Antisocial personality disorder (ASPD) is characterized by a lifelong pattern of behavior that violates the law and other people’s rights. Its primary relevance to the field of psychology and law stems from its association with criminal and violent behavior, as well as its implications for attempting to reduce the risk thereof through treatment. This research paper reviews the diagnostic criteria for ASPD, its phenomenology (common attitudinal, cognitive, emotional, and behavioral features), assessment approaches, treatment issues, etiological factors, and current controversies.
Antisocial Personality Disorder Description
There are a number of definitional elements to personality disorder (PD) generally that apply to ASPD. A PD is a pattern of inflexible interpersonal relations, behavior, and internal experiences (emotional, cognitive, or attitudinal tendencies) that is stable across the life span and starts in adolescence (or early adulthood). It is inconsistent with cultural norms or expectations and involves distress or impairment to the individual. The core of ASPD involves consistently disregarding social norms or rules and violating other people’s rights.
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The official diagnostic criteria for ASPD, as with all PDs, are provided by the Diagnostic and Statistical Manual of Mental Disorders, currently in its fourth edition, which includes a textual revision (DSM-IV-TR), published by the American Psychiatric Association. To receive a diagnosis of ASPD, an individual must be at least 18 years old; there must be evidence of conduct disorder (CD) with an onset before the age of 15; antisocial behavior must not be limited in its occurrence solely within the course of schizophrenia or a manic episode; and there must be a pattern of violating or disregarding others’ rights since the individual was 15 years old.
More specifically, an individual must meet three of seven diagnostic criteria—as specified in the DSM-IV-TR—since the age of 15. Paraphrasing, these include (1) repeated criminal behavior; (2) frequent lying or manipulation; (3) impulsive behavior; (4) aggression, including physical violence; (5) jeopardizing other people’s safety (e.g., driving while intoxicated); (6) being irresponsible (i.e., refusing to pay one’s bills or debts); and (7) not experiencing remorse for one’s harmful behaviors.
In addition to meeting at least three of these seven criteria since age 15, an individual must also have shown evidence of CD prior to the age of 15. Although the DSM-IV-TR does not specify the number of CD symptoms required to satisfy this diagnostic criterion, some experts, and common assessment instruments (see below), have suggested that as few as 2 (of 15) CD symptoms would suffice. The 15 symptoms of CD include, among others, aggressive behaviors (e.g., stealing, fighting, using weapons, robbery, sexual assault), destroying property, lying, and other rule-breaking behavior (e.g., skipping school, running away from home).
Antisocial Personality Disorder Phenomenology, Associated Features, and Correlates
Attitudinally, individuals with ASPD may hold disparaging views of others and consider them to be avenues to fulfill their own needs (e.g., for money, sex, pleasure). They tend to have a hostile and distrustful view of the world, believing that others may be out to harm or deceive them and hence their own harmful or deceptive behavior is justified. ASPD is associated with negative views of societal institutions such as law enforcement, the judiciary, or the government. Procriminal attitudes that support, condone, or justify criminal behavior are common.
Cognitively, ASPD is associated with impulsive decision making involving little forethought, even if negative consequences are serious and probable. People with ASPD also may show poor concentration abilities and an impaired ability to devote sustained attention to routine activities. On the other hand, they may indeed be able to devote attention to activities that they consider pleasurable or exciting (e.g., gambling).
Emotionally, some, though not all or even the majority of, people with ASPD show serious deficits in the depth and breadth of emotional experience. That is, they tend not to experience extremes (positive or negative) of emotion, such as despair or love, to the same degree as people without ASPD. This type of emotional poverty would be most likely to occur in individuals with ASPD who also meet definitions of the more classic form of antisocial personality pathology—namely, psychopathy, a hallmark of which is emotional detachment.
People with ASPD commonly are prone to negative emotionality, or the tendency to have feelings of anger, irritability, hostility, dissatisfaction, unhappiness, displeasure, and anxiety. Such an emotional disposition may account, in part, for the tendency of people with ASPD to have problems initiating or sustaining positive interpersonal relationships. Furthermore, such emotional tendencies could explain the increased risk of suicide-related behavior in ASPD.
