INTRODUCTION — Antisocial personality disorder (ASPD) is defined as a pattern of socially irresponsible, exploitative, and guiltless behavior that begins in childhood or early adolescence and is manifested by disturbances in many areas of life [1]. ASPD is usually a lifelong disorder that begins in childhood and is fully manifest by the late 20s or early 30s [2].

Typical behaviors include criminality and failure to conform to the law, failure to sustain consistent employment, manipulation of others for personal gain, and failure to develop stable interpersonal relationships. Other features of ASPD include lacking empathy for others, rarely experiencing remorse, and failing to learn from the negative results of one’s experiences [3,4].

This topic describes treatment for ASPD. The epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis of ASPD are discussed separately. Pharmacotherapy for personality disorders is reviewed separately. (See "Antisocial personality disorder: Epidemiology, clinical manifestations, course and diagnosis", section on 'Diagnosis' and "Pharmacotherapy for personality disorders".)

MEDICATION — We suggest that patients with antisocial personality disorder (ASPD) not be routinely treated with medication for the disorder. No medications have been found to be efficacious in the treatment of ASPD. Medications may be useful in the treatment of severe aggressive behavior in patients with ASPD. (See 'Aggressive behavior in ASPD' below.)

Medication may also be appropriate to treat a comorbid psychiatric disorder in persons with ASPD, although medications with abuse potential should be avoided when possible. (See 'Treatment of co-occurring disorders' below.)

Aggressive behavior in ASPD — Aggressive behavior, which can be prominent in some patients with antisocial personality disorder (ASPD), may be a target symptom of daily medication treatment. Pharmacotherapy for emergent management of the acutely agitated, aggressive patient is discussed separately. (See "Assessment and emergency management of the acutely agitated or violent adult".)

The decision to treat aggression with medication in patients with ASPD should be based upon:

●The severity of symptoms in terms of impairing the individual’s ability to function in their environment (eg, in the community or in an institutional setting)

●The patient’s willingness to take the medication

●The availability of a clinician to monitor treatment and evaluate its effectiveness

In patients with ASPD and severe aggression who are willing to take medication, we suggest treatment with a second-generation antipsychotic medication over other medications. Examples include risperidone (2 to 4 mg/day) or quetiapine (100 to 300 mg/day). If a second-generation antipsychotic is ineffective or not tolerated, a selective serotonergic antidepressant, eg, sertraline (100 to 200 mg/day) or fluoxetine (20 mg/day), would be our next choice. Other reasonable alternatives include mood stabilizers such as lithium carbonate or carbamazepine, which should be used at doses and blood levels recommended for bipolar disorder. (See "Second-generation antipsychotic medications: Pharmacology, administration, and side effects" and "Bipolar disorder in adults and lithium: Pharmacology, administration, and management of adverse effects".)

Efficacy in aggressive behavior — Only one, negative trial has been conducted of pharmacotherapy to treat aggression specifically in patients with ASPD [5]; the other clinical trials and case reports described below suggest that several medications may reduce aggressive behavior in samples associated with higher rates of ASPD, including prisoners and patients with a history of aggression, as well as in samples of children with conduct disorder [6,7].

Antipsychotic medications — There are no randomized trials of antipsychotic medications for aggressive behavior in patients with ASPD; however, case reports [8,9] suggest that these drugs may be useful:

●A case series of four patients with ASPD and aggressive behavior, referred to a maximum-security inpatient psychiatric facility for pretrial evaluation, found that voluntary treatment with quetiapine was associated with decreased irritability, impulsivity, and aggressiveness [8]. Typical dose was 600 to 800 mg/day.

●In a single case report, a 32-year-old man with ASPD was successfully treated with risperidone for severe violent behavior [9]. He was initially treated with 6 mg/day and developed extrapyramidal symptoms that required treatment with biperiden, propranolol, and diazepam. He continued treatment on a maintenance dose of risperidone 3 mg/day.

