Antisocial personality disorder: signs, causes, assessment and treatment

The NHS explains that a person with a personality disorder thinks, feels, behaves or relates to others very differently from the average person. There are several types. A person with antisocial personality traits will typically get easily frustrated and have difficulty controlling their anger. They may blame other people for problems in their life, and be aggressive and violent, upsetting others with their behaviour.

Diagnosis is changing. The NHS notes that instead of being diagnosed with a specific type, people may be given a diagnosis of mild, moderate or severe personality disorder with particular traits. NICE adds that the current ICD-11 does not distinguish the previous separate types and classifies personality disorder as a single condition by severity.

These are descriptions of patterns, not judgements about character. A diagnosis should be made by a mental health professional after a full assessment.

The NHS says symptoms vary depending on the type of personality disorder. A person with antisocial personality traits will typically get easily frustrated and have difficulty controlling their anger. They may blame other people for problems in their life, and be aggressive and violent, upsetting others with their behaviour.

Someone with a personality disorder may also have other mental health problems, such as depression and drug addiction, according to the NHS. NICE says drug and alcohol misuse commonly occurs alongside antisocial personality disorder and is likely to aggravate risk of harm to self and others.

These are descriptions of patterns rather than judgements of character. The NHS says a mental health professional can talk to you about what a diagnosis means, and that the way personality disorders are diagnosed is changing, with mild, moderate or severe personality disorder with particular traits replacing separate types.

The NHS says treatment for a personality disorder usually involves a talking therapy and can also include other types of therapy and medicine. Treatment can last several months or years. Therapeutic communities, where people attend or stay for intensive group therapy, may be offered to some people.

NICE is specific for antisocial personality disorder. It says the evidence base is limited, and that for people in community and mental health services, including those with substance misuse problems, group-based cognitive and behavioural interventions should be considered to address impulsivity, interpersonal difficulties and antisocial behaviour. It says pharmacological interventions should not be routinely used for the disorder or for associated aggression, anger and impulsivity, but that comorbid conditions such as depression and anxiety should be treated in line with the relevant NICE guideline.

The NHS says it is not clear exactly what causes personality disorders. They are thought to result from a combination of the genes a person inherits and early environmental influences, for example a distressing childhood experience such as abuse or neglect.

NICE guidance also looks at prevention. It describes the potential value of identifying children at risk of developing conduct problems and supporting them and their families, and it cautions that care should be taken not to increase stigma or label a child as antisocial or problematic.

NICE says that assessment in secondary and forensic services should look at antisocial behaviours, personality functioning, coping strategies, strengths and vulnerabilities, comorbid mental disorders, the need for psychological treatment, social care and support, and domestic violence and abuse. Structured assessment methods should be used whenever possible.

Risk assessment is part of care planning. NICE says assessing risk of violence is not routine in primary care, but where it is needed a history of current or previous violence, comorbid disorder or substance misuse, current stressors and information from records or families should be considered, because the person might not always be a reliable source of information. For people considered high risk, a comprehensive risk management plan involving health, social care and criminal justice agencies is recommended.

NICE highlights comorbid disorders including depression and anxiety, drug or alcohol misuse, post-traumatic stress disorder and other personality disorders. It says that in primary and secondary care services antisocial personality disorder is under-recognised, and that when it is identified, significant comorbid disorders such as treatable depression or anxiety are often not detected.

NICE also notes that women with antisocial personality disorder have higher rates of common comorbid mental health problems and other personality disorders, and that interventions may need to be adapted. The NHS says medicine may be prescribed to treat problems associated with a personality disorder such as depression, anxiety or psychotic symptoms.

The NHS says many people with a personality disorder recover over time. Psychological or medical treatment is often helpful, but support is sometimes all that is needed, and no single approach suits everyone. Treatment should be tailored to the individual.

The NHS points to Mind and Rethink Mental Illness and to the Royal College of Psychiatrists for information, and suggests asking a GP about local support groups. NICE emphasises that people can be vulnerable to dropping out of treatment, so motivation and engagement should be part of care from the start, and that regular one-to-one reviews are valuable even when treatment is group based.

Families and carers can be affected too. NICE says their needs should be considered, including the impact of behaviour on the family and the safety of any children.

NICE guidance on antisocial personality disorder also looks at prevention. It describes the potential value of identifying children at risk of developing conduct problems and offering them and their families support, such as parent-training programmes.

NICE cautions that care should be taken not to increase stigma or label a child as antisocial or problematic. If you are worried about a child's behaviour, a GP, school or children's mental health service is the usual starting point.

The NHS suggests asking a GP about support and about how to access NHS mental health services. It says that having a personality disorder can have a big effect on the person's life as well as on family and friends, and that support is available.

If someone is in immediate danger, or you are worried about harm to yourself or others, call 999.

On the NHS, a GP is usually the first step, with referral to community mental health, specialist personality disorder or forensic services depending on needs and risk. NICE recommends that depression, anxiety and substance misuse are treated whichever service the person is under.

Some people seek a private psychiatric or psychological assessment, which can be quicker. Specialist long-term therapy programmes are limited in both sectors, so it is worth asking about the evidence for any programme offered and keeping your GP informed.