Treatment of antisocial personality disorder*

ASPD: antisocial personality disorder; SGA: second-generation antipsychotic; CBT: cognitive-behavioral therapy; SSRI: selective serotonin reuptake inhibitor.

* Individuals with ASPD may present with symptoms along a continuum of severity. We consider individuals with a constellation of symptoms such as lack of emotional connection with others and an incapacity for guilt or remorse to fall at the severe end of the antisocial spectrum.

¶ We treat comorbid conditions according to established protocols for those conditions. In all individuals with ASPD, we avoid treatment with medications that have an increased risk of misuse or dependence (eg, benzodiazepines, stimulants). Refer to UpToDate content for further discussion on treating specific conditions.

Δ We typically use an SGA for the treatment of aggression in the context of ASPD of any severity. Refer to UpToDate content for issues related to monitoring metabolic parameters and movement abnormalities during treatment with antipsychotic medications.

◊ Refer to UpToDate content for initial dose and titration, and monitoring of metabolic parameters and movement disorders during treatment with SGAs.

§ We do not treat individuals with severe ASPD (eg, psychopathy) with CBT. Refer to UpToDate content for further discussion.

¥ For individuals with limited response to CBT, or as the clinical situation warrants, we often augment CBT with additional psychosocial interventions such as marital therapy, schema therapy, psychoeducation, or anger management.

‡ In order to avoid polypharmacy in individuals with ASPD, our preference is to taper off of the first medication, then begin to titrate the second.