Adverse effects of second-generation antipsychotics include extrapyramidal symptoms, weight gain, and metabolic syndrome. (See "Second-generation antipsychotic medications: Pharmacology, administration, and side effects" and "Schizophrenia in adults: Maintenance therapy and side effect management", section on 'Side effect management'.)

Selective serotonin reuptake inhibitors — Selective serotonin reuptake inhibitors (SSRIs) have not been tested in randomized trials of patients with ASPD; however, three small trials of impulsive aggression or anger in patients with personality disorders have found mixed results.

●A randomized trial of 40 patients with a personality disorder, impulsive aggressive behavior, and irritability found sustained reductions in aggression and irritability in patients over three months of treatment with fluoxetine compared with placebo [10].

●A 13-week trial randomly assigned 22 patients with mild to moderately severe borderline personality disorder to treatment with fluoxetine or placebo [11]. Patients treated with fluoxetine experienced a clinically and statistically significant reduction in anger compared with placebo.

●A trial randomly assigned 38 patients with borderline personality disorder to six weeks treatment with fluvoxamine or placebo [12]. Patients taking fluvoxamine experienced a reduction in rapid mood shifts compared with placebo, but no difference was seen between groups on impulsivity or aggression. This latter finding may be due to gender-specific differences in impulsivity and aggression.

Lithium — Lithium carbonate has been found to reduce threatening behavior and assaults in prison inmates in one randomized trial [13]. In the trial, 66 male inmates with a history of chronic, impulsive aggressive behavior received either lithium or placebo for three months, dosed to achieve a blood level of 0.6 to 1.0 MEq per liter [14]. Individuals receiving lithium committed fewer infractions of prison rules involving threatening behavior or assaults than individuals receiving placebo.

Anticonvulsants — Anticonvulsant medications have been found to reduce impulsive aggression in randomized trials of diverse study populations [15,16]. None of the studies were limited to individuals with ASPD; however, none of the trials excluded patients with personality disorders or substance use disorders.

●A meta-analysis of four randomized trials found phenytoin to reduce aggressive behavior in patients with a history of aggression [16]. Trials were conducted in a combination of prison and community settings.

●Oxcarbazepine and carbamazepine, respectively, were found to reduce aggressive behavior in two randomized trials, one in a sample of patients with impulsive aggression [17] and the other with intermittent explosive disorder [18].

●Two trials of divalproex in adults with a history of aggressive behavior showed mixed results [16].

Other medications in adults — Other drugs have been used to treat aggression primarily in brain-injured or intellectually challenged patients, including propranolol, buspirone, and trazodone [19,20]. Response to medication has been variable; while some patients have shown improvement, others failed to improve at all. Improvement, when it has occurred, has been partial, meaning that the individual had fewer outbursts than before, or had longer periods between them.

Children with conduct disorder — There is limited evidence of efficacy for lithium, risperidone, and divalproex in reducing aggression and other symptoms in children with disruptive behavior or diagnosed with conduct disorder. (See "Antisocial personality disorder: Epidemiology, clinical manifestations, course and diagnosis", section on 'Conduct disorder'.)

●In a randomized trial, 50 severely aggressive children with conduct disorder were treated with either lithium or placebo for eight weeks. Lithium led to greater reductions in aggressive behaviors, including bullying, fighting, and temper outbursts, compared with placebo [21].

●In a randomized trial, 20 children and adolescents (ages 10 to 18) with conduct disorder or oppositional defiant disorder were treated with either divalproex or placebo for six weeks. Divalproex reduced temper outbursts and mood lability compared with placebo [22].

●In a six-week, randomized trial of 118 children with severe disruptive behaviors, participants treated with risperidone showed greater reduction in disruptive behaviors than those treated with placebo [23].

●In a trial of 335 children with disruptive behavior disorder who had responded to risperidone treatment over 12 weeks, participants were randomly assigned to six months of treatment with risperidone or placebo. At the end of six months, time to symptom recurrence was significantly longer in patients who continued risperidone than in those switched to placebo [24].

