Antisocial personality disorder: diagnosis and management

Personality is the characteristic pattern of how individuals think, experience and express emotions, and how they perceive and relate to others around them. A personality disorder (PD) is, therefore, best understood as a deviation from the expected norms in society.

Antisocial PD (ASPD) is one of nine recognised types of PD according to the ‘International Statistical Classification of Diseases and Related Health Problems’ (ISCDRHP), and is defined by the ISCDRHP 10th Revision (ICD-10) as “disregard for social obligations and callous unconcern for the feelings of others. There is gross disparity between behaviour and the prevailing social norms. Behaviour is not readily modifiable by adverse experience, including punishment. There is a low tolerance to frustration and a low threshold for discharge of aggression, including violence; there is a tendency to blame others, or to offer plausible rationalisations for the behaviour bringing the patient into conflict with society”^[1]
.

Many people with ASPD are incarcerated in prison over their lifetime and commonly have histories of multiple prison sentences starting from an early age, owing to their inability to conform to social norms with respect to lawful behaviours^[2]
. It is estimated that at least 50% of UK prisoners meet the criteria for ASPD^[3]
, which contributes to high rates of recidivism and violence in the prison population. People with ASPD also often have poor general health and a reduced life expectancy^[2]
.

The 2014 Mental Health and Wellbeing in England survey by NHS Digital and the office for National Statistics reported an expected 2.8–4.0% of 18–64-year-olds to be diagnosed with ASPD. The rate is significantly higher in men (4.9%) than women (1.8%). The diagnosis rate tends to decrease as age increases, which is common for both men and women^[4]
.

This article will focus on the diagnosis and management of ASPD, cover how pharmacists can help improve medicine adherence in these patients and explain how to improve local prescribing practices.

Aetiology

There is no completely accepted model for the development of ASPD; however, the factors that are commonly noted in patient case histories are listed in Box 1. The healthcare community broadly agrees that development of ASPD involves a combination of factors including biological susceptibility (genetics); significant events in the person’s early to teen years of life involving social role models (e.g. physical abuse in childhood); and social factors that maintain or intensify problematic traits (e.g. use of illicit drugs). 

Children with several of the common characteristics of ASPD in their past have poor attachment to parental or caring figures, and those who exhibit troublesome behaviours that are not suppressed by their local social groups are at high risk of developing a PD.

Individuals with ASPD may show conduct disorder from an early age, be callous or sadistic, view others with contempt, have a strong need for dominance and have a low tolerance for frustration. Most of the symptomatic behaviour begins in adolescence and does not persist past early middle age (a phenomenon known as ‘antisocial burnout’).

Categorisation

There are different ways to describe and categorise PDs, although they are generally based on patterns in personality traits.

The ICD-10 categorises PDs into nine types^[1]
, although there is some overlap between them (see Table 1). As a result, PDs may also be grouped into three clusters of similar personality traits: suspicious, emotional/impulsive and anxious^[5]
.

The Diagnostic and Statistical Manual of Mental Disorder 5th Edition (DSM-5), another widely used clinical manual, uses specific criteria to diagnose ASPD^[6]
:

1. The individual has demonstrated conduct disorder with onset prior to the age of 15 years;
2. Since the age of 15 years, three or more of the following have been present:
   • Failure to conform to social norms with respect to lawful behaviours;
   • Deceitfulness (repeated lying, use of aliases or conning others for personal profit or pleasure);
   • Lack of remorse;
   • Impulsivity or failure to plan ahead;
   • Irritability or aggressiveness as indicated by repeated physical fights or assaults;
   • Reckless disregard for the safety of self or others;
   • Consistent irresponsibility;
3. An age of at least 18 years.

Individuals with ASPD may rigidly view the world as a hostile place where it is ‘everyone for themselves’ and where survival is only possible by exploitation and manipulation of others around them. They may struggle to hold others’ points of view, be dismissive of close attachments and view relationships along a continuum of dominance and submission.

Diagnosis

ASPD is underrecognised in both primary and secondary care^[2]
. Furthermore, patients will not present to healthcare professionals asking for relief from their personality difficulties. Therefore, healthcare professionals who work in settings where ASPD is more prevalent (e.g. drug and alcohol services) should be able to recognise at-risk patients. There should also be consideration of other comorbid mental health conditions (e.g. depression) in these patients^[2]
.

In all PDs the symptoms are defined as ‘the three P’s’:

• Problematic — The individual’s personality characteristics need to be outside the norm for the society in which they live and cause difficulties for themselves or others;
• Persistent — PDs are chronic conditions, meaning that the symptoms usually emerge in adolescence or early adulthood, are inflexible and relatively stable, and persist into later life;
• Pervasive — The individual’s behaviour causes distress or impaired functioning in several different personal and social contexts, such as intimate, family and social relationships, employment and offending behaviour.