Behaviorally, there are numerous correlates of ASPD that span all domains of life functioning. Perhaps most notably, ASPD is commonly associated with criminal and violent behavior. This observation is complicated by the fact that crime and violence form part of its diagnostic criteria, and hence, not surprisingly, individuals with ASPD have more crime and violence in their histories than those without ASPD. However, ASPD also is predictive of future criminal behavior once persons are released from prisons or forensic institutions. In addition to criminal behavior, risk-taking behavior is common. This can take a variety of forms, such as problematic substance use that is associated with adverse outcomes, such as crime, injury, personal neglect, or financial difficulties. It also may include irresponsible behaviors, such as reckless driving, failing to care for children adequately, sexual behavior that puts others’ safety at risk, or gambling problems.
In terms of more general life functioning, the effects of ASPD are notable as well. For instance, ASPD is associated with low socioeconomic attainment, poor employment records and performance, low educational attainment and success, and unstable interpersonal relationships. The latter may include broken ties with one’s family, abuse and other mistreatment within romantic relationships, and having only friends of convenience. Furthermore, ASPD predicts increased morbidity and mortality associated with accidental death and injury, as well as suicide.
Antisocial Personality Disorder Association with Other Disorders
Most PDs are associated with other PDs, and ASPD is no exception. It is common for people with ASPD to show symptoms of other PDs involving dysregulation of affect and impulsive behavior, such as borderline, narcissistic, or histrionic PDs. In addition, perhaps stemming from the high degree of negative emotionality commonly present in ASPD, some depressive and anxiety disorders are overrepresented in ASPD. Substance-related disorders also are disproportionately present in persons with ASPD relative to those without.
Antisocial Personality Disorder Assessment
Both self-report and interview-based measures are available to assess ASPD. Although conducting an interview is regarded as meeting a higher standard of clinical care when assessing personality (or other) pathology, self-report tools may be desirable additions to an assessment because they tend to be relatively brief, may be appropriate for group administration, and do not require an examiner with advanced credentials. On the other hand, self-reports require cooperation from the examinee and a minimum level of literacy.
Several (semi)structured interviews exist for assessing ASPD, including the Diagnostic Interview for DSM-IV Personality Disorders, the Structured Interview for DSM-IV Personality Disorders, the Personality Disorder Examination, the Diagnostic Interview Schedule, and the Composite International Diagnostic Interview. Perhaps the most widely used and researched semi-structured interview schedule for use by trained clinicians in assessing ASPD (and other PDs) is the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II). Each symptom criterion is assessed by an item that the interviewer rates using a 3-point scale (1 = absent or false; 2 = subthreshold; and 3 = threshold or true). Research indicates acceptable levels of internal consistency, test-retest reliability, and interrater reliability for the SCID-II ASPD module.
Several self-report measures that include modules for assessing ASPD also have been developed, such as the Personality Diagnostic Questionnaire—1 (PDQ-1), the Assessment of DSM-IV Personality Disorders Questionnaire, and the Wisconsin Personality Disorders Inventory. Self-reports whose items closely track the diagnostic criteria, such as the PDQ-1, have greater clinical relevance to the assessment of ASPD than those that do not. Although many self-report personality measures and diagnostic inventories include scales for assessing features of ASPD (e.g., the California Psychological Inventory, the Minnesota Multiphasic Personality Inventory-2, the Millon Clinical Multiaxial Inventory-III, and the Personality Assessment Inventory), they often emphasize conceptualizations of delinquent personality other than ASPD (e.g., psychopathy). These scales typically demonstrate low concordance with SCID-II diagnoses of ASPD, which likely is related to their lack of representation of the DSM criteria for ASPD. Compared with interview-based measures, self-reports tend to yield elevated prevalence rates of ASPD. Furthermore, an actual diagnosis of ASPD must be made by a qualified mental health professional, who interprets whatever tests and measures are used, rather than simply relying on scores on a test or measure.
Research studies comparing the utility of self-report and interview measures for ASPD generally conclude that whereas agreement for dichotomous diagnostic classification tends to be poor, concordance is much higher when a dimensional perspective is considered. Although knowing the rates of categorical classification is attractive from a clinical perspective, there nevertheless is substantial empirical support for the use of dimensional representations of PDs. In terms of relevance to applied practice, information regarding the severity of symptoms (i.e., a dimensional perspective) can be useful for treatment planning and case management.
