Psychological treatments for people with antisocial personality disorder

Background

People with antisocial personality disorder (AsPD) may behave in a way that is harmful to themselves or others and is against the law. They can be dishonest and act aggressively without thinking. Many also misuse drugs and alcohol. Certain types of psychological treatment, such as talking or thinking therapies, may help people with AsPD. Such treatments aim to change the person’s behaviour, to change the person’s thinking, or to help the person manage feelings of anger, self-harm, drug and alcohol abuse or negative behaviour.

This review updates one published in 2010.

Review question

What are the effects of talking or thinking therapies for adults (aged 18 years and older) with AsPD, compared to treatment-as-usual (TAU), waiting list or no treatment?

Study characteristics

We searched for relevant studies up to 5 September 2019. We found 19 relevant studies for 18 different psychological interventions. Data were reported for 10 studies involving 605 adults (aged 18 years and older) with a diagnosis of AsPD, living in the community, hospital or prison. Eight interventions reported on the main outcomes of the review (aggression, reconviction, general/social functioning and adverse events), but few had data for participants with AsPD. The studies compared a psychological intervention against TAU, which is sometimes referred to as 'standard maintenance' (SM).

Most studies were conducted in the UK or North America and were financed by grants from major research councils. They included more male (75%) participants than females (25%), the average age of which was 35.5 years. The length of the studies ranged from 4 weeks to 156 weeks. Most of the studies (10 of the 19) used methods that were flawed, which means we cannot be certain of their findings and, as a result, are unable to draw any firm conclusions. 

Main results

Below, we report the findings for each comparison, where data were available for a primary outcome.

Cognitive behaviour therapy (CBT) + TAU versus TAU. There was no difference between CBT + TAU and TAU for physical aggression or social functioning but the evidence is uncertain.

Impulsive lifestyle counselling (ILC) + TAU versus TAU. There was no difference between ILC + TAU and TAU for aggression or the adverse events of death or incarceration but the evidence is very uncertain.

Contingency management (CM) + SM versus SM. CM + SM, compared to SM, may improve social functioning slightly.

‘Driving whilst intoxicated' programme (DWI) + incarceration versus incarceration. There was no difference between DWI + incarceration and incarceration on reconviction (re-arrest) rates but the evidence is very uncertain.

Schema therapy (ST) versus TAU. The evidence is very uncertain about the effect of ST compared to TAU on reconviction. There is some evidence that, compared to TAU, ST may improve one aspect of social functioning: time to unescorted leave. There was no difference between ST and TAU for overall adverse events classified globally as negative outcomes but the evidence is very uncertain.

Social problem-solving therapy (SPS) + psychoeducation (PE) versus TAU. There was no difference between SPS + PE and TAU for participants’ level of social functioning but the evidence is very uncertain.

Dialectical behaviour therapy (DBT) versus TAU. There was a suggestion that, compared to TAU, DBT may reduce for the number of self-harm days but the evidence is very uncertain.

Psychosocial risk management (PSRM 'Resettle' programme) versus TAU. There was no difference between PSRM and TAU for the number of offences reported one year after release from prison, or for the risk of dying during the study, although the evidence is very uncertain.

Conclusions

The review shows that there is not enough good quality evidence to recommend or reject any psychological treatment for people with a diagnosis of AsPD.

Authors' conclusions: 

There is very limited evidence available on psychological interventions for adults with AsPD. Few interventions addressed the primary outcomes of this review and, of the eight that did, only three (CM + SM, ST and DBT) showed evidence that the intervention may be more effective than the control condition. No intervention reported compelling evidence of change in antisocial behaviour. Overall, the certainty of the evidence was low or very low, meaning that we have little confidence in the effect estimates reported.

The conclusions of this update have not changed from those of the original review, despite the addition of eight new studies. This highlights the ongoing need for further methodologically rigorous studies to yield further data to guide the development and application of psychological interventions for AsPD and may suggest that a new approach is required.

Read the full abstract...
Background: 

Antisocial personality disorder (AsPD) is associated with poor mental health, criminality, substance use and relationship difficulties. This review updates Gibbon 2010 (previous version of the review).

Objectives: 

To evaluate the potential benefits and adverse effects of psychological interventions for adults with AsPD.

Search strategy: 

We searched CENTRAL, MEDLINE, Embase, 13 other databases and two trials registers up to 5 September 2019. We also searched reference lists and contacted study authors to identify studies.