PSYCHOSOCIAL INTERVENTIONS — Clinical trials of the best studied psychotherapy, cognitive-behavioral therapy (CBT) for persons with antisocial personality disorder (ASPD) have been negative. It is possible, however, that CBT may benefit those with milder forms of the disorder (eg, not physically dangerous) and who possess some insight and reason to improve. Examples of the latter would be patients who risk losing a spouse or job if their behavior were not controlled. Psychoanalysis or psychodynamic therapy were historically preferred approaches to treating ASPD, but these gradually have given way to CBT, which has been adapted from models developed for depression and anxiety disorders. (See 'Efficacy' below.)

Antisocial persons often possess traits that actively interfere with the process of psychotherapy and make working with them difficult (eg, impulsivity, blaming others) [4]. No matter how determined the therapist may be to help an antisocial patient, it is possible that the patient’s criminal past, irresponsibility, and tendency toward violence may render him thoroughly unlikable. For that reason, many therapists will find it difficult, if not impossible to work with such a patient. Therapists must be aware of their own feelings and remain vigilant to prevent countertransference from disrupting therapy [25]. The best prospects for treatment come with mental health professionals experienced in treating ASPD who are able to anticipate their emotions and to present an attitude of acceptance tempered with the need to set limits and confront manipulative behaviors without moralizing [26].

Psychotherapy may be ineffective or even harmful when provided to persons with psychopathy or severe ASPD [27,28]. One perspective is that the rigid personality structure of these individuals generally resists outside influence [27], observing that in therapy, many often simply go through the motions, and may even learn skills that help them better manipulate others. This concern is particularly pronounced for group therapy. (See "Antisocial personality disorder: Epidemiology, clinical manifestations, course and diagnosis", section on 'Psychopathy'.)

Cognitive-behavioral therapy — CBT for ASPD focuses on the patient’s beliefs about him or herself and others, and behaviors that impair social functioning [26]. The therapist focuses on evaluating situations in which the patient’s distorted beliefs and attitudes may have interfered with interpersonal functioning or in achieving goals. Once the patient has gained an understanding of how he has contributed to his own problems, the therapist can help him or her to gradually make sensible changes in thinking and behavior. Guidelines are set for the patient’s involvement, including regular attendance, active participation, and completion of homework outside of office visits [29].

Efficacy — Two clinical trials of CBT for ASPD have been negative [6,30-32]. As an example, a trial randomly assigned 52 men with ASPD and recent aggression to receive CBT plus treatment as usual or treatment as usual alone [31]. At 12 months, no significant differences were seen between groups. Both groups reported a decrease in aggressive acts. Trends in favor of CBT were seen for problematic drinking, social functioning and beliefs about others, suggesting that larger randomized trials are needed.

CBT may be useful in the treatment of some disorders that co-occur with ASPD. (See 'Treatment of co-occurring disorders' below.)

Other psychosocial interventions

●Psychoeducation – A subgroup analysis of a trial of psychoeducation and problem-solving therapy for personality disorders found no evidence of efficacy for ASPD. Twenty-four patients with ASPD were randomly assigned to receive either brief psychoeducation plus problem-solving group sessions or to a waiting list with treatment as usual. After an average of 24 weeks, no difference was seen between groups on measures of problem solving or social functioning [32].

A clinical trial comparing a short-term psychoeducational program with treatment as usual in 175 people with ASPD receiving treatment for a substance use disorder (SUD) found that the program improved adherence to SUD treatment [33]. The direct effects of the program on abstinence and ASPD behaviors were not reported. However, a post-hoc secondary analysis found that the program increased the subject’s sense of having received help for their ASPD, which was associated with more days abstinent, fewer treatment drop outs, and increased treatment satisfaction with regard to their comorbid SUD [34]. The six-session program was designed to address impulsive and self-destructive behaviors associated with ASPD.

