Antisocial Personality Disorder and Addiction
Antisocial personality disorder (ASPD) is a mental health condition characterized by a demonstrated inability to conform to lawful or ethical behavior and an egocentric lack of concern for others, exhibited by long-term patterns of manipulation, exploitation, etc.1,2 Historically, descriptions of people who exhibit these traits may have included the terms psychopathy or sociopathy. As individuals with antisocial personality disorder fail to adhere to social norms in terms of lawful behavior, some may repeatedly perform criminal acts that are grounds for arrest.2
A diagnosis of antisocial personality disorder can only be made in people 18 or older, though a history of a childhood behavioral disorder (known as conduct disorder) is one of the diagnostic criteria for the adult personality disorder.3 While not all children with conduct disorder go on to develop antisocial personality disorder; an adult is required to have met the criteria for conduct disorder prior to the age of 15 in order to be diagnosed with antisocial personality disorder. The likelihood of developing antisocial personality disorder in adulthood is increased if the accompanying onset of conduct disorder occurred before 10 years of age.2
Lifetime prevalence rates for the disorder have been estimated to range from 1-4% of the general population.4,8 Substance use disorders are found to commonly co-occur with several of the personality disorders—in as many as 22.6% of people with any type of personality disorder according to national surveying.5,6 When it comes to antisocial personality disorder, specifically, as many as 40.5% of those with the condition were found to have some form of a co-occurring substance use disorder (SUD).6
Diagnostic Signs & Symptoms of Antisocial Personality Disorder
Though deceit and manipulation are core features of antisocial personality disorder, some people may exhibit charm or wit in conning people for their own personal gain.2,7 However, they may also exhibit consistent irresponsibility (such as with work or financial obligations), behave violently or impulsively, but lack any remorse or guilt for any of their pathological behavior. Below are some other characteristic signs and symptoms of antisocial personality disorder: 2,7
- Disregard for what’s right and wrong
- Intimidation, lying, and deceit to exploit others
- Arrogant sense of superiority
- Callous or cynical disrespect for other people
- Hostile, irritability, agitation, aggression, or violence
- Impulsivity or failure to plan ahead
- Lack of empathy for others and lack of remorse for harmful behavior
- History of poor or abusive relationships
The diagnosis of antisocial personality disorder is made in people 18 or older. Though people may struggle all of their adult lives with this chronic condition, certain symptoms—including criminal and destructive behavior—may decrease somewhat with age.7
Causes of Antisocial Personality Disorder
The causes of antisocial personality disorder are not well understood, though it appears that its development is influenced by certain genetic and environmental factors (e.g., history of child abuse).1,9 Having a parent with this disorder or a parent with alcoholism may also increase the risk. A history of certain pathological behaviors, including cruelty to animals and setting fires, are sometimes present during childhood in people with this disorder.1 Antisocial personality disorder is much more common among men than women and is most prevalent amongst a demographic that includes people in substance abuse clinics, prisons, or other forensic settings.2
Co-occurrence with Addiction
The co-occurrence of addiction among people with antisocial personality disorder is common. Within a drug treatment programs, past estimates of the prevalence of such a co-occurrence have been even higher—NIDA estimates that 40-50% of people who enter treatment for addiction or substance abuse have antisocial personality disorder, compared with roughly 1-4% of the general population.8,10
The Graduate Journal of Counseling Psychology reports that as many as 90% of people with antisocial personality disorder have a co-occurring substance use disorder. There has historically been some reluctance in the treatment realm to work with the ASPN population because of their difficult or complicated clinical management; people with antisocial personality disorder may encounter difficulties being treated for their co-occurring substance use disorder due to the symptoms of the personality disorder.11
A study published by the Journal of Substance Abuse Treatment found that court mandates increased treatment retention among people in residential substance use treatment programs—a population for which treatment retention has historically been very low. This population may also be more prone to relapse into substance use and return to criminal behavior.12
Alcohol use disorder is particularly common amongst the types of addictions found to co-occur with antisocial personality disorder.11,12Aggressive or violent behavior can be more common among people with this addiction.11 Those with antisocial personality disorder may also be more likely to exhibit alcohol-related aggression than those without ASPD, according to the National Institute on Alcohol Abuse and Alcoholism (NIAAA).13
Despite the prevalence of comorbid substance use disorders among people with antisocial personality disorder, this combination of issues can be challenging to treat. As personality disorders alone are commonly viewed as being difficult to treat, the additional complexity presented by co-occurring addiction may exclude this population from certain treatment programs. Such programs may not be equipped to or experienced in treating both antisocial personality disorder and addiction, adding to the frustration faced by people in this population attempting to find an appropriate treatment source.
