CLINICAL NEED FOR THE GUIDELINE
Personality disorders are long-standing and maladaptive patterns of perceiving and responding to other people and to stressful circumstances. Antisocial personality disorder is characterised by a gross disparity between behaviour and the prevailing social norms and a pervasive pattern of disregard for, and violation of, the rights of others that begins in childhood or early adolescence and continues into adulthood. It is one of the most common of the personality disorders and is strongly associated with social impairment, offending behaviours and increased risks of both mental and physical health problems, particularly substance misuse (including alcoholism).
General diagnostic criteria for a personality disorder must be met for a diagnosis of antisocial personality disorder. There are two main sets of diagnostic criteria in current use, the International Classification of Mental and Behavioural Disorders 10th Revision (ICD-10) and the Diagnostic and Statistical Manual of Mental Disorders fourth edition (DSM-IV). General criteria for personality disorders are similar in ICD-10 and DSM-IV. Both require an individual to have an enduring pattern of inner experience and behaviour that deviates markedly from the expectations of their culture, is pervasive and inflexible across a range of situations, leads to significant distress or impairment, is stable and of long duration (with onset in childhood, adolescence or early adulthood), and cannot be explained as a manifestation or consequence of other mental disorders, substance use, or organic brain disease, injury or dysfunction.
Diagnostic criteria for antisocial personality disorder are broadly similar in both ICD-10 and DSM-IV, although the latter has a heavy emphasis on criminality. ICD-10 uses the term dissocial personality disorder, which is characterised by at least three of the following features: a disregard for the feelings of others and social norms, rules and obligations; gross and persistent irresponsibility; incapacity to maintain relationships; a low tolerance to frustration and a low threshold for aggression and violence; incapacity to experience guilt or learn from experience (including punishment); and a tendency to blame others or offer rational explanations for antisocial behaviour. Additional criteria included in the DSM-IV definition of antisocial personality disorder are repeatedly performing acts that are grounds for arrest, deceitfulness, impulsiveness, and a disregard for the safety of others. DSM-IV criteria do not include lack of concern for the feeling of others and incapacity to maintain relationships or profit from experience.
Antisocial personality disorder can only be diagnosed in adults. In ICD-10 the specific personality disorders come within the overall grouping of disorders of adult personality. In DSM-IV antisocial personality disorder cannot be diagnosed in those under 18 years of age, although a number of juvenile criteria (that is, features present before the age of 15) are specified that must be met in addition to abnormal behaviour in adulthood.
ICD-10 notes that people with personality disorders may have other coexisting or superimposed mental disorders, behavioural syndromes and developmental disorders. In DSM-IV common comorbidities in people with antisocial personality disorder include anxiety and depressive disorders, mood disorders, substance-related disorders, somatisation disorder, pathological gambling and other disorders of impulse control. DSM-IV also notes that while the personality disorders have overlapping features and must be distinguished from one another by their distinguishing features, they can (and often do) co-occur.
Antisocial, aggressive or criminal behaviour that does not meet the full criteria for antisocial personality disorder is described as adult antisocial behaviour in DSM-IV, with the diagnosis of antisocial personality disorder only applying to those whose antisocial personality traits are inflexible, maladaptive and persistent, and a cause of significant impairment or distress. Antisocial personality disorder is distinguished from criminal behaviour for gain where the characteristic features of antisocial personality disorder are absent.
The aetiology of antisocial personality disorder is uncertain. Antisocial personality disorder may be the consequence of the accumulation and interaction of multiple factors through development, including temperament, childhood and adolescent experiences, and other environmental factors. The risk factor most predictive of adult antisocial personality is the severity and extent of child and adolescent conduct symptoms and a history of childhood or adolescent conduct disorder is common in people with antisocial personality disorder (and is one of the diagnostic criteria in DSM-IV). Other childhood and adolescent risk factors for adult antisocial personality disorder include other psychopathology (particularly depression, oppositional disorder, and substance misuse) and callous temperament.
Childhood and adolescent risk factors associated with the broader category of adult antisocial behaviour include: individual characteristics such as an undercontrolled, impulsive, aggressive or hyperactive temperament, low IQ and poor educational achievement; family factors such as having an antisocial parent, poor supervision, abuse and violence between parents; and wider societal factors such as an antisocial peer group and high levels of delinquency in school. Risk factors for antisocial behaviour are often correlated with one another. A number of childhood factors are protective against the development of later antisocial behaviour, including temperamental characteristics such as shyness and inhibition, intelligence, a close relationship with at least one adult, good school or sporting achievement, and non-antisocial peers.