●Marital/family therapy – Although not tested in clinical trials, marital or family therapy may be useful for couples or families that include a family member with ASPD. As an example, family members may wish to receive guidance about their interactions with their antisocial relative. Likewise, a couple in which one member of the dyad is antisocial may benefit from gaining a better understanding of how the disorder has impacted the relationship and how best to respond. Couples therapy will not be beneficial if the antisocial person is disruptive or lacks empathy.

●Other psychological interventions that appear effective in small, randomized controlled trials include schema therapy and contingency management, which both improved social functioning and dialectical behavior therapy, which reduced the number of self-harm days compared with treatment as usual [35]. The evidence in each case was of low certainty. (See "Contingency management for substance use disorders: Theoretical foundation, principles, assessment, and components" and "Psychotherapy for borderline personality disorder".)

There are no clinical trials of psychoanalytic or psychodynamic psychotherapy for ASPD.

PREVENTION — Several psychosocial interventions have been used to treat conduct disorder in children, seeking to reduce misbehavior and reduce the risk of antisocial personality disorder (ASPD) in adulthood.

Treatment programs for juvenile offenders that emphasize behavior modification or skills training may produce modest benefits and reduce recidivism [36]. A meta-analysis found that the programs reduced recidivism among juvenile delinquents by 10 percent compared with a control condition. The most successful programs were more structured and specific, emphasizing behavior modification or skills training.

There is some evidence that early judicial adjudication is helpful, and that youth who are apprehended, prosecuted, and punished for their first offenses are less likely to have adult convictions than those who escape penalties [37]. In one follow-up study of 82 antisocial men, those who had done better had served brief jail sentences early in their life, a finding consistent with this observation in youth [38].

Family therapy for children with conduct disorder may offer the best help for dealing with misbehavior in children [39]. Treatment should focus on enhancing parental management skills to improve communication and to provide more effective and consistent discipline. Parents can learn to more effectively supervise the child, and learn how to steer impressionable children away from troubled peers. In these programs, parents also learn skills to help stop misbehavior before it escalates into violence, which may eventually help to reduce their child’s risk for ASPD [40].

Group parent training — Group parent training was recently evaluated in two randomized clinical trials involving 1) children with severe antisocial behavior in whom treatment was indicated, and 2) children with elevated antisocial behavior selectively screened from the community [41]. Compared with controls, at follow-up in adolescence antisocial behavior and antisocial character traits were improved in the first group, but not in the second group.

Other interventions — Unsuccessful approaches have generally included traditional counseling and deterrent strategies. “Shock” incarceration gives young offenders stiff sentences that are later reduced to spur improvement. “Boot camps” or “wilderness” programs have been developed in an effort to foster good behavior in misbehaving children. Taking place in isolated settings, the troubled children are separated from their peers and have little or no access to drugs and alcohol. Whether these programs offer more than transitory benefit is unclear.

“Scared Straight” and similar interventions are designed to deter juvenile delinquents from future criminal offenses through in-person observation of prison life. A meta-analysis of seven clinical trials involving 794 participants, mostly male with an average age of 16, found these interventions to be more harmful than a control condition [42]. Subjects receiving the intervention were 1.7 times more likely to commit a crime before their first follow-up assessment compared with those in the nonintervention control group (odds ratio = 1.68, 95% CI 1.20-2.36).

TREATMENT OF CO-OCCURRING DISORDERS — We recommend treating psychiatric disorders that co-occur with antisocial personality disorder (ASPD; eg, major depression, substance use disorders [SUDs], anxiety disorders) in antisocial patients.

Research shows that many people with ASPD seek psychiatric care, particularly for co-occurring depression, substance misuse, or for problems relating to marital adjustment, anger dyscontrol, or suicidal behavior [43-45]. Others may present for court-mandated assessment (eg, an evaluation for competency to stand trial) or treatment.

