Introduction

Personality disorders are mental health conditions that affect how someone thinks, perceives, feels or relates to others.

Antisocial personality disorder is a particularly challenging type of personality disorder, characterised by impulsive, irresponsible and often criminal behaviour.

Someone with antisocial personality disorder will typically be manipulative, deceitful and reckless, and won't care for other people's feelings.

Like other types of personality disorder, antisocial personality disorder is on a spectrum, which means it can range in severity from occasional bad behaviour to repeatedly breaking the law and committing serious crimes. Psychopaths are considered to have a severe form of antisocial personality disorder.

Signs of antisocial personality disorder

A person with antisocial personality disorder may:

  • exploit, manipulate or violate the rights of others
  • lack concern, regret or remorse about other people's distress
  • behave irresponsibly and show disregard for normal social behaviour
  • have difficulty sustaining long-term relationships
  • be unable to control their anger
  • lack guilt, or not learn from their mistakes
  • blame others for problems in their lives
  • repeatedly break the law

A person with antisocial personality disorder will have a history of conduct disorder during childhood, such as truancy (not going to school), delinquency – for example, committing crimes or substance misuse – and other disruptive and aggressive behaviours.

Who develops antisocial personality disorder?

Antisocial personality disorder affects more men than women.

It's not known why some people develop antisocial personality disorder, but both genetics and traumatic childhood experiences, such as child abuse or neglect, are thought to play a role.

A person with antisocial personality disorder will have often grown up in difficult family circumstances. One or both parents may misuse alcohol, and parental conflict and harsh, inconsistent parenting are common. As a result of these problems, social services may become involved with the child's care.

These types of difficulties in childhood will often lead to behavioural problems during adolescence and adulthood.

Effects of antisocial personality disorder

Criminal behaviour is a key feature of antisocial personality disorder, and there's a high risk that someone with the disorder will commit crimes and be imprisoned at some point in their life.

Men with antisocial personality disorder have been found to be three to five times more likely to misuse alcohol and drugs than those without the disorder, and have an increased risk of dying prematurely as a result of reckless behaviour or attempting suicide.

People with antisocial personality disorder are also more likely to have relationship problems during adulthood and be unemployed and homeless.

Diagnosing antisocial personality disorder

To be diagnosed with antisocial personality disorder, a person must have a history of conduct disorder before the age of 15.

Antisocial personality disorder is diagnosed after rigorous psychological assessment. A diagnosis can only be made if the person is aged 18 years or older and at least three of the following criteria apply:

  • repeatedly breaking the law
  • repeatedly being deceitful
  • being impulsive or incapable of planning ahead
  • being irritable and aggressive
  • having a reckless disregard for their safety or the safety of others
  • being consistently irresponsible
  • lack of remorse

These signs must not be part of a schizophrenic or manic episode – they must be part of the person's everyday personality.

This behaviour usually becomes most extreme and challenging during the late teens and early 20s. It may improve by the time the person reaches their 40s.

Treating antisocial personality disorder

In the past, antisocial personality disorder was thought to be a lifelong disorder, but that's not always the case and it can sometimes be managed and treated. Evidence suggests that behaviour can improve over time with therapy, even if core characteristics such as lack of empathy remain.

However, antisocial personality disorder is one of the most difficult types of personality disorders to treat. A person with antisocial personality disorder may also be reluctant to seek treatment and may only start therapy when ordered to do so by a court.

The recommended treatment for someone with antisocial personality disorder will depend on their circumstances, taking into account factors such as age, offending history and whether there are any associated problems, such as alcohol or drug misuse.

The person's family and friends will often play an active role in making decisions about their treatment and care. In some cases, substance misuse services and social care may also need to be involved.

The National Institute for Health and Care Excellence (NICE) has published guidelines about the treatment, management and prevention of antisocial personality disorder (PDF, 250kb).

Talking therapies

Cognitive behavioural therapy (CBT) is sometimes used to treat antisocial personality disorder. It's a talking therapy that aims to help a person manage their problems by changing the way they think and behave.

Mentalisation-based therapy (MBT) is another type of talking therapy that's becoming more popular in the treatment of antisocial personality disorder. The therapist will encourage the person to consider the way they think and how their mental state affects their behaviour.

Democratic therapeutic communities (DTC)

Evidence suggests community-based programmes can be an effective long-term treatment method for people with antisocial personality disorder, and is becoming increasingly popular in prisons.

DTC is a type of social therapy that aims to address the person's risk of offending, as well as their emotional and psychological needs. It's based around large and small therapy groups and focuses on community issues, creating an environment where both staff and prisoners contribute to the decisions of the community. There may also be opportunities for educational and vocational work.

The recommended length of treatment is 18 months as there needs to be enough time for a person to make changes and put new skills into practice. Self-motivation is another important factor for acceptance on to this type of scheme. For example, the person must be willing to work as part of a community, participate in groups and be subject to the democratic process.

The Ministry of Justice has more information about DTC in their guide Working with personality disordered offenders (PDF, 969kb).

Medication

There's little evidence to support the use of medication for treating antisocial personality disorder, although certain antipsychotic and antidepressant medications may be helpful in some instances.

