Antisocial personality disorder: new directions

The National Institute for Health and Care Excellence (NICE) guidelines for antisocial personality disorder (National Institute for Health and Clinical Excellence 2009) were welcomed for drawing attention to this relatively common but debilitating and costly condition that until recently many psychiatrists believed was untreatable. In the past decade, the historical antipathy of psychiatrists and other mental health professionals in treating personality disorder has been effectively challenged by the publication of influential documents such as Personality Disorder: No Longer a Diagnosis of Exclusion (Department of Health 2003), the development of specific psychological therapies and the subsequent proliferation of dedicated mental health services nationally. However, the focus has been on developing effective treatments for patients with borderline personality disorder, and there remains a lack of service provision for individuals with a diagnosis of antisocial personality disorder, particularly those in the community whose behaviour is not assessed as dangerous enough or who lack a concurrent severe mental illness (usually psychosis) to meet criteria for referral to forensic mental health services. Individuals with antisocial personality disorder often present to primary care in midlife with anxiety or depression, and may be considered for treat ment in secondary mental health services. How ever, when their history of violence and aggressive behaviour is uncovered, health professionals often, understandably, become less willing to offer treatment owing to concerns regarding risk – particularly if no acute mental illness is identified – and professionals themselves risk being criticised for failing to adequately treat such individuals if they reoffend. Treatment providers may become further demoralised by patients’ chaotic lifestyles, frequent substance misuse and the difficulties in engaging them in any treatment offered. This pessimistic picture has been challenged, however, by emerging research into the aetiology of antisocial and aggressive behaviour that suggests that antisocial personality disorder may be conceptualised as a developmental disorder in which early attachment experiences are critical. These findings are important in designing early interventions for high-risk families and children with conduct disorder which may prevent the development of antisocial disorder in adulthood, as well as informing approaches to the management and treatment of individuals who already have the disorder. In this article, we focus on the difficulties and challenges posed by the latter group, highlighting Antisocial personality disorder: new directions