Despite the ease of use and availability of self-report measures and (semi)structured interviews, clinicians should be aware of the circumstances under which a diagnosis of ASPD is not warranted. First, a diagnosis of ASPD should not be given to individuals who display antisocial behavior only during acute phases of psychotic or mood disorders (e.g., a manic episode). In cases where the examinee has a substance use disorder and adult antisocial behaviors are observed, ASPD should be diagnosed only if features of the disorder were present during childhood. Also, given the high degree of comorbidity between PDs, differentiating between features of ASPD that are similar to those of other PDs is critical. Of course, ASPD also needs to be differentiated from certain Axis I disorders with similar symptoms (e.g., grandiosity and impulsivity, observed in bipolar disorder). Finally, collateral information is useful to consider in assessments in light of the characteristic deceitfulness of individuals with the disorder.
Antisocial Personality Disorder Treatment
ASPD is extremely difficult to treat, and at present, the prognosis for antisocial individuals typically is considered poor. The empirical treatment literature bearing on ASPD is in its infancy, with few controlled studies having been conducted. In addition, research in this area tends to examine the outcomes of interventions for behaviors associated with ASPD, such as substance abuse and violence, rather than treatments aimed at altering the underlying personality features of the disorder. In addition, relatively little research has examined intervention outcomes with women— and when women are included in samples, results typically are not disaggregated by gender. Nevertheless, the body of literature on this topic has grown over the past decade, and some broad trends are apparent.
Several studies have investigated the outcomes of substance abuse treatment among individuals with ASPD. Most results indicate that persons with co-occurring substance abuse problems and ASPD make treatment gains on par with those of individuals in substance abuse treatment without ASPD. However, other studies on this topic suggest less improvement in individuals with ASPD than in others. Furthermore, research suggests that broad classifications such as “substance abuser” may be too generic and that differences based on an individual’s drug of choice and the severity of the impact on daily functioning may be important to treatment outcome.
Given the nature of the diagnosis, it is not surprising that most treatment outcome studies on ASPD have been conducted with offender samples. Although at this time, research data do not endorse a specific type of treatment for ASPD, there is strong empirical support for the effectiveness of certain guiding principles. The principles of risk, need, and responsivity indicate that treatment outcome will be maximized as a function of a treatment program’s match with an individual’s level of risk, criminogenic needs (changeable risk factors), and learning style. Meta-analytic reviews indicate that the strongest predictor of success across different correctional programs and offender groups—including both men and women—is treatment that adheres to these three principles.
Another aspect of treatment with empirical support is the multimodal hypothesis, which suggests that correctional treatment is most effective when multiple need areas of an offender are targeted. Research demonstrates that multimodal programs that incorporate cognitive-behavioral and social learning strategies are associated with substantially larger treatment gains than are nonbehavioral interventions. In addition, there is a positive association between the number of criminogenic needs targeted for intervention and subsequent reductions in recidivism. In contrast, approaches that are contraindicated for treating ASPD because they are viewed as unresponsive to offenders’ criminogenic needs and/or learning style include traditional “talk” psychotherapy of the psychodynamic, client-centered, and insight-oriented ilk.
Programs that include a relapse prevention element are associated with enhanced reductions in recidivism. Relapse prevention is a cognitive-behavioral approach to self-management that entails teaching individuals alternate (more effective) responses to high-risk situations. Components of relapse prevention that seem to be especially effective in reducing recidivism include identifying one’s offense-chain and high-risk situations and, subsequently, role-playing alternate (more effective) ways of handling such situations.
Antisocial Personality Disorder Etiology
Specifying etiological mechanisms for ASPD is difficult because of the nonspecificity of the disorder. That is, there are innumerable symptom combinations that can give rise to a diagnosis. Furthermore, a diagnosis can arise almost solely from a person having engaged in chronic criminal and violent behavior. That is, there are no pathognomonic, necessary, or sufficient signs of ASPD. Therefore, almost anything that predicts chronic crime and violence ostensibly could be considered a candidate etiological factor for ASPD.
Nevertheless, there is evidence for certain genetic, biological, and environmental etiological mechanisms in ASPD. Large-scale twin and adoption research shows a high degree of heritability for PDs generally, as well as for ASPD specifically. An interesting line of research by Robert Krueger and colleagues has shown that ASPD might be construed as part of a heritable externalizing spectrum of psychopathology that includes antisocial personality features and behavior, substance use problems, conduct problems, sensation seeking, and low constraint.