The antisocial person’s mental health care needs can generally be addressed in outpatient settings where an array of services is available (eg, medication management, individual psychotherapy, family therapy). There is generally little reason to hospitalize antisocial patients, who can be disruptive to the hospital milieu [46]. The exception is when the person needs supervision to provide a safe environment and protection from harm to self or others. Reasons to hospitalize antisocial persons include recent suicidal behavior, recent violent or assaultive acts, or needed alcohol/drug detoxification or withdrawal monitoring.

Medication — There are no clinical trials on the efficacy of pharmacotherapy for psychiatric disorders co-occurring with ASPD. Medications may be effective in the treatment of disorders comorbid with ASPD; however, research suggests that patients with personality disorders (including ASPD) treated for comorbid depression do not respond as well to medication as do persons without a personality disorder [47]. (See "Unipolar major depression in adults: Choosing initial treatment" and "Pharmacotherapy for panic disorder with or without agoraphobia in adults" and "Pharmacotherapy for posttraumatic stress disorder in adults" and "Bulimia nervosa in adults: Pharmacotherapy" and "Pharmacotherapy for obsessive-compulsive disorder in adults" and "Intermittent explosive disorder in adults: Treatment and prognosis" and "Bipolar major depression in adults: Choosing treatment" and "Treatment of acute stress disorder in adults" and "Schizophrenia in adults: Maintenance therapy and side effect management" and "Generalized anxiety disorder in adults: Management".)

Addictive medications — The prescription of medications that are addictive or have potential for abuse should be avoided when possible in patients with ASPD.

Benzodiazepines should not be used in patients with ASPD, who are at increased risk of addiction. It is possible that benzodiazepines will increase aggressive outbursts and other externalizing behaviors in these patients, an adverse response that has been documented in persons with borderline personality disorder [48].

Patients with adult attention deficit hyperactivity disorder co-occurring with ASPD should initially be treated with non-addicting medications such as bupropion or atomoxetine [49]. As a second-line option, stimulant medication such as methylphenidate or dextroamphetamine can be prescribed in selected patients (eg, those without a history of a substance use disorder). Clinicians should monitor use of these medications closely due to their potential for abuse. Stimulants should not be used in patients with a current SUD, though their use can be considered for patients with a past SUD. (See "Attention deficit hyperactivity disorder in adults: Epidemiology, pathogenesis, clinical features, course, assessment, and diagnosis".)

The use of opiates to treat pain should be avoided in patients with ASPD when alternative treatments are available. (See "Management of acute perioperative pain" and "Approach to the management of chronic non-cancer pain in adults".)

Psychotherapy — Psychotherapy with efficacy in specified disorders appears to remain effective when the disorders co-occur with ASPD:

●In two uncontrolled cohorts of 64 and 65 patients, co-occurring ASPD did not appear to interfere with the efficacy of Systems Training for Emotional Predictability and Problems Solving group therapy for borderline personality disorder [50].

●A clinical trial randomly assigned 40 patients with co-occurring borderline personality disorder and ASPD to receive mentalization-based therapy or structured clinical management [51]. After treatment for 18 months, both groups showed overall symptom improvement, but patients assigned to mentalization-based therapy had greater improvement in anger, hostility, paranoia, and suicidal and self-harm behaviors. (See "Psychotherapy for borderline personality disorder".)

●In an uncontrolled trial in a correctional setting, 30 men with co-occurring borderline personality disorder and antisocial behavior received 12 months of dialectical behavior therapy and were then followed for one year. The men had significant reductions in self-harm, verbal and physical aggression, and criminal reoffending, as well as symptoms of borderline personality disorder [52].

SUD treatment — Substance use disorders (SUDs) co-occurring with ASPD be treated with medical management of withdrawal (if needed) followed by an inpatient or outpatient psychosocial addictions program, with a goal of abstinence. A study of antisocial persons with an SUD treated with methadone maintenance found that patients who abstained from use were less likely to engage in antisocial or criminal behaviors, and had fewer family conflicts and emotional problems [53]. (See "Antisocial personality disorder: Epidemiology, clinical manifestations, course and diagnosis", section on 'Epidemiology' and "Management of moderate and severe alcohol withdrawal syndromes" and "Benzodiazepine poisoning and withdrawal" and "Medically supervised opioid withdrawal during treatment for addiction" and "Medication for opioid use disorder" and "Alcohol use disorder: Psychosocial treatment".)

