Pharmacological and Psychological Interventions for Antisocial Personality Disorder – Results of Two Cochrane Reviews

Simon Gibbon, Birgit A Völlm, Conor Duggan, Najat Khalifa, Jutta Stoffers, Nick Huband, Michael Ferriter, Klaus Lieb
European Psychiatric Review, 2011;4(1):52-58
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Abstract

Antisocial Personality Disorder (AsPD) is a relatively common condition. It is associated with a high number of adverse outcomes for the people affected, their families and society. Little is known about the best way to treat this condition. This paper summarises the results of two separate but complementary Cochrane systematic reviews: one looking at the effectiveness of psychological interventions and the other into the effectiveness of pharmacological interventions. Only a small number of randomised controlled trials were identified for inclusion in the reviews (11 for psychological, eight for pharmacological interventions). The majority of these studies did not focus solely on AsPD but selected participants for other conditions, most commonly substance misuse disorders. Most trials tested a different psychological or pharmacological intervention, so very few conclusions can be drawn. Among the pharmacological approaches tested, nortriptyline and bromocriptine had some effect in men with alcohol dependency. Both drugs reduced anxiety levels, nortriptyline also had a positive effect on substance use related outcomes. Phenytoin was reported as superior to placebo on frequency and intensity of aggressive acts in male prisoners. Psychological interventions, that proved superior to the control condition, included cognitive behaviour therapy (CBT) and contingency management in men with AsPD and cocaine dependency.

Acknowledgements: We are grateful for the assistance of Jo Abbott (Cochrane Developmental, Psychosocial and Learning Problems Group) for running the electronic searches, Renate Reniers for translation of a paper from Dutch and Cathy Bennett for advice and helpful comments on an early draft of the review.
Keywords
Antisocial personality disorder, dissocial personality disorder, psychological interventions, pharmacological interventions, treatment, systematic review
Disclosure This work was funded by a grant from the National Institute for Health Research and the German Federal Ministry of Education and Research. It was supported by the Cochrane Developmental, Psychosocial and Learning Problems Group, the University of Nottingham and Nottinghamshire Healthcare NHS Trust.
Received: January 28, 2011 Accepted March 03, 2011
Correspondence: Simon Gibbon, St Andrew’s Healthcare, Billing Road, Northampton, NN1 5DG, UK. E: sgibbon@standrew.co.uk

Antisocial personality disorder (AsPD) is one of the specific types of personality disorder described in the current edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM-IV-TR).1 In addition to meeting the general criteria for personality disorder (i.e. the person must display “an enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the person’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment”), those with AsPD also display traits such as failure to conform to social norms, repeated deceitfulness, impulsivity, irritability and aggression, consistent irresponsibility, disregard for their own safety or the safety of others and a lack of remorse for the negative consequences of their actions.1 Although the focus of these reviews was on AsPD, the International Classification of Diseases – tenth edition (ICD-10)2 – describes a similar condition, dissocial personality disorder. Despite some differences there is considerable overlap between these two conditions and clinicians often use these terms interchangeably (see Table 1).

AsPD is a relatively common condition that, even by the most conservative estimates, has a prevalence at least equal to that of schizophrenia. Most studies report a prevalence of AsPD of between 2 and 3% in the general population3,4 but in forensic populations its prevalence is reported to be much higher – for example 63% of male remand prisoners, 49% of male sentenced prisoners and 31% of female prisoners.5 AsPD has a major negative impact upon both the person affected, their families and society and it is associated with a wide range of adverse outcomes including: criminality, homelessness, relationship difficulties, substance use, and unemployment.6–10 Men aged under 40 with AsPD have a standardised mortality ratio (SMR) of 33 and are thus 33 times more likely to die than men under the age of 40 without AsPD.11 Those with AsPD who develop a mental illness have a much worse prognosis than those without AsPD.12,9

Psychological interventions have long been the mainstay of treatment for AsPD and encompass a wide range of interventions13 but maybe broadly classified into four main categories: psychoanalytic psychotherapy; cognitive behavioural therapy; therapeutic community and nidotherapy. Psychoanalytic therapies (for example, dynamic psychotherapy, transference-focused psychotherapy, mentalisation-based therapy and group psychotherapy) aim to help the person with AsPD understand and reflect on their inner mental processes and make links between past events and relationships and their current difficulties. Cognitive behavioural therapy (CBT)-based treatments place emphasis on encouraging the person with AsPD to challenge any unhelpful core beliefs and to gain insight into how their thoughts and feelings affect their behaviour.

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