Potential biological mechanisms include neurochemical imbalances, such as low serotonin levels, that are related to impulsive and aggressive behavior. Some biological etiological mechanisms have been advanced more specifically for psychopathy, which includes additional interpersonal and emotional deficits. For instance, some experts propose that psychopathy, and as such some cases of ASPD, is associated with functional brain deficits, such as a diminished ability to process emotion or impaired information processing. Other mechanisms could include temperamental deficiencies, such as decreased startle potentiation. Structural, as opposed to functional, neuroanatomic models have been proposed as well, including deficits in prefrontal and temporal lobe gray matter. It is important to note that all such research on the biological mechanisms of psychopathy and ASPD is in its infancy and cannot yet support definitive statements about clear etiological factors.
Environmental factors also may elevate the risk of development of ASPD. For instance, abusive, inconsistent, or permissive parental disciplinary styles predict delinquency and adult criminality. Similarly, other family-of-origin and formative experiences predict delinquent and criminal behavior, such as parental criminality, violence, and substance use problems. Social learning theory would posit that such parental behaviors model criminal behavior for children, who then learn to use crime and violence in their own lives.
Of course, many such parental factors could be acting as mere proxies for genetic etiological mechanisms, and future research will need to disentangle genetic from environmental risk factors. Some interesting emerging research has started to do so. For instance, parental physical maltreatment of children has been found to predict antisocial behavior above and beyond the heritable aspects of parental antisociality. Furthermore, research is starting to address gene-environment interactions vis-a-vis antisocial behavior and personality, which posit that genetic and environmental factors might be multiplicative in their influence on such outcomes rather than merely additive.
Antisocial Personality Disorder Controversies
The ASPD diagnosis has generated controversy on several fronts. The debate that has received the most commentary pertains to whether the diagnostic criteria should emphasize objective behaviors or personality features. The introduction of ASPD into the DSM was intended to reflect the clinical disorder known as psychopathy, which includes features such as callousness, remorselessness, guiltlessness, superficiality, and shallow affect. The ASPD criteria were written with a behavioral focus in the service of the decreasing subjectivity involved in rating personality features, thereby increasing reliability. In the current diagnostic nomenclature, ASPD is presented as being largely the same as psychopathy—even though many of the descriptors traditionally associated with psychopathy are absent from the diagnostic criteria. That the two disorders are not in fact synonymous is highlighted by the results of contemporary prevalence studies demonstrating that about three quarters of prisoners meet the criteria for ASPD whereas only about one quarter, or less, meets the criteria for psychopathy.
Additionally, the criteria have been criticized for lacking specificity; for instance, meeting diagnostic criteria may arise from a boggling number of permutations of the 7 adult disorder and 15 CD symptoms. An important impact of the imprecision with which the outcome of ASPD is delineated is that it renders investigation into the disorder’s causal factors much more challenging, as noted above. Moreover, the validity of ASPD has been challenged in light of the paucity of available longitudinal data. Critics of the ASPD criteria also argue that they are underinclusive (in that individuals will not be identified who have the core antisocial personality features but have not been criminally sanctioned or who demonstrate antisociality during adulthood but for whom there is no evidence of CD). In contrast, others advance concerns that the criteria are overinclusive (in that there likely are several etiological bases for antisociality, only one of which may be psychopathy). As noted earlier, the criteria largely reflect the behavioral difficulties associated with crime and substance use. This is noted to be problematic because behaviors can be influenced by external circumstances, whereas personality traits are viewed as being more reflective of underlying pathology.
Another controversy surrounding the diagnostic criteria is the apparent diagnostic biases they invoke. Although the prevalence of ASPD genuinely may be higher among men (estimated at 3% of the population) than among women (estimated at 1%), research has documented elevated rates among men even when men and women do not differ in symptomatology. Some researchers have argued in favor of amending the diagnostic criteria to include behaviors associated specifically with antisociality in women in an effort to make the criteria more gender neutral. Finally, concerns also have been raised that ASPD may be disproportionately overdiagnosed among prisoners and persons with substance use problems in light of the behavioral focus of the criteria.
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