Psychological treatments for people with antisocial personality disorder

Antisocial personality disorder is a condition that leads to persistent rule-breaking, criminality, and drug or alcohol misuse. It causes a great deal of hardship for the person concerned, as well as for the person’s immediate family and society in general. This review systematically examines the evidence for the effectiveness of psychological treatments used to help people with antisocial personality disorder. 

We considered 11 studies, but were unable to draw any firm conclusions from the evidence available. Although several studies looked at treatments to reduce drug or alcohol misuse in people with antisocial personality disorder, few studies focused on treating the disorder itself. Only three studies reported outcome measures that were originally defined in the review protocol as being of particular importance in this disorder (reconviction and aggression). Nonetheless, there was some evidence that a type of treatment known as contingency management (which provides rewards for progress in treatment) could help people with antisocial personality disorder to reduce their misuse of drugs or alcohol.

Further research is urgently needed to clarify which psychological treatments are effective for people with this disorder. This research is best carried out using carefully designed clinical trials. Such trials should focus on the key features of antisocial personality disorder. To be informative, they need to be carried out with samples of participants of sufficient size.

Authors' conclusions: 

Results suggest that there is insufficient trial evidence to justify using any psychological intervention for adults with AsPD. Disappointingly few of the included studies addressed the primary outcomes defined in this review (aggression, reconviction, global functioning, social functioning, adverse effects). Three interventions (contingency management with standard maintenance; CBT with standard maintenance; 'Driving Whilst Intoxicated program' with incarceration) appeared effective, compared to the control condition, in terms of improvement in at least one outcome in at least one study. Each of these interventions had been originally developed for people with substance misuse problems. Significant improvements were mainly confined to outcomes related to substance misuse. No study reported significant change in any specific antisocial behaviour. Further research is urgently needed for this prevalent and costly condition.

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Background: 

Antisocial personality disorder (AsPD) is associated with a wide range of disturbance including persistent rule-breaking, criminality, substance use, unemployment, homelessness and relationship difficulties.

Objectives: 

To evaluate the potential beneficial and adverse effects of psychological interventions for people with AsPD.

Search strategy: 

Our search included CENTRAL Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, PsycINFO, ASSIA, BIOSIS and COPAC.

Selection criteria: 

Prospective, controlled trials in which participants with AsPD were randomly allocated to a psychological intervention and a control condition (either treatment as usual, waiting list or no treatment).

Data collection and analysis: 

Three authors independently selected studies. Two authors independently extracted data. We calculated mean differences, with odds ratios for dichotomous data.

Main results: 

Eleven studies involving 471 participants with AsPD met the inclusion criteria, although data were available from only five studies involving 276 participants with AsPD. Only two studies focused solely on an AsPD sample. Eleven different psychological interventions were examined. Only two studies reported on reconviction, and only one on aggression. Compared to the control condition, cognitive behaviour therapy (CBT) plus standard maintenance was superior for outpatients with cocaine dependence in one study, but CBT plus treatment as usual was not superior for male outpatients with recent verbal/physical violence in another. Contingency management plus standard maintenance was superior for drug misuse for outpatients with cocaine dependence in one study but not in another, possibly because of differences in the behavioural intervention. However, contingency management was superior in social functioning and counselling session attendance in the latter. A multi-component intervention utilising motivational interviewing principles, the ‘Driving Whilst Intoxicated program’, plus incarceration was superior to incarceration alone for imprisoned drink-driving offenders.

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