antisocial personality disorders

**Definition (DSM-5-TR):** Pervasive pattern of disregard for and violation of others' rights since age 15, in a patient ≥18 years old, with evidence of conduct disorder before age 15. Requires ≥3 of the following (mnemonic "CORRUPT"): - Consistent irresponsibility (work/financial obligations) - Obligation failure / lack of remorse (indifferent to or rationalizes harming others) - Reckless disregard for safety of self/others - Remorselessness - Unlawful behavior (repeated acts that are grounds for arrest) - Pathological lying/deceitfulness (conning, aliases) - Temper: irritability and aggressiveness (repeated fights/assaults) (Also impulsivity/failure to plan ahead.)

**Epidemiology and risk factors:** Male > female (about 3:1). Associated with childhood abuse/neglect, harsh or inconsistent parenting, parental antisocial behavior or substance use, and family history (genetic contribution). Strongly comorbid with substance use disorders, ADHD, and other Cluster B disorders. Associated with high rates of incarceration, early mortality (suicide, accidents, violence).

**Pathophysiology:** Heritable and environmental. Neuroimaging suggests reduced prefrontal cortex (especially orbitofrontal) volume/function and amygdala dysfunction, which lead to impaired empathy, fear conditioning, and impulse control. Low serotonergic activity is linked to impulsive aggression.

**Key points for boards:** - Cluster B ("dramatic, emotional, erratic"): antisocial, borderline, histrionic, narcissistic. - Conduct disorder in childhood is the precursor. If the patient is <18, diagnose conduct disorder, not ASPD. - Ego-syntonic: patients usually don't see their behavior as a problem and often present only when mandated by courts. - Defense mechanisms: acting out, projection, denial, rationalization. - Distinguish from psychopathy (a related but distinct construct measured by the Hare Psychopathy Checklist, with more emphasis on affective traits such as callousness and shallow affect). ASPD is not the same as psychopathy. - Differential: bipolar disorder (mania), substance-induced behavior, narcissistic PD (exploits others for self-esteem rather than for material gain/power), borderline PD. - Behavior should not occur exclusively during schizophrenia or a manic episode.

**Management:** Hard to treat. Psychotherapy (e.g., limit-setting, structured/CBT-based and mentalization-based approaches) has limited evidence. Treat comorbid substance use, depression, and ADHD. Pharmacotherapy is symptomatic only (e.g., mood stabilizers or SSRIs for impulsive aggression). Antipsychotics may be used for severe aggression or transient psychotic symptoms. Avoid benzodiazepines and other addictive agents because of misuse risk. Prognosis: symptoms (especially criminal behavior) often tend to decrease with age.

**Clinical vignette pattern:** A 25-year-old man with a history of truancy, fights, animal cruelty and setting fires as a teen, multiple arrests, repeated job loss, lying to obtain money, and no remorse → antisocial personality disorder.