DSM-II

In DSM-II, this disorder is called Antisocial personality

This term is reserved for individuals who are basically unsocialized and whose behavior pattern brings them repeatedly into conflict with society. They are incapable of significant loyalty to individuals, groups, or social values. They are grossly selfish, callous, irresponsible, impulsive, and unable to feel guilt or to learn from experience and punishment. Frustration tolerance is low. They tend to blame others or offer plausible rationalizations for their behavior. A mere history of repeated legal or social offenses is not sufficient to justify this diagnosis. Group delinquent reaction of childhood (or adolescence), and Social maladjustment without manifest psychiatric disorder should be ruled out before making this diagnosis.

DSM-III

Diagnostic Criteria

A. Current age at least 18.

B. Onset before age 15 as indicated by a history of three or more of the following before that age:

  1. truancy (positive if it amounted to at least five days per year for at least two years, not including the last year of school)
  2. expulsion or suspension from school for misbehavior
  3. delinquency (arrested or referred to juvenile court because of behavior)
  4. running away from home overnight at least twice while living in parental or parental surrogate home
  5. persistent lying
  6. repeated sexual intercourse in a casual relationship
  7. repeated drunkenness or substance abuse
  8. thefts
  9. vandalism
  10. school grades markedly below expectations in relation to estimated or known IQ (may have resulted in repeating a year)
  11. chronic violations of rules at home and/or at school (other than truancy)
  12. initiation of fights

C. At least four of the following manifestations of the disorder since age 18:

  1. inability to sustain consistent work behavior, as indicated by any of the following:
    • a. too frequent job changes (e.g., three or more jobs in five years not accounted for by nature of job or economic or seasonal fluctuation)
    • b. significant unemployment (e.g., six months or more in five years when expected to work)
    • c. serious absenteeism from work (e.g., average three days or more of lateness or absence per month)
    • d. walking off several jobs without other jobs in sight
    • (Note: similar behavior in an academic setting during the last few years of school may substitute for this criterion in individuals who by reason of their age or circumstances have not had an opportunity to demonstrate occupational adjustment)
  2. lack of ability to function as a responsible parent as evidenced by one or more of the following:
    • a. child's malnutrition
    • b. child's illness resulting from lack of minimal hygiene standards
    • c. failure to obtain medical care for a seriously ill child
    • d. child's dependence on neighbors or nonresident relatives for food or shelter
    • e. failure to arrange for a caretaker for a child under six when parent is away from home
    • f. repeated squandering, on personal items, of money required for household necessities
  3. failure to accept social norms with respect to lawful behavior, as indicated by any of the following: repeated thefts, illegal occupation (pimping, prostitutions, fencing, selling drugs), multiple arrests, a felony conviction
  4. inability to maintain enduring attachment to a sexual partner as indicated by two or more divorces and/or separations (whether legally married or not), desertion of spouse, promiscuity (ten or more sexual partners within one year)
  5. irritability and aggressiveness as indicated by repeated physical fights or assaults (not required by one's job or to defend someone or oneself), including spouse or child beating
  6. failure to honor financial obligations, as indicated by repeated defaulting on debts, failure to provide child support, failure to support other dependents on a regular basis
  7. failure to plan ahead, or impulsivity, as indicated by traveling from place to place without a prearranged job or clear goal for the period of travel or clear idea about when the travel would terminate, or lack of a fixed address for a month or more
  8. disregard for the truth as indicated by repeated lying, use of aliases, "conning" others for personal profit
  9. recklessness, as indicated by driving while intoxicated or recurrent speeding

D. A pattern of continuous antisocial behavior in which the rights of others are violated, with no intervening period of at least five years without antisocial behavior between age 15 and the present time (except when the individual was bedridden or confined in a hospital or penal institution).

E. Antisocial behavior is not due to either Severe Mental Retardation, Schizophrenia or manic episodes.

Differential Diagnosis

Conduct Disorder

Conduct Disorder consists of the typical childhood signs of Antisocial Personality Disorder. Since such behavior may terminate spontaneously or evolve into other disorders such as Schizophrenia, a diagnosis of Antisocial Personality Disorder should not be made in children; it is reserved for adults (18 or over), who have had time to show the full longitudinal pattern.

Adult Antisocial Behavior

Adult Antisocial Behavior, in the category Conditions Not Attributable to a Mental Disorder, should be considered when criminal or other aggressive or antisocial behavior occurs in individuals who do not meet the full criteria for Antisocial Personality Disorder and whose antisocial behavior cannot be attributed to any other mental disorder.

Substance Abuse

When Substance Abuse and antisocial behavior begin in childhood and continue into adult life, both Substance Use Disorder and Antisocial Personality Disorder should be diagnosed if the criteria for each disorder are met, regardless of the extent to which some of the antisocial behavior may be a consequence of the Substance Use Disorder, e.g., illegal selling of drugs, or the assaultive behavior associated with Alcohol Intoxication. When antisocial behavior in an adult is associated with a Substance Use Disorder, the diagnosis of Antisocial Personality Disorder is not made unless the childhood signs of Antisocial Personality Disorder were also present and continued without a remission of five years or more between age 15 and adult life.

