How to treat antisocial personality disorder

Antisocial personality disorder (ASPD) is a mental health condition that can impact an individual’s mood, behavior, and interpersonal relationships. Common symptoms include violent and criminal behavior, a lack of empathy and remorse, and volatile relationships. Evidence for effective ASPD treatment is limited, but there are various options that may be helpful.

Antisocial personality disorder therapies

There is limited evidence to demonstrate which therapies are the most effective at treating ASPD. This is partly because many individuals with ASPD do not seek treatment for this condition or are not deemed appropriate recipients of mental health services. Similarly, those who begin therapy are likely to discontinue, so they may not receive the full benefit of these treatments ^[1][2].

However, some evidence supports the use of various therapeutic interventions for individuals with ASPD, particularly those with comorbid conditions ^[2][3]. This may include:

Group-based cognitive and behavioral therapies

The purpose of group-based therapy for individuals with ASPD is to provide a setting to learn skills to improve interpersonal relationships and difficulties. Additionally, these group therapies help people reduce antisocial and criminal behaviors and learn to control impulsive behaviors ^[4].

Alcohol or substance use therapy

Many people with ASPD experience comorbid substance or alcohol use disorders, which may worsen symptoms of ASPD, such as impulsivity and aggression. As such, reducing alcohol or substance use can be a beneficial part of treatment and may also help reduce criminal activities used to gather the finances or means to ascertain substances ^[2][4].

By reducing alcohol and substance use, it is possible to reduce aggression, violence, and crime, thereby helping to improve the individual’s quality of life and reducing the risk of incarceration ^[1][5].

Cognitive behavioral therapy (CBT)

CBT can be a helpful intervention for individuals with milder symptoms who wish to engage in treatment. The purpose of CBT is to learn how to identify and challenge harmful thoughts and behaviors, and then develop new and more positive patterns ^[6][7].

CBT techniques can be applied to symptoms of ASPD, such as aggression and violence, helping the individual to adapt these behaviors. Similarly, it can be applied to comorbid symptoms, such as depression and anxiety, by allowing the individual to learn coping strategies for emotional distress and reduce the risk of self-harm or suicide ^[3].

Mentalization-based therapy

Mentalization-based therapy is a therapeutic approach that teaches individuals to be more aware of their thoughts and emotions and how these impact their behaviors. This can help individuals with ASPD to identify the mental processes that occur in reaction to others or challenging situations. Thus, they may learn how to regulate their responses and reduce antisocial or violent behaviors ^[7][8].

Dialectical behavior therapy (DBT)

DBT is a talk therapy similar to CBT, initially designed to treat borderline personality disorder. It has since been found to be effective in treating various other conditions, such as depression, eating disorders, and substance use disorders. DBT often includes group therapy sessions and individual sessions ^[9].

DBT aims to help individuals learn to accept themselves and their emotions while teaching skills to cope with emotional distress and adapt harmful behaviors. This can help people with ASPD reduce antisocial behaviors and symptoms such as self-harm or substance use ^[1][9].

Schema-focused therapy (SFT)

SFT involves several therapeutic approaches, such as CBT and psychodynamic techniques. The aim is to help individuals identify harmful thought and behavior patterns (schemas) that began as maladaptive responses to early experiences, such as childhood trauma. After recognizing these schemas, individuals can challenge and alter them, developing positive alternatives ^[1][3].

Antisocial personality disorder medication

There are no FDA-approved medications for the treatment of ASPD, as there is limited evidence for the effectiveness of medicinal treatment for this condition ^[6]. Additionally, there is a high risk within this population of medication noncompliance, misuse, or drug and alcohol interaction, so medications can potentially create additional risks ^[4].

Many people with ASPD have comorbid conditions, such as depression, alcohol or substance use disorders, and anxiety disorders, which can often be effectively treated with medication. Medications are sometimes prescribed to individuals with ASPD to help manage these conditions or specific symptoms ^[6][10].

Antidepressants

For example, antidepressant medications can be used to manage low mood, suicidal ideation, anxiety symptoms, impulsive behaviors, and addiction or withdrawal symptoms. This might include selective serotonin reuptake inhibitors (SSRIs), such as sertraline, fluoxetine, and citalopram ^[10][11].

Antipsychotics

Antipsychotic medications may be prescribed to individuals with ASPD to help manage symptoms, such as aggressive or violent behaviors, impulsivity, and extreme mood changes. This might include medications such as risperidone and quetiapine ^[2][10].

Mood stabilizers

Anticonvulsant or mood stabilizer medications may be prescribed to manage symptoms such as impulsivity, aggression, violence, and extreme mood changes. This could include medications such as lithium and carbamazepine ^[7].

Addiction and withdrawal

Medications might also be prescribed to people with ASPD to help reduce substance and alcohol use or manage withdrawal symptoms. This could include ^[11]:

• Disulfiram or naltrexone for alcohol dependence
• Methadone or buprenorphine for opioid dependence
• Bupropion, benzodiazepines, or anxiolytics for withdrawal symptoms

Do people with antisocial personality disorder ever require hospitalization?

Generally, it is thought among professionals that inpatient treatment provides little benefit to individuals with ASPD. If inpatient treatment is required, it is likely to be short-term crisis management or to treat a comorbid condition, such as reducing suicide risk, managing comorbid symptoms such as psychosis or mania, or treating substance or alcohol use disorders ^[1][4].

It is recommended that ASPD inpatient treatment should have a clear purpose and end date to prevent unnecessarily prolonged hospitalization. It is believed that ASPD can only be effectively treated in hospitals in specific circumstances. As such, hospitalization is unlikely to be beneficial and may potentially cause unnecessary risks to the individual or others and may worsen symptoms ^[4][10].

When people with ASPD receive inpatient treatment, it should be in specialized or forensic services, with staff specifically trained to work with this condition. This ensures that risks are effectively managed, boundaries managed and enforced, and violence or specific needs are responded to appropriately ^[4].

It is more common for individuals with ASPD to be in prison than in a psychiatric hospital, as this group has a high prevalence of drug- or violence-related crime. It is debated among professionals whether this is a suitable placement for these individuals, as they may pose a risk of harm to others, and their symptoms may be exacerbated if appropriate care is not provided ^[2][5].

Self-care strategies for people with antisocial personality disorder

People with ASPD may be unlikely or unwilling to recognize the existence of their condition and thus may not utilize self-care strategies. However, self-care techniques may benefit those with ASPD who experience comorbid conditions and symptoms, such as suicidal thoughts, depression, anxiety, and substance or alcohol use disorders ^[1][2].

This could include ^[12]:

• Reducing alcohol or substance use: Symptoms may be improved by reducing the use of alcohol or illicit substances. Some may be able to achieve this without needing professional intervention, although various services and resources can help if required.
• Seeking professional help: Asking for help can feel challenging and frightening. However, it is often much easier to cope with emotional distress with the support of a trained professional. Additionally, professionals can provide advice and information about ASPD and any co-existing conditions that may help to understand and manage symptoms.
• Talking to friends and family: Speaking to loved ones about worries and negative emotions can help to reduce their impact. Having a support network can significantly improve symptoms such as low mood, loneliness, and anxiety and make it easier to cope with distressing circumstances.
• Making healthy choices: Forming healthy habits can significantly improve mental and physical health. This might include eating a healthy and balanced diet, utilizing a sleep routine, and exercising regularly.
• Mindfulness and relaxation exercises: Utilizing mindfulness and relaxation exercises can help to improve several symptoms, such as stress, anxiety, depression, and agitation. This could include breathing exercises, yoga, meditation, body scanning, or relaxing activities such as going for a walk or taking a bath.