Carbamazepine and lithium may help control symptoms such as aggression and impulsive behaviour, and a class of antidepressant called selective serotonin reuptake inhibitors (SSRIs) may improve anger and general personality disorder symptoms.

About personality disorders

Personality disorders affect how someone thinks, perceives, feels or relates to others. They range from mild to severe.

The signs typically emerge in adolescence and persist into adulthood. People with personality disorders often have other mental health problems, particularly depression and substance misuse.

Personality disorders may be associated with genetic and family factors, and experiences of distress or fear during childhood, such as neglect or abuse, are common. Although personality disorders may run in families, psychopathy is thought to have a higher genetic component.

Treatment for personality disorders usually involves a course of psychological therapy.

 

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Symptoms

The different types of personality disorder that might need treatment can be broadly grouped into one of three clusters, called A, B or C.

Cluster A personality disorders

A person with a cluster A personality disorder tends to have difficulty relating to others and usually shows patterns of behaviour most people would regard as odd and eccentric.

The main personality disorders in this category are listed below.

Paranoid personality disorder

A person with a paranoid personality disorder is extremely distrustful and suspicious. Other symptoms include:

  • thinking other people are lying to them or trying to manipulate them
  • feeling they cannot really trust their friends and associates
  • worrying any confidential information shared with others will be used against them
  • thinking there are hidden meanings in remarks most would regard as innocent
  • worrying their spouse or partner is unfaithful, despite a lack of evidence

Schizoid personality disorder

A person with a schizoid personality disorder may appear cold and detached, and avoid making close social contact with others. Other symptoms include:

  • preferring to take part in activities that do not require interaction with others
  • having little desire to form close relationships, including sexual relationships
  • being uninterested when receiving criticism or praise
  • having a limited ability to experience pleasure or joy

Schizotypal personality disorder

A person with a schizotypal personality disorder is likely to have poor social skills and delusional thoughts, and behave in unusual ways. Other symptoms include:

  • attaching undue and misguided significance to everyday events, such as thinking newspaper headlines are secret messages to them
  • believing in special powers, such as telepathy or the ability to influence other people’s emotions and actions
  • having unusual ways of speaking, such as long, rambling vague sentences or going off on a tangent
  • experiencing excessive anxiety in social situations, even if they have known a particular person or group of people a long time

Cluster B personality disorders

A person with a cluster B personality disorder struggles to relate to others. As a result, they show patterns of behaviour most would regard as dramatic, erratic and threatening or disturbing.

The main personality disorders in this category are listed below.

Antisocial personality disorder

A person with an antisocial personality disorder sees other people as vulnerable and may intimidate or bully others without remorse. They lack concern about consequences their actions may have.

Symptoms include:

  • lack of concern, regret or remorse about other people's distress
  • irresponsibility and disregard for normal social behaviour
  • difficulty in sustaining long-term relationships
  • little ability to tolerate frustration and to control their anger
  • lack of guilt, or not learning from their mistakes
  • blaming others for problems in their lives

The National Institute for Health and Clinical Excellence (NICE) has recently published guidelines on how people with antisocial personality disorders should be treated. For more information, see NICE: antisocial personality disorder (PDF, 1.71Mb).

Borderline personality disorder

A person with a borderline personality disorder is emotionally unstable, has impulses to self-harm and has very intense and unstable relationships with others..

Histrionic personality disorder

A person with a histrionic personality disorder is anxious about being ignored. As a result, they feel a compulsion (overwhelming urge) to be noticed and the centre of everybody’s attention. Symptoms and behaviours include:

  • displaying excessive emotion yet appearing to lack real emotional sincerity
  • dressing provocatively and engaging in inappropriate flirting or sexually seductive behaviour
  • moving quickly from one emotional state to another
  • being self-centred and caring little about other people
  • constantly seeking reassurance and approval from other people

Symptoms and signs may co-exist with borderline and narcissistic personality disorders.

Narcissistic personality disorder

A person with a narcissistic personality disorder swings between seeing themselves as special and fearing they are worthless. They may act as if they have an inflated sense of their own importance and show an intense need for other people to look up to them.

Other symptoms include:

  • exaggerating their own achievements and abilities
  • thinking they are entitled to be treated better than other people
  • exploiting other people for their own personal gain
  • lacking empathy for other people's weaknesses
  • looking down on people they feel are ‘beneath’ them, while feeling deeply envious of people they see as being ‘above’ them

Cluster C personality disorders

A person with a cluster C personality disorder fears personal relationships and shows patterns of anxious and fearful behaviour around other people. Others may be withdrawn and reluctant to socialise.

The main personality disorders in this category are listed below.

Avoidant personality disorder

A person with an avoidant personality disorder appears painfully shy, is socially inhibited, feels inadequate and is extremely sensitive to rejection.

Unlike people with schizoid personality disorders, they desire close relationships with others but lack the confidence and ability to form them.

