How to Treat Antisocial Personality Disorder

Medically Reviewed
illustration of medication and an image representing therapy, which are two ways to treat antisocial personality disorder
Both drug treatment and talk therapy may be helpful for antisocial personality disorder, but the condition is extremely challenging to treat.iStock (2)

Antisocial personality disorder (ASPD), like most personality disorders, is very difficult to treat. The first challenge is persuading a person with the condition that they need treatment.?

Put simply, a person with ASPD doesn’t feel wrong or uncomfortable. People with ASPD, given their lack of empathy for fellow humans and their suffering, often don’t take the consequences of their actions into account. Believing they can do no wrong, and that their lies and manipulations are necessary for getting what they want, they typically don’t experience the kind of discomfort that might prompt people with other personality disorders to seek help.

“There is no distress other than not having their needs met or avoiding being held accountable,” says?David M. Reiss, MD, a psychiatrist in private practice in San Diego.

That said, there are a couple of specific circumstances in which a person with ASPD may seek or receive help:

  • Ending up in the criminal justice system. Because some people with?ASPD end up incarcerated, they may receive treatment in the system, though it?can be inconsistent.?(1)?
  • Having a co-occurring mental health condition or substance use disorder. Though individuals with ASPD may not seek treatment for their ASPD, they frequently have other conditions, such as anxiety, depression, or substance use.??

If a person has full-blown ASPD, “their personality structure cannot really change, though there may be some progress with harm reduction if the person can be convinced that it is in their own best interest to avoid certain behaviors and their consequences,” says Dr. Reiss.

On their own, some people with ASPD learn to mimic empathy so they can use it in a manipulative fashion when needed. “They act as if they were empathic, not because they are truly empathic or as part of a specific scheme, but because they have learned that life is easier for them acting that way,” Reiss says.?

Even if someone does seek treatment, no drugs or therapy options for ASPD have been consistently shown in studies to be effective at treating the symptoms or thinking patterns.

But studies have looked at treating people with?ASPD?for other medical problems or symptoms they have besides their personality disorder, such as substance dependence or coexisting psychiatric illness.

Behavioral Therapy for Antisocial Personality Disorder

To understand what the most up-to-date evidence is for a treatment, researchers conduct a large study called a systematic review. A systematic review involves finding and analyzing all existing, relevant studies on a particular condition or treatment.

The most recent systematic review on behavioral therapy for ASPD treatment was done in 2010. But researchers found only 11 studies, and only three were related to actual?symptoms of ASPD. (2)

Cognitive Behavioral Therapy (CBT) for Antisocial Personality Disorder

One study showed that?cognitive behavioral therapy?— which aims to change patterns of maladaptive thinking and behavior —?was effective in people with ASPD who also had cocaine dependence, but this therapy did not work in another study. Similarly, a therapy called?contingency management?was effective at improving social functioning in one study, but not in another. Contingency management involves using positive reinforcement to reward desired behavior. It is most often used in treating substance use disorders. (3)

Behavioral Therapy for Teens

Teens with antisocial behavior do appear to respond to CBT. A review of the evidence on treating youth with antisocial behaviors found 12 studies evaluating this therapy during institutionalization among teens who had committed crimes. Teens who underwent cognitive behavioral therapy showed?less criminal behavior?during the year after their release than teens who received standard treatment. (4)

Are There Preventive Treatment Options for ASPD?

There’s currently no way to prevent ASPD, but early interventions may be beneficial, the Cleveland Clinic notes.?(5) A 2014 study found that in children ages 3 to 7 with “severe antisocial behavior,” parental interventions involving specific training for parents may prevent the development of ASPD in adolescence and can improve academic performance. (6)

Psychotherapy for ASPD

While research doesn’t show that psychotherapy (or talk therapy) can treat ASPD very effectively, the Cleveland Clinic notes that it may help people become more aware of the impact of their behavior on others. (5)

Success Rates for Behavioral Therapy and Psychotherapy

As mentioned above, the current research on treatment outcomes for ASPD is conflicting, but not particularly optimistic. The difference in whether a therapy works or not may depend on whether an individual with ASPD wants to change. If a person with this disorder wants to decrease their aggressiveness or increase their ability to use empathy, therapy may be more successful. But there is debate among researchers about whether ASPD can be or should be treated at all. (8)

Medication for Antisocial Personality Disorder

Another systematic review in 2010 examined the evidence on medication for ASPD But none of the eight studies the researchers found included only people with ASPD as participants, and most focused on treating substance dependence. One study found that the antidepressant drug nortriptyline (Pamelor) helped treat misuse of alcohol in people with ASPD. (9)

Researchers have also studied antiepileptic drugs for treating aggression in people with ASPD. These drugs are typically used to control seizures in people with epilepsy as well as to treat mood disorders, such as bipolar disorder. They are additionally prescribed to treat aggression or impulsivity in certain psychiatric or neurological disorders.

