Antisocial Personality Disorder (ASPD)

Antisocial Personality Disorder affects roughly 3% of men and 1% of women. It is the most difficult personality disorder to treat — but cognitive remediation and contingency management in structured residential settings produce meaningful gains.

ASPD involves a pervasive pattern of disregard for and violation of others’ rights, beginning since age 15 and continuing into adulthood. Diagnosis requires the person be at least 18 with evidence of conduct disorder before age 15.

DSM-5 Criteria

Diagnosis requires three or more of: failure to conform to social norms with respect to lawful behaviors; deceitfulness; impulsivity; irritability and aggressiveness; reckless disregard for safety; consistent irresponsibility; lack of remorse.

Evidence of conduct disorder before age 15 is required; the pattern cannot occur exclusively during schizophrenia or bipolar disorder.

Treatment Approaches

ASPD is the hardest personality disorder to treat because individuals often don’t experience subjective distress and don’t seek treatment voluntarily. When treatment occurs, it’s often court-ordered or driven by co-occurring conditions.

Cognitive remediation programs and contingency management in structured residential settings produce modest but real gains. Substance use treatment is critical — most people with ASPD have co-occurring SUD. Medication is reserved for co-occurring conditions and impulsive aggression.