There have been two trials of contingency management for a substance use disorder co-occurring with ASPD, with largely negative results. Contingency management seeks to reduce substance use disorder by linking use to systematically applied environmental consequences, ie, reinforcement and punishment.

●In a clinical trial, 40 patients with ASPD and drug abuse were randomly assigned to receive either a structured contingency management intervention in addition to standard substance abuse treatment, or to standard substance abuse treatment alone [54]. Improvement was seen in both groups over 17 weeks of treatment, but no significant differences were seen between groups.

●In a clinical trial, 100 patients with opioid dependence and ASPD were randomly assigned to a structured contingency management intervention plus methadone maintenance or to methadone maintenance alone. No differences were seen between intervention groups in drug abstinence. The group receiving the experimental intervention had better attendance than subjects receiving methadone maintenance alone [55].

Patients with a co-occurring SUD should be encouraged to attend meetings of Alcoholics Anonymous or sister organizations (eg, Narcotics Anonymous, Cocaine Addicts Anonymous). There are few formal treatment programs for pathological gambling; antisocial persons with the disorder should be encouraged to attend Gamblers Anonymous. (See "Antisocial personality disorder: Epidemiology, clinical manifestations, course and diagnosis", section on 'Clinical manifestations'.)

A clinical trial of psychoeducation for co-occurring ASPD and SUD is reviewed above. (See 'Other psychosocial interventions' above.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Personality disorders".)

SUMMARY AND RECOMMENDATIONS

●We suggest cognitive-behavioral therapy (CBT) for persons with mild antisocial personality disorder (ASPD) who possess some insight and reason to improve (eg, those who risk losing a spouse or job if their behavior is not controlled) (Grade 2C). (See 'Cognitive-behavioral therapy' above.)

●Therapists treating patients with ASPD should be vigilant to prevent their potentially negative feelings and mindful of the potential for the antisocial person’s manipulation of the therapeutic relationship. (See 'Psychosocial interventions' above.)

●We suggest that patients with ASPD not be routinely treated with medication (Grade 2C). (See 'Medication' above.)

●For patients with ASPD and severe aggression who are willing to take medication, we suggest treatment with a second-generation antipsychotic medication over other medications (Grade 2C). Examples include risperidone (2 to 4 mg/day) or quetiapine (100 to 300 mg/day).

If a second-generation antipsychotic is ineffective or not tolerated, a selective serotonergic antidepressant, eg, sertraline (100-200 mg/day) or fluoxetine (20 mg/day), would be our next choice. Other reasonable alternatives include mood stabilizers such as lithium carbonate or carbamazepine, which should be used at doses and blood levels recommended for bipolar disorder. (See 'Aggressive behavior in ASPD' above and "Second-generation antipsychotic medications: Pharmacology, administration, and side effects" and "Bipolar disorder in adults and lithium: Pharmacology, administration, and management of adverse effects".)

●Early intervention with group parent training may help prevent antisocial personality in adolescence in children in whom treatment is indicated; further trials of this and other family interventions are needed. (See 'Group parent training' above.)

●We suggest that interventions designed to deter juvenile delinquents from future criminal offenses through in-person observation of prison life (eg, “Scared Straight”) not be used (Grade 2B). (See 'Prevention' above.)

●When psychiatric disorders co-occur with ASPD (eg, depression, substance use disorders, anxiety disorders), treatment should typically be with the first-line treatment recommended for the comorbid disorder, although medications with potential for abuse should be avoided when possible. (See 'Treatment of co-occurring disorders' above and "Antisocial personality disorder: Epidemiology, clinical manifestations, course and diagnosis", section on 'Epidemiology'.)