Antisocial personality disorder: prevention and management

Context

This guideline makes recommendations for the treatment, management and prevention of antisocial personality disorder in primary, secondary and forensic healthcare. This guideline is concerned with the treatment of people with antisocial personality disorder across a wide range of services including those provided within mental health (including substance misuse) services, social care and the criminal justice system.

People with antisocial personality disorder exhibit traits of impulsivity, high negative emotionality, low conscientiousness and associated behaviours including irresponsible and exploitative behaviour, recklessness and deceitfulness. This is manifest in unstable interpersonal relationships, disregard for the consequences of one's behaviour, a failure to learn from experience, egocentricity and a disregard for the feelings of others. The condition is associated with a wide range of interpersonal and social disturbance.

People with antisocial personality disorder have often grown up in fractured families in which parental conflict is typical and parenting is harsh and inconsistent. As a result of parental inadequacies and/or the child's difficult behaviour, the child's care is often interrupted and transferred to agencies outside the family. This in turn often leads to truancy, having delinquent associates and substance misuse, which frequently result in increased rates of unemployment, poor and unstable housing situations, and inconsistency in relationships in adulthood. Many people with antisocial personality disorder have a criminal conviction and are imprisoned or die prematurely as a result of reckless behaviour.

Criminal behaviour is central to the definition of antisocial personality disorder, although it is often the culmination of previous and long-standing difficulties, such as socioeconomic, educational and family problems. Antisocial personality disorder therefore amounts to more than criminal behaviour alone, otherwise everyone convicted of a criminal offence would meet the criteria for antisocial personality disorder and a diagnosis of antisocial personality disorder would be rare in people with no criminal history. This is not the case. The prevalence of antisocial personality disorder among prisoners is slightly less than 50%. It is estimated in epidemiological studies in the community that only 47% of people who meet the criteria for antisocial personality disorder have significant arrest records. A history of aggression, unemployment and promiscuity were more common than serious crimes among people with antisocial personality disorder. The prevalence of antisocial personality disorder in the general population is 3% in men and 1% in women.

Under current diagnostic systems, antisocial personality disorder is not formally diagnosed before the age of 18 but the features of the disorder can manifest earlier as conduct disorder. People with conduct disorder typically show antisocial, aggressive or defiant behaviour, which is persistent and repetitive, including aggression to people or animals, destruction of property, deceitfulness, theft and serious rule-breaking. A history of conduct disorder before the age of 15 is a requirement for a diagnosis of antisocial personality disorder in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV).

The course of antisocial personality disorder is variable and although recovery is attainable over time, some people may continue to experience social and interpersonal difficulties. Antisocial personality disorder is often comorbid with depression, anxiety, and alcohol and drug misuse.

Families or carers are important in prevention and treatment of antisocial personality disorder. This guideline uses the term 'families or carers' to apply to all family members and other people, such as friends and advocates, who have regular close contact with the person with antisocial personality disorder.

This guideline draws on the best available evidence. However, there are significant limitations to the evidence base, notably a relatively small number of randomised controlled trials (RCTs) of interventions with few outcomes in common. Some of the limitations are addressed in the recommendations for research.

At the time of publication (January 2009), no drug has UK marketing authorisation for the treatment of antisocial personality disorder. The guideline assumes that prescribers will use a drug's summary of product characteristics to inform their decisions for each person.

NICE has also developed a guideline on borderline personality disorder: recognition and management.