Neurobiological mechanisms for antisocial personality disorder and antisocial behaviour have also been proposed and there is evidence that there is a genetic component in the development of antisocial behaviour. It has been proposed that a genetic predisposition may increase the likelihood that exposures to adverse environmental influences and life events will lead to the development of antisocial personality disorder.
The personality disorders are associated with a significant burden to the individual, those around them and society as a whole, with the impact of the disorder generally being greatest in early adulthood and diminishing with age. Their families commonly endure episodes of explosive anger and rage, a callous and unemotional behavioural pattern, depression, self-harm, and suicide attempts. Antisocial personality disorder is also associated with significant drug and alcohol misuse, with further attendant costs to the individual, their family and society.
The antisocial, violent and offending behaviour associated with antisocial personality disorder has a negative impact across society and results in a range of costs to society including those to victims of the behaviour (including physical harm and the impact of intimidation and fear), the costs of policing and other national and local measures to curb antisocial behaviour, and general costs to the criminal justice system including the costs of detention and other punitive measures.
People with personality disorders tend to make heavy but dysfunctional demands on services, having frequent contact with mental health and social services, A&E, GPs and the criminal justice system, and may be high-cost, persistent, and intensive users of mental health services.
Some people with antisocial personality disorder will also be categorised as having a dangerous and severe personality disorder (DSPD). DSPD is not a diagnostic category; rather, it is a term used to describe a category of dangerous offenders whose offending is linked to severe personality disorder and who present a very high risk of serious violent and/or sexual offending. People in this category will have committed a violent and/or sexual crime and may have been detained under the criminal justice system or mental health legislation.
The prevalence of antisocial personality disorder in the general population of Great Britain has been estimated at 0.6%, with the rate in men (1%) five times that in women (0.2%). Surveys conducted in other countries report prevalence rates for antisocial personality disorder ranging from 0.2 to 4.1%. Higher prevalence rates for personality disorders appear to be found in urban populations and this may account for some of the range in reported prevalence – the estimate of 0.6% for the prevalence of antisocial personality disorder in Great Britain was based on data gathered from a survey covering a range of locations.
Antisocial personality disorder is common among drug and alcohol misusers in both treatment and custodial settings. The prevalence of personality disorders, and antisocial personality disorder in particular, is particularly high in the prison population. In England and Wales 78% of male remand prisoners, 64% of male sentenced prisoners, and 50% of female prisoners have personality disorders, with the prevalence of antisocial personality disorder being 63% among male remand prisoners (just over half of whom have antisocial personality disorder plus another personality disorder), 49% among sentenced male prisoners (two fifths of whom have antisocial personality disorder plus another personality disorder) and 31% among female prisoners (two thirds of whom have antisocial personality disorder plus another personality disorder).
Many clinicians are sceptical about the effectiveness of treatment interventions for personality disorder, and hence often reluctant to accept people with a primary diagnosis of personality disorder for treatment. Established antisocial personality disorder is difficult to treat and evidence on the effectiveness of therapeutic interventions is sparse.
The diagnosis of antisocial personality disorder requires evidence that the features of the disorder onset in childhood or adolescence (ICD-10) or evidence of conduct disorder with onset before age 15 years (DSM-IV) and this, combined with the difficulty of treating adult antisocial personality disorder, has led to a focus on preventative interventions with children and young people at risk of later antisocial personality disorder. Early prevention during childhood may be desirable, but many individuals who go on to develop adult antisocial personality disorder are not identified before adolescence.
It should be noted that a separate guideline on borderline personality disorder is being developed in parallel to the development of the antisocial personality disorder guideline. Beyond the differences in the diagnostic criteria for borderline personality disorder and antisocial personality disorder, there are good grounds for developing two separate guidelines for these disorders, rather than one unified guideline on personality disorders, as there are marked differences in the populations the guidelines will address in terms of their interaction with services. People with borderline personality disorder tend to be treatment seeking and at high risk of self-harm and suicide, whereas people with antisocial personality disorder tend not to seek treatment, are likely to come into contact with services via the criminal justice system and their behaviour is more likely to be a risk to others. Nevertheless, it is acknowledged that people with either of these diagnoses may present with some symptoms and behaviour normally associated with the other diagnosis.