However, over the past few decades, there has been growing evidence to support the use of psychosocial interventions to treat ASPD.14
Like other co-occurring disorders or dual diagnosis situations, prevention and treatment strategies for both ASPD and SUD should apply an integrated approach to simultaneously address both conditions.15 Behavioral therapeutic approaches, such as contingency management to reward appropriate behaviors, may be successful for some people.1,11 Psychotherapy (sometimes termed talk therapy) may also play a therapeutic role for people with ASPD.7,11 Research additionally supports cognitive behavioral therapy as an effective mode of therapy in the treatment of addiction among people with antisocial personality disorder.11
While improvement in substance use disorders among this population has been demonstrated, longer-term psychodynamic therapy may be needed to manage the personality disorder.11 Because both SUD and ASPD are chronic conditions, diligent long-term management of these dually diagnosed mental health issues is necessary.
Though there are no pharmacologic interventions specifically FDA-approved for the treatment of ASPD, several psychiatric medications may be prescribed in conjunction with some of the psychotherapeutic approaches mentioned above to better manage some of the mental health issues that may be associated with the condition—such as depression and/or anxiety. In addition, in applicable situations—such as a co-occurring alcohol use disorder or opioid use disorder—FDA-approved treatment medications for those conditions may be utilized (e.g., naltrexone, disulfiram, acamprosate, opioid agonist therapy, respectively).
Cases of co-occurring antisocial personality disorder and addiction may be quite prevalent. Though many of the defining features of the personality disorder bring innate challenges to the treatment of people in this situation, improvement in both ASPD and substance use disorders is possible with treatment. A combination of behavioral, psychodynamic, and medication approaches may be needed to effectively treat people suffering from these co-occurring disorders. Loved ones can support those who need help by first locating and then encouraging the use of treatment resources skilled in managing both conditions.
- U.S. National Library of Medicine—MedlinePlus. (2018). Antisocial Personality Disorder.
- Diagnostic and statistical manual of mental disorders: DSM-5 (5th ed.). (2013). Washington, D.C.: American Psychiatric Association.
- U.S. National Library of Medicine—MedlinePlus. (2020). Conduct Disorder.
- Werner, K. B., Few, L. R., & Bucholz, K. K. (2015). Epidemiology, Comorbidity, and Behavioral Genetics of Antisocial Personality Disorder and Psychopathy. Psychiatric annals, 45(4), 195–199.
- National Institute of Mental Health. (2017). Personality Disorders.
- Lenzenweger, M. F., Lane, M. C., Loranger, A. W., & Kessler, R. C. (2007). DSM-IV personality disorders in the National Comorbidity Survey Replication. Biological psychiatry, 62(6), 553–564.
- Mayo Clinic. (2019). Antisocial Personality Disorder.
- Helle, A. C., Watts, A. L., Trull, T. J., & Sher, K. J. (2019). Alcohol Use Disorder and Antisocial and Borderline Personality Disorders. Alcohol research : current reviews, 40(1), arcr.v40.1.05.
- Department of Health and Human Services—MentalHealth.gov. (2017). Antisocial Personality Disorder.
- National Institute on Drug Abuse. (2009). Court Mandates Help Men With Antisocial Personality Disorders Stay in Treatment.
- Haase, J.M. (2009). Co-occurring Antisocial Personality Disorder and Substance Use Disorder: Treatment Interventions. Graduate Journal of Counseling Psychology: Vol. 1, Iss. 2, Article 6.
- Daughters, S. B., Stipelman, B. A., Sargeant, M. N., Schuster, R., Bornovalova, M. A., & Lejuez, C. W. (2008). The interactive effects of antisocial personality disorder and court-mandated status on substance abuse treatment dropout. Journal of substance abuse treatment, 34(2), 157–164.
- Moeller, F. G., & Dougherty, D. M. (2001). Antisocial personality disorder, alcohol, and aggression. Alcohol research & health : the journal of the National Institute on Alcohol Abuse and Alcoholism, 25(1), 5–11.
- Miller, S. C., Fiellin, D. A., Rosenthal, R. N., & Saitz, R. (2019). The ASAM Principles of Addiction Medicine, Sixth Edition. Philadelphia: Wolters Kluwer.
- National Institute on Alcohol Abuse and Alcoholism. (2005). Adult Antisocial Syndrome Common Among Substance Use Disorders.