Treatment

Undertaken by specialist services.

Assessing risk of violence is not routine in primary care, but if such assessment is required consider (1):

• current or previous violence, including severity, circumstances, precipitants and victims
• the presence of comorbid mental disorders and/or substance misuse
• current life stressors, relationships and life events
• additional information from written records or families and carers (subject to the person's consent and right to confidentiality), because the person with antisocial personality disorder might not always be a reliable source of information
• healthcare professionals in primary care should consider contact with and/or referral to secondary or forensic services where there is current violence or threats that suggest significant risk and/or a history of serious violence, including predatory offending or targeting of children or other vulnerable people

Various types of treatment have been applied, but their efficacy remains to be demonstrated.

• medication:
  • pharmacological interventions should not be routinely used for the treatment of antisocial personality disorder or associated behaviours of aggression, anger and impulsivity (1)
  • beneficial effects of drugs for the treatment of personality disorders are usually quite modest (2)
  • mood stabilizers, such as lithium, may have a role in treating antisocial, aggressive, emotionally unstable and assaultive behaviour (2)
  • pharmacological intervention may be indicated for co-morbid disorders such as depression and anxiety or drug misuse

Individual psychotherapy: some psychopaths may be helped by a form of supportive psychotherapy in which the therapist is friendly, sympathetic, and mildly directive without being disapproving.

Group psychotherapy:

Authoritarian disciplinary regimes - an example is Herstedvester (Denmark), a locked, maximum security institution for the treatment of criminal psychopaths. The main factors are an indeterminate sentence, strict discipline and individual psychotherapy at moments of crisis.

Controlled trials of treatment - Craft studied psychopaths where one group of patients received group psychotherapy in a self-governing ward, and another group were given firm discipline and direction with a hierachical staffing system. After a two year follow-up the authoritarian group did better in terms of such criteria as number of offences committed, need for further institutional care etc.

Reference:

• 1. NICE (January 2009). Antisocial personality disorder - treatment and management.
• 2. Tredget, J. E. The aetiology, presentation and treatment of personality disorders. Journal of Psychiatric & Mental Health Nursing 2001;8 (4): 347-356.
• 3. Craft, M (1985) Ten Studies in Psychopathic Personality. John Wright and Sons Ltd. 118 pages (see especially summaries at the end of chapters)