There are a number of investigations that can be used to diagnose a PD; these are documented by either a psychologist or psychiatrist following a referral from primary care (see Box 2).

Management

PDs are disturbances in an individual’s personality and behaviours, and do not directly result from disease, damage or other insult, or from another psychiatric disorder. No medicines have established efficacy in treating or managing ASPD, but may sometimes be useful in short-term management of crisis or treatment of comorbid conditions^[11]
.

Therefore, the mainstay of treatment is talking therapies. According to the National Institute of Health and Care Excellence (NICE), treatment should focus on the provision of cognitive behaviour therapy (CBT) and mentalisation behaviour therapy (MBT)^[2]
. CBT looks at how feelings, thoughts and behaviour influence each other and how patients can change these patterns. MBT is a long-term talking treatment that aims to improve the patient’s ability to recognise and understand their and other people’s mental states, as well as to help them examine thoughts about themselves and others.

In the criminal justice system, focus is increasingly being placed on pathways for identified offenders that provide placements in therapeutic communities or specialist prison units to tackle the repeat offending nature and break the cycle that patient’s find themselves in.

The role of the pharmacist

With increased risk taking and impulsivity observed over long periods, people with ASPD commonly present with substance misuse problems, including illicit, prescribed and alcohol dependencies, as well as co-existing mental health issues (e.g. anxiety, depression and attention deficient hyperactivity disorder). This is where interactions with a pharmacist are likely to occur and gives them the opportunity to provide advice and support to patients. The co-morbid conditions should be treated as per usual guidance; however, this can be challenging owing to erratic or unconventional patient behaviour.

Although the patient’s PD is possibly not the main reason for a consultation with a pharmacist, it still presents an opportunity to deliver healthcare interventions and improve patient care. Below are the main interventions where pharmacists can utilise their specific skill set for the benefit of people with ASPD.

Improve local prescribing practices

Co-morbid disorders should be treated appropriately in line with their corresponding NICE recommendations^[2]
. However, misuse of prescription medicine, especially antipsychotic medicine and benzodiazepines, is common — some patients can become manipulative or aggressive in consultations in order to obtain them.

Antipsychotics are not licensed for PD; NICE issued a quality statement in 2015^[11]
highlighting that antipsychotics are helpful for short-term crisis management (no longer than one week) or comorbid conditions, but have no established efficacy in treating or managing ASPD. Also, benzodiazepines are generally only licensed for short-term use. Pharmacists should refer to the patient’s GP if they suspect the patient is misusing the prescription or if they have been taking benzodiazepines for longer than four weeks.

Improve medicine adherence

Patients who misuse illicit substances and groin inject are at high risk of deep vein thrombosis (DVT). Multiple DVTs is an indication for life-long anticoagulation, and if the patient takes anticoagulants infrequently, this can have catastrophic results.

Unfortunately, concordance with medicine is likely to be poor. Therefore, it is important to check if the patient is taking their antidepressant/antipsychotic/antiepileptic/anticoagulant medicine regularly, that they understand how important their medicine is and the impact of not taking it as prescribed.

Pharmacists should outline the benefits of a repeat prescriptions services (e.g. it can save the patient time because they do not need to make a special trip to their GP to order a repeat prescription). If the patient has already signed up for a repeat prescription, the pharmacist should flag any infrequent collection with the patient’s GP.

Emphasise medicine safety

It is important to highlight the dangers and potential drug interactions to patients, especially those that can affect the Corrected QT (QTc) interval (e.g. methadone, antipsychotics and certain antidepressants). Medicines prescribed by the GP or psychiatrist should have at least yearly monitoring, but other illicit medicines (including novel psychoactive substances) will be unknown to the prescriber and the effects may be unpredictable.

Keep messages clear and easy to understand

There is often an association between ASPD and other mental health disorders, and some patients may also have learning difficulties. Pharmacists should adapt communication-styles for these patients because it could improve engagement with treatment. There are many ways this could be achieved, including providing the patient with a compliance aid to help improve concordance, or providing large print or easy read patient information leaflets.

Build trusting relationships

It is important to develop an optimistic and trusting relationship with the patient. Avoid having too many rules — the more restrictions there are, the more likely they will be broken, causing a breakdown of the relationship between the pharmacist and the patient. If a plan is agreed, ensure you and the patient follow it. Patients often see authority figures/institutions as failing them and repeat examples reinforce this belief. It is good practice to have a standard treatment contract for services, such as methadone provision, to prevent disruptive behaviours in community settings.