Key Facts

ASPD is characterised by a pervasive pattern of disregard for and violation of the rights of others. It is strongly associated with criminal behaviour, substance misuse, and violence.

Epidemiology

Prevalence ~3% in men, ~1% in women. Up to 50-80% of prison populations meet criteria. Strong association with socioeconomic deprivation, substance misuse, and childhood adversity.

Aetiology

• Genetic: Heritability ~50%; callous-unemotional traits are highly heritable
• Environmental: Childhood abuse/neglect, inconsistent parenting, peer influences, poverty
• Neurodevelopmental: Conduct disorder in childhood (essential prerequisite for diagnosis)
• Neurobiology: Reduced amygdala and prefrontal cortex activation; reduced autonomic arousal (fearlessness theory)

Pathophysiology

• Reduced amygdala function: Impaired fear conditioning, empathy, and moral reasoning
• Prefrontal cortex dysfunction: Poor impulse control, decision-making, and behavioural regulation
• Low cortisol: Reduced stress reactivity - may explain sensation-seeking and risk-taking
• Reduced autonomic arousal: Low resting heart rate in childhood predicts antisocial behaviour

Core Features

• Persistent disregard for social norms and the law
• Deceitfulness - repeated lying, conning for personal gain
• Impulsivity, failure to plan ahead
• Irritability and aggressiveness - repeated fights or assaults
• Reckless disregard for safety of self and others
• Consistent irresponsibility (work, financial)
• Lack of remorse - indifferent or rationalises harm to others

Diagnostic Requirements

• Age ≥18 years
• Evidence of conduct disorder before age 15
• Pattern not explained by schizophrenia or bipolar disorder

Red Flags

• Domestic violence perpetration - safeguarding concern
• Substance misuse with violent behaviour
• Fire-setting or sexual offending - forensic risk
• Macdonald triad in childhood (enuresis, fire-setting, animal cruelty) - historical predictors

Bedside

• Detailed clinical assessment: Full personal, forensic, and developmental history
• Risk assessment: Violence (HCR-20), sexual violence (Risk Matrix 2000), domestic abuse
• Collateral history: Essential - from probation, family, medical records
• AUDIT/DAST: Substance misuse screening

Bloods

• FBC, LFTs: Alcohol effects, baseline
• Urine drug screen: Substance misuse
• TFTs: Exclude organic personality change

Special Tests

• PCL-R (Psychopathy Checklist-Revised): 20-item assessment; ≥30/40 indicates psychopathy - use by trained professionals only
• HCR-20: Structured professional judgment for violence risk

Non-pharmacological (NICE CG77)

• Group-based cognitive-behavioural programmes: Focus on problem-solving, social skills, anger management
• Therapeutic communities: Democratic therapeutic community model - extended residential programmes
• Functional family therapy: For adolescents with conduct disorder (prevention)
• Multi-systemic therapy (MST): For young people at risk of ASPD
• Substance misuse treatment: Integrated approach

Pharmacological

• No medication recommended for core ASPD features
• Treat comorbid conditions on their own merits:
  • Depression: SSRI
  • ADHD: Stimulant medication (with careful monitoring)
  • Psychosis: Antipsychotic
• Avoid prescribing drugs with abuse potential (benzodiazepines, opioids)

Referral Criteria

• Forensic risk - forensic psychiatry/psychology
• Comorbid substance misuse - specialist addiction services
• Young people with conduct disorder - CAMHS
• DSPD (dangerous and severe personality disorder) units - specialist services

• Antisocial behaviour tends to attenuate after age 40 - particularly impulsivity and aggression
• Psychopathic traits (callousness, manipulativeness) tend to persist
• Mortality: Increased (substance misuse, violence, suicide, accidents) - life expectancy reduced by ~18 years
• Treatment response: Generally poor; best outcomes with early intervention in conduct disorder
• DSPD programme: Intensive treatment for highest-risk individuals - limited evidence of effectiveness
• Comorbid substance misuse significantly worsens prognosis and increases violence risk

Hare's Psychopathy Checklist (PCL-R) Factors

Conduct Disorder Predictors of ASPD