The 2010 review of medication for ASPD included one study in which the anti-epileptic drug phenytoin (Dilantin) helped “reduce the intensity of impulsive aggressive acts” in people with ASPD. (9) Another study also found that the anti-epileptic drugs valproate (Depacon),?divalproex sodium (Depakote), carbamazepine (Tegretol), and oxcarbazepine (Trileptal), in addition to phenytoin, reduced aggression in this population. But in a different, third study, valproate, carbamazepine, and phenytoin had no effect on aggression. (10)

There’s some evidence that medication-based therapy (MBT) can be effective in people with co-occurring ASPD and borderline personality disorder. A 2016 study found that for individuals with both of these conditions, MBT improved mood, general psychiatric symptoms, and helped with interpersonal problems. (11)

Contradictory results from studies can be frustrating for families who want a loved one with this condition to get help. Unfortunately, scientists have not been able to find treatments that consistently work.

What Doctors Treat ASPD?

Psychologists,?psychiatrists,?and certain other licensed mental health professionals?diagnose ASPD and provide psychotherapy for individuals. They can also lead group and family counseling, which may be helpful for those with a family member diagnosed with ASPD, notes the Cleveland Clinic. (5) Psychiatrists can also prescribe medications that can help with related mental health issues that often coexist with ASPD.?

Treating Other Medical Needs

Even if ASPD itself cannot be treated, people with the condition can seek treatment for other mental health problems. Psychiatric conditions in general are much more common in this population than in the general population. (8)

In one study, 90 percent of people with ASPD had another psychiatric illness. The most common coexisting diagnosis is a substance use disorder. Women with ASPD are at higher risk for substance use disorders than men with the disorder. (8)

Substance dependence may be treated with medication, depending on the specific addiction a person has. For example, a person with an opioid addiction may be prescribed buprenorphine (Subutex), methadone (Dolophine), or extended-release naltrexone (Vivitrol). (13) Similarly, naltrexone, acamprosate (Campral), and disulfiram (Antabuse) can be used to treat alcohol dependence in a person with (or without) ASPD. (14)

People with an ASPD diagnosis are also at higher risk for anxiety and depression. About half of all people with ASPD have an anxiety disorder, and about one-quarter of them have depression. (8) These conditions are treated similarly in those with and without ASPD. But there is not much research on whether those treatments are as effective in people with ASPD.

The most common first-line treatment for anxiety and depression disorder is a class of drugs called selective serotonin reuptake inhibitors (SSRIs). These drugs work by altering the amount of serotonin, a chemical called a neurotransmitter, in the brain. Serotonin plays a role in a person’s mood.

Several other groups of drugs also alter the concentration of certain neurotransmitters in the brain and can be used to treat depression, some anxiety disorders, or?attention deficit hyperactivity disorder (ADHD). These include the following:

Someone with both bipolar disorder and ASPD may be prescribed mood stabilizers, possibly including anti-epileptics like those discussed above. Someone with bipolar disorder or?schizophrenia-like disorders may be prescribed an?antipsychotic drug?as well. None of these drugs are specifically approved to treat ASPD, but if they successfully treat another condition in a person with ASPD, that may reduce the person’s antisocial tendencies as well. (8)

Additional reporting by Denise Schipani.

Editorial Sources and Fact-Checking

  1. Peters R, Young M, Rojas EC, Gorey C. Evidence-Based Treatment and Supervision Practices for Co-occurring Mental and Substance Use Disorders in the Criminal Justice System. The American Journal of Drug and Alcohol Abuse. 2017.
  2. Gibbon S, Duggan C, Stoffers J, et al. Psychological Interventions for Antisocial Personality Disorder.?Cochrane Database of Systematic Reviews. June 16, 2010.
  3. Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition) [PDF].?National Institute on Drug Abuse. January 2018.
  4. Armelius BA, Andreassen TH. Cognitive-Behavioral Treatment for Antisocial Behavior in Youth in Residential Treatment.?Cochrane Database of Systematic Reviews. October 17, 2007.
  5. Antisocial Personality Disorder (ASPD).?Cleveland Clinic. May 12, 2021.
  6. Scott S, Briskman J, O’Connor TG.?Early Prevention of Antisocial Personality: Long-Term Follow-Up of Two Randomized Controlled Trials Comparing Indicated and Selective Approaches.?American Journal of Psychiatry. June 2014.
  7. Deleted, October 6, 2022.
  8. Antisocial Personality Disorder: Treatment, Management, and Prevention. NICE Clinical Guidelines No. 77.?National Institute for Health and Care Excellence. 2010.
  9. Khalifa N, Duggan C, Stoffers J, et al. Pharmacological Interventions for Antisocial Personality Disorder.?Cochrane Database of Systematic Reviews. August 4, 2010.
  10. Huband N, Ferriter M, Nathan R, Jones H. Antiepileptics for Aggression and Associated Impulsivity.?Cochrane Database of Systematic Reviews. February 17, 2010.
  11. Bateman A, O’Connell J, Lorenzini N, et al. A Randomised Controlled Trial of Mentalization-Based Treatment Versus Structured Clinical Management for Patients With Comorbid Borderline Personality Disorder and Antisocial Personality Disorder.?BMC Psychiatry. August 30, 2016.
  12. Deleted, October 6, 2022.
  13. Effective Treatments for Opioid Addiction.?National Institute on Drug Abuse. November 2016.
  14. Prescribing Medications for Alcohol Dependence. Helping Patients Who Drink Too Much: A Clinician’s Guide [PDF].?National Institute on Alcohol Abuse and Alcoholism. October 2008.

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