Dependent personality disorder

A person with a dependent personality disorder feels they have no ability to be independent. They may show an excessive need for others to look after them and are ‘clingy’. Other symptoms include:

  • finding it difficult to make decisions without other people’s guidance
  • needing others to take responsibility over what should be their own important life choices
  • not being able to express disagreement with other people
  • finding it difficult to start new activities due to a lack of confidence
  • going to extremes to obtain support and comfort
  • feeling helpless and uncomfortable when alone
  • urgently needing to start a new relationship once a previous relationship comes to an end
  • having an unrealistic and constant fear they will be left alone to fend for themselves

Obsessive compulsive personality disorder

A person with an obsessive compulsive personality disorder is anxious about issues that seem out of control or 'messy'. They are preoccupied with orderliness and ways to control their environment and may come across to others as a ‘control freak’.

Other symptoms include:

  • having an excessive interest in lists, timetables and rules
  • being so concerned with completing a task perfectly that they have problems completing it (perfectionism)
  • being a workaholic
  • having very rigid views about issues such as morality, ethics and how a person should behave in daily life
  • hoarding items that seem to have no monetary or sentimental value
  • being unable to delegate tasks to other people
  • disliking spending money, as they think it is always better to save for a ‘rainy day’

This personality disorder differs from obsessive compulsive disorder (OCD), a related mental health condition, in several important ways:

  • People with OCD are aware their behaviour is abnormal and are anxious about it. Most people with obsessive compulsive personality disorder think their behaviour is perfectly acceptable and have no desire to change it.
  • Some people with OCD are compelled to carry out rituals, such as having to touch every second lamppost as they walk down the street. This is not usually the case with people with obsessive compulsive personality disorder.
  • People with OCD may feel compelled to make lists or organise items in their house but feel anxious about doing so. People with obsessive compulsive personality disorder find relief from anxiety when doing such tasks and may become irritated when prevented from doing so.

Read more information about obsessive compulsive disorder.

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Treatment

Treatment for most personality disorders usually involves a course of psychological therapy. This normally lasts at least six months,  often longer, depending on the severity of the condition and other co-existing problems.

Psychological therapies

Psychotherapy is a treatment that involves discussion of thoughts, feelings and emotions with a trained professional. The aim of all psychological therapies is to improve people's ability to regulate their thoughts and emotions.

Some therapies focus on dysfunctional thoughts, while others focus on self-reflection and being aware of how your own mind works. Some therapies, especially group therapies, help people understand social relationships better.

Psychological therapies can be effective for many personality disorders. However, they should only be delivered by a trained professional who has experience of working with personality disorders and other clinical conditions. This is because personality disorders are serious conditions that can be associated with high-risk behaviours, such as self-harm.

As well as listening and discussing important issues with you, the psychotherapist can suggest strategies to resolve problems and, if necessary, can help you change your attitudes and behaviour.

A range of different psychotherapies are used to treat personality disorders. They can be broadly classified into three types of therapy, outlined below.

Psychodynamic (reflective) psychotherapy

Psychodynamic psychotherapy is based on the idea that many adult patterns of behaviour are related to negative early childhood experiences. These experiences cause patterns of distorted thinking and beliefs that may have been understandable in childhood but do not work in adult life. The goal of therapy is to explore these distortions, understand how they arose, and find effective ways to overcome their influence on your thinking and behaviour.

Both individual and group dynamic therapy may be helpful for personality disorders, especially borderline personality disorder (BPD). A particular form, called mentalisation-based therapy, is recommended for BPD.

Read about treating BPD for more information on mentalisation-based therapy.

Cognitive behavioural therapy

Cognitive behavioural therapy (CBT) is based on the theory that how we think about a situation affects how we act. In turn, our actions can affect how we think and feel. Therefore, it is necessary to change both the act of thinking (cognition) and behaviour at the same time.

A type of CBT called dialectical behaviour therapy (DBT) has proved successful in helping people reduce impulsive self-harming behaviours, especially in borderline personality disorder. DBT is designed to help you cope better with emotional instability, while at the same time encouraging you to behave in a more positive way.

Interpersonal therapy

Interpersonal therapy (IPT) is based on the theory that our relationships with other people and the outside world in general have a powerful effect on our mental health.

Several personality disorders may be associated with feelings of low self-esteem, anxiety and self-doubt caused by problems interacting with people.

During IPT, the therapist will explore any negative issues associated with your interpersonal relationships and how these issues can be resolved.

Therapeutic communities

Therapeutic communities (TCs) are a form of group therapy in which the experience of having a personality disorder is explored in depth. TCs are an intensive form of therapy.

The minimum type of TC is one day a week, but others are 9-5pm, five days a week. They have been shown to be effective for mild to moderate personality disorders, but require a high level of commitment.

Medication

Currently, no medication has been licensed for the treatment of any personality disorder. However, medications may be prescribed to treat associated problems such as depression, anxiety or psychotic symptoms.

For example, if you have moderate to severe symptoms of depression that make it difficult to approach your therapy with confidence or enthusiasm, you may be prescribed a type of antidepressant called a selective serotonin reuptake inhibitor (SSRI).

Some people, especially those with borderline personality disorder, have found mood-stabilising medication helpful.

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The information on this page has been adapted by NHS Wales from original content supplied by NHS Choices.
Last Updated: 19/09/2017 10:50:13