behavior that violates probations, thus taking responsibility for their own actions. Positive consequences that demonstrate to patients the benefits of appropriate behavior should also be designed and incorporated into the treatment plan. Financial incentives and opportunities for power or recognition can be a key element of treatment.

Case management may involve coordinating care with a variety of other professionals and individuals, including those in the criminal justice system, AOD counselors, and family members. Therapists need to make it clear to patients that the therapist must talk to other providers and to family members. Thus, it is helpful for patients to sign releases of information for all people involved in their treatment.

The question of terminating therapy can be a puzzling one for therapists treating antisocial patients. The patient may frequently express a desire to end treatment. This desire should be closely examined to determine whether it is a manifestation of patient resistance or whether it is a valid request. There is some question about whether it is appropriate to terminate therapy with patients who have antisocial personality disorder who may need ongoing treatment. Reasons for termination may include noncompliance with treatment, continued drug use without improvement, any aggressive behavior, parasitic relationship with other patients, or any unsafe behavior.

Patients with antisocial personality disorder compulsively try to break rules. If a treatment plan is not devised to work with a person who wants to redefine rules, termination should be considered and transfer to more appropriate care should be arranged.

Continued thinking-error work may help patients to identify various types of rationalizations that they may use regarding their behaviors.



Group therapy is a useful setting in which people with antisocial personality disorder can learn to identify errors not only in their own thinking, but in the thinking of others. The group can help identify relapse thinking. For example, when an individual begins to glamorize stories of AOD use or criminal and acting-out behaviors, the group can help to limit that grandiosity. Therapists may also ask people with antisocial personality disorder to discuss feelings associated with the behavior being glamorized.

Role-play exercises can be useful tools in group therapy. However, therapists should be careful to prevent patients with antisocial personality disorder from using newly learned skills to exploit or control other group members. In group therapy, patients with antisocial personality disorder can be encouraged to model prosocial behaviors and learn by practicing them. Role-play exercises can help these patients to focus on their shortcomings rather than on the faults of others.

AOD therapists should avoid creating groups that consist entirely of patients with antisocial personality disorder. Such groups are best conducted in very controlled settings in which therapists have control over the environment.

Patients with antisocial personality disorder may be asked to sign contracts that establish healthy and nonparasitic relationships with other group members. This means not becoming romantically involved with other members, not borrowing money from them, and not developing exploitive relationships.

Therapists themselves should try not to become obsessed with being manipulated or tricked by group members. Such power struggles are not helpful.



A key to treating people with antisocial personality disorder is to be flexible within an array of containment interventions. Therapists should have the ability to quickly move a patient from a less controlled environment to a more controlled environment. Patients benefit from sanctions that match the degree of severity of behavior. Sanctions should not be ’punishments’ but responses to the need for containment and more intensive treatment. Antisocial patients need a range of treatment and other services: from residential to outpatient treatment, from vocational education to participation in long-term relapse prevention support groups, and from 12-step programs to jail.

When patients with antisocial personality disorder shed aspects of the disorder, they may become more dependent. Therapists often try to limit such dependence. However, with regard to antisocial patients, such a transition should be allowed rather than confronted. It often represents a healthy change. Feelings of dependency are easily frustrated at this stage, and disappointment may result in relapse.