Few individuals seek medical attention specifically for antisocial personality disorder (ASP). People with antisocial personality disorder who seek care do so for other problems such as marital discord, alcohol or drug abuse or suicidal thoughts. Family members or the courts may send some people with ASP to a mental health counselor for evaluation. People with ASP often appear to have poor insight and may reject the diagnosis or deny their symptoms.
People with antisocial personality who seek help (or are referred) can be offered evaluation and treatment as outpatients. Patients can be offered an array of services, including neuropsychological assessment, individual psychotherapy, medication management, and family or marital counseling.
Unless the person risks harming himself or others, hospital care is not needed. In fact, people with ASP can be disruptive in inpatient units — for example, becoming belligerent when their demands are unmet or using manipulation to gain favors.
Psychotherapy for people with ASP should focus on helping the individual understand the nature and consequences of his disorder so he can be helped to control his behavior. Exploratory or insight-oriented forms of psychotherapy are generally not helpful to people with ASP.
Cognitive therapy for Antisocial Personality
Cognitive therapy — first developed to help patients with depression — has recently been applied to ASP. The therapist should set guidelines for the patient’s involvement, including regular attendance, active participation and completion of any necessary work outside of office visits. The patient who submits to therapy only to avoid a jail term is not intent on improving. Therapy must be more than a means by which the antisocial tries to elude the consequences of his behavior. The cognitive therapy’s major goal is to help the patient understand how he creates his own problems and how his distorted perceptions prevent him from seeing himself the way others view him.
Because people antisocial personality tend to blame others, have a low tolerance for frustration, are impulsive and rarely form trusting relationships, working with these individuals is difficult. People with ASP often lack the motivation to improve and are notoriously poor self-observers. They simply do not see themselves as others do.
Therapists must be aware of their own feelings and remain vigilant to prevent their emotional responses to their patients from disrupting the therapy process. No matter how determined the therapist may be to help an antisocial patient, it is possible that the patient’s criminal past, irresponsibility and unpredictable tendency toward violence may render him thoroughly unlikable. The best treatment prospects come with professionals well versed in ASP, who can anticipate their emotions and present an attitude of acceptance without moralizing.
Medications for Antisocial Personality
No medications are routinely used or specifically approved for ASP treatment. Several drugs, however, have been shown to reduce aggression, a common problem for many antisocials.
The best-documented medication is lithium carbonate, which has been found to reduce anger, threatening behavior and combativeness among prisoners. More recently, the drug was shown to reduce behaviors such as bullying, fighting and temper outbursts in aggressive children.
Phenytoin (Dilantin), an anticonvulsant, has also been shown to reduce impulsive aggression in prison settings.
Other drugs have been used to treat aggression primarily in brain-injured or mentally retarded patients. These include carbamazepine, valproate, propranolol, buspirone and trazodone.
Antipsychotic medications also have been studied in similar populations. They may deter aggression, but potentially induce irreversible side effects. Tranquilizers from the benzodiazepine class should not be used to treat people with ASP because they are potentially addictive and may lead to loss of behavioral control.
Medication may help alleviate other psychiatric disorders that coexist with ASP, including major depression, anxiety disorder or attention-deficit/hyperactivity disorder, thus producing a ripple effect that can reduce antisocial behavior. Mood disorders are some of the most common conditions accompanying ASP and are among the more treatable. For reasons that remain unknown, depressed patients with personality disorders tend to not respond as well to antidepressant medication as depressed patients without personality disorders.
Antisocials with bipolar disorder may respond to lithium carbonate, carbamazepine or valproate, which can help stabilize moods and may lessen antisocial behavior as well. Stimulant medication can be used to reduce symptoms of attention deficit disorder, a condition that can compound the aggression and impulsivity that may accompany ASP. Stimulants must be considered judiciously because they can be addictive. Uncontrollable and dangerous forms of sexual behavior may be targeted by injections of medroxyprogesterone acetate, a synthetic hormone that reduces testosterone levels.
Addiction and Family Counseling
Alcohol and drug abuse present major barriers for treatment of a person with underlying ASP. Although abstinence from drugs and alcohol does not guarantee a reduction in antisocial behavior, people with ASP who stop abusing drugs are less likely to engage in antisocial or criminal behaviors and have fewer family conflicts and emotional problems. Following a treatment program, patients should be encouraged to attend meetings of Alcoholics Anonymous, Narcotics Anonymous or Cocaine Addicts Anonymous.
Pathological gambling (a separate disorder that is quite different from social or professional gambling) is another addictive behavior common to people with this condition. Although few formal treatment programs exist for people so preoccupied with gambling that nothing else matters, people with the disorder should be encouraged to attend Gamblers Anonymous.
People with antisocial personality disorder with spouses and families may benefit from marriage and family counseling. Bringing family members into the process may help antisocial patients realize the impact of their disorder. Therapists who specialize in family counseling may help address the antisocial person’s trouble maintaining an enduring attachment to his spouse or partner, his inability to be an effective parent, problems with honesty and responsibility, and the anger and hostility that can lead to domestic violence. Antisocials who were poorly parented may need help learning appropriate parenting skills.
Incarceration may be the best way to control the most severe and persistent cases of antisocial personality disorder. Keeping antisocial offenders behind bars during their most active criminal periods reduces their behaviors’ social impact.