Antisocial personality disorder

Antisocial personality disorder (ASPD or APD) is defined by the American Psychiatric

Association's Diagnostic and Statistical Manual as "...a pervasive pattern of disregard for, and
violation of, the rights of others that begins in childhood or early adolescence and continues into
adulthood."

Antisocial personality disorder is sometimes known as sociopathic personality disorder. It

is also sometimes referred to as psychopathy. Some researchers believe that antisocial
personality disorder and psychopathic personality are different conditions, however.

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.

Signs and symptoms

Characteristics of people with antisocial personality disorder may include:

 Persistent lying or stealing

 Apparent lack of remorse[3] or empathy for others
 Cruelty to animals[4]
 Poor behavioral controls — expressions of irritability, annoyance, impatience, threats,
aggression, and verbal abuse; inadequate control of anger and temper
 A history of childhood conduct disorder
 Recurring difficulties with the law
 Promiscuity
 Tendency to violate the boundaries and rights of others
 Aggressive, often violent behavior; prone to getting involved in fights
 Inability to tolerate boredom
 Disregard for right and wrong
 Poor or abusive relationships
 Irresponsible work behavior
 Disregard for safety

Client Assessment Database

Circulation

Heart Rate: Slight increase may be demonstrated when anticipating stress (correlates with
electrodermal responses indicating minimal anxiety)
Ego Integrity

Lacks motivation for change, often not seeking therapy voluntarily (unless client can no
longer tolerate the mess he or she has made of own life or is facing long-term imprisonment)

Absence of feelings of guilt/shame

Use of aliases

Neurosensory

Mental Status: Personality appears charming, engaging, and is usually intelligent;

demeanor is often a pretense intended to deceive or facilitate exploitation of others; manipulation
is style of operating (e.g., needs and demands immediate gratification); low tolerance level
results in feelings of frustration when desires are not immediately gratified

Mood: Adaptive to individual’s intended goal, mood may range from charming and
pleasant to intensely angry

Affect: Emotional reactions may be erratic and extreme, with lack of concern for other
people’s feelings

Thought Processes: Client is preoccupied with own interests and has grandiose
expressions of own importance, poor insight/judgment, and impulsivity or failure to plan ahead

Signs of personal distress possibly evident (e.g., tension and poor tolerance for boredom)

Lacks emotional attachment to others—even parents

Displays preference for stimulation rather than isolation

Diagnosis

EEG: Abnormally higher amounts of slow-wave activity, reflecting a possible deficit in

inhibitory mechanisms, which may lessen impact of punishment.

Aversive Stimuli: Tends to be slower in learning to avoid shock, associated with a lower than
normal level of physiological arousal; heightened ability to tune out aversive stimuli.

Psychopathy Checklist: Recently developed rating scale identifies 2 sets of characteristics

(impulsiveness and instability; callousness, egocentricity, and limitation of capacity for anxiety)
that are useful in predicting client outcome and likelihood of future violent crime activity.

Drug Screen: Determines substance use

DSM: The Diagnostic and Statistical Manual of Mental Disorders fourth edition, DSM IV-TR =
301.7, a widely used manual for diagnosing mental disorders, defines antisocial personality
disorder (in Axis II Cluster B) as:

A) There is a pervasive pattern of disregard for and violation of the rights of others
occurring for as long as either childhood, or in the case of many who are influenced by
environmental factors, around age 15, 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 repeatedly 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;
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;
8. promiscuity;
9. having shallow or seemingly nonexistent feelings.

New evidence points to the fact that children often develop Antisocial Personality
Disorder as a cause of their environment, as well as their genetic line. The individual does not
need to meet a certain age requirement in order to be diagnosed with this disorder.

Subtypes

Theodore Millon identified five subtypes of antisocial. Any individual antisocial may exhibit
none, one or more than one of the following:

 covetous antisocial - variant of the pure pattern where individuals feel that life has not
given them their due.
 reputation-defending antisocial - including narcissistic features
 risk-taking antisocial - including histrionic features
 nomadic antisocial - including schizoid, avoidant features
 malevolent antisocial - including sadistic, paranoid features.

Differential diagnosis

The following conditions commonly coexist with antisocial personality disorder:

 Anxiety disorders
  Depressive disorder
 Substance-related disorders
 Somatization disorder
 Pathological risk-seeking
 Borderline personality disorder
 Histrionic personality disorder
 Narcissistic personality disorder

When combined with alcoholism, people may show frontal function deficits on
neuropsychological tests greater than those associated with each condition.

Treatment

To date there have been no controlled studies reported which found an effective treatment
for ASPD, although contingency management programs, or a reward system, has been shown
moderately effective for behavioral change. Some studies have found that the presence of ASPD
does not significantly interfere with treatment for other disorders, such as substance abuse,
although others have reported contradictory findings. Schema therapy is being investigated as a
treatment for antisocial personality disorder, as well as medicinal marijuana treatments.

Nursing Management

1. Limit aggressive behavior; promote socially acceptable responses.

2. Develop a trusting relationship.
3. Assist client to learn healthy ways to deal with anxiety.
4. Increase sense of self-worth.
5. Promote development of alternate, constructive methods of interacting with others.

Discharge Goals

1. Self-control maintained.
2. Assertive behaviors used to gain desired responses.
3. A trusting relationship initiated.
4. Anxiety recognized and diminished/managed.
5. Client/family involved in ongoing therapy/support groups.
6. Plan in place to meet needs after discharge.