Selection criteria: 

Randomised controlled trials of adults, where participants with an AsPD or dissocial personality disorder diagnosis comprised at least 75% of the sample randomly allocated to receive a psychological intervention, treatment-as-usual (TAU), waiting list or no treatment. The primary outcomes were aggression, reconviction, global state/functioning, social functioning and adverse events.

Data collection and analysis: 

We used standard methodological procedures expected by Cochrane.

Main results: 

This review includes 19 studies (eight new to this update), comparing a psychological intervention against TAU (also called 'standard Maintenance'(SM) in some studies). Eight of the 18 psychological interventions reported data on our primary outcomes.

Four studies focussed exclusively on participants with AsPD, and 15 on subgroups of participants with AsPD. Data were available from only 10 studies involving 605 participants.

Eight studies were conducted in the UK and North America, and one each in Iran, Denmark and the Netherlands. Study duration ranged from 4 to 156 weeks (median = 26 weeks). Most participants (75%) were male; the mean age was 35.5 years. Eleven studies (58%) were funded by research councils. Risk of bias was high for 13% of criteria, unclear for 54% and low for 33%.

Cognitive behaviour therapy (CBT) + TAU versus TAU

One study (52 participants) found no evidence of a difference between CBT + TAU and TAU for physical aggression (odds ratio (OR) 0.92, 95% CI 0.28 to 3.07; low-certainty evidence) for outpatients at 12 months post-intervention.

One study (39 participants) found no evidence of a difference between CBT + TAU and TAU for social functioning (mean difference (MD) −1.60 points, 95% CI −5.21 to 2.01; very low-certainty evidence), measured by the Social Functioning Questionnaire (SFQ; range = 0-24), for outpatients at 12 months post-intervention.

Impulsive lifestyle counselling (ILC) + TAU versus TAU

One study (118 participants) found no evidence of a difference between ILC + TAU and TAU for trait aggression (assessed with Buss-Perry Aggression Questionnaire-Short Form) for outpatients at nine months (MD 0.07, CI −0.35 to 0.49; very low-certainty evidence).

One study (142 participants) found no evidence of a difference between ILC + TAU and TAU alone for the adverse event of death (OR 0.40, 95% CI 0.04 to 4.54; very low-certainty evidence) or incarceration (OR 0.70, 95% CI 0.27 to 1.86; very low-certainty evidence) for outpatients between three and nine months follow-up.

Contingency management (CM) + SM versus SM

One study (83 participants) found evidence that, compared to SM alone, CM + SM may improve social functioning measured by family/social scores on the Addiction Severity Index (ASI; range = 0 (no problems) to 1 (severe problems); MD −0.08, 95% CI −0.14 to −0.02; low-certainty evidence) for outpatients at six months.

‘Driving whilst intoxicated' programme (DWI) + incarceration versus incarceration

One study (52 participants) found no evidence of a difference between DWI + incarceration and incarceration alone on reconviction rates (hazard ratio 0.56, CI −0.19 to 1.31; very low-certainty evidence) for prisoner participants at 24 months.

Schema therapy (ST) versus TAU

One study (30 participants in a secure psychiatric hospital, 87% had AsPD diagnosis) found no evidence of a difference between ST and TAU for the number of participants who were reconvicted (OR 2.81, 95% CI 0.11 to 74.56, P = 0.54) at three years. The same study found that ST may be more likely to improve social functioning (assessed by the mean number of days until patients gain unsupervised leave (MD −137.33, 95% CI −271.31 to −3.35) compared to TAU, and no evidence of a difference between the groups for overall adverse events, classified as the number of people experiencing a global negative outcome over a three-year period (OR 0.42, 95% CI 0.08 to 2.19). The certainty of the evidence for all outcomes was very low.

Social problem-solving (SPS) + psychoeducation (PE) versus TAU

One study (17 participants) found no evidence of a difference between SPS + PE and TAU for participants’ level of social functioning (MD −1.60 points, 95% CI −5.43 to 2.23; very low-certainty evidence) assessed with the SFQ at six months post-intervention.

Dialectical behaviour therapy versus TAU

One study (skewed data, 14 participants) provided very low-certainty, narrative evidence that DBT may reduce the number of self-harm days for outpatients at two months post-intervention compared to TAU.

Psychosocial risk management (PSRM; 'Resettle') versus TAU

One study (skewed data, 35 participants) found no evidence of a difference between PSRM and TAU for a number of officially recorded offences at one year after release from prison. It also found no evidence of difference between the PSRM and TAU for the adverse event of death during the study period (OR 0.89, 95% CI 0.05 to 14.83, P = 0.94, 72 participants (90% had AsPD), 1 study, very low-certainty evidence).

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