Mental Retardation and Schizophrenia

Severe Mental Retardation and Schizophrenia preempt the diagnosis of Antisocial Personality Disorder, because at the present time there is no way to determine when antisocial behavior that occurs in an individual with severe Mental Retardation or Schizophrenia is due to these more severe disorders or to Antisocial Personality Disorder.

Manic episodes

Manic episodes may be associated with antisocial behavior. The differential diagnosis is easily made by noting the absence of severe behavior problems in childhood and the sudden change in adult behavior.

DSM-IV

Diagnostic Criteria

A. There is a pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years, as indicated by three (or more) of the following:

  1. failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest
  2. deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure
  3. impulsivity or failure to plan ahead
  4. irritability and aggressiveness, as indicated by repeated physical fights or assaults
  5. reckless disregard for safety of self or others
  6. consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations
  7. lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another

B. The individual is at least age 18 years.

C. There is evidence of Conduct Disorder with onset before age 15 years.

D. The occurrence of antisocial behavior is not exclusively during the course of Schizophrenia or a Manic Episode.

Differential Diagnosis

Conduct Disorder

The diagnosis of Antisocial Personality Disorder is not given to individuals under age 18 years and is given only if there is a history of some symptoms of Conduct Disorder before age 15 years. For individuals over age 18 years, a diagnosis of Conduct Disorder is given only if the criteria for Antisocial Personality Disorder are not met.

Substance-Related Disorders

When antisocial behavior in an adult is associated with a Substance-Related Disorder, the diagnosis of Antisocial Personality Disorder is not made unless the signs of Antisocial Personality Disorder were also present in childhood and have continued into adulthood. When substance use and antisocial behavior both began in childhood and continued into adulthood, both a Substance-Related Disorder and Antisocial Personality Disorder should be diagnosed if the criteria for both are met, even though some antisocial acts may be a consequence of the Substance-Related Disorder (e.g., illegal selling of drugs or thefts to obtain money for drugs).

Schizophrenia and Manic Episodes

Antisocial behavior that occurs exclusively during the course of Schizophrenia or a Manic Episode should not be diagnosed as Antisocial Personality Disorder

Other Personality Disorders

Other Personality Disorders may be confused with Antisocial Personality Disorder because they have certain features in common. It is, therefore, important to distinguish among these disorders based on differences in their characteristic features. However, if an individual has personality features that meet criteria for one or more Personality Disorders in addition to Antisocial Personality Disorder, all can be diagnosed.

Narcissistic Personality Disorder

Individuals with Antisocial Personality Disorder and Narcissistic Personality Disorder share a tendency to be tough-minded, glib, superficial, exploitative, and unempathetic. However, Narcissistic Personality Disorder does not include characteristics of impulsivity, aggression, and deceit. In addition, individuals with Antisocial Personality Disorder may not be as needy of the admiration and envy of others, and persons with Narcissistic Personality Disorder usually lack the history of Conduct Disorder in childhood or criminal behavior in adulthood.

Histrionic and Borderline Personality Disorders

Individuals with Antisocial Personality Disorder and Histrionic Personality Disorder share a tendency to be impulsive, superficial, excitement seeking, reckless, seductive, and manipulative, but persons with Histrionic Personality Disorder tend to be more exaggerated in their emotions and do not characteristically engage in antisocial behaviors. Individuals with Histrionic and Borderline Personality Disorders are manipulative to gain nurturance, whereas those with Antisocial Personality Disorder are manipulative to gain profit, power, or some other material gratification. Individuals with Antisocial Personality Disorder tend to be less emotionally unstable and more aggressive than those with Borderline Personality Disorder.

Paranoid Personality Disorder

Although antisocial behavior may be present in some individuals with Paranoid Personality Disorder, it is not usually motivated by a desire for personal gain or to exploit others as in Antisocial Personality Disorder, but rather is more often due to a desire for revenge.

Adult Antisocial Behavior

Antisocial Personality Disorder must be distinguished from criminal behavior undertaken for gain that is not accompanied by the personality features characteristic of this disorder. Adult Antisocial Behavior can be used to describe criminal, aggressive, or other antisocial behavior that comes to clinical attention but that does not meet the full criteria for Antisocial Personality Disorder. Only when antisocial personality traits are inflexible, maladaptive, and persistent and cause significant functional impairment or subjective distress do they constitute Antisocial Personality Disorder.

 DSM-5

Diagnostic Criteria

A. A pervasive pattern of disregard for and violation of the rights of others, occurring since age 15 years, as indicated by three (or more) of the following:

  1. Failure to conform to social norms with respect to lawful behaviors, as indicated by repeatedly performing acts that are grounds for arrest.
  2. Deceitfulness, as indicated by repeatedly lying, use of aliases, or conning others for personal profit or pleasure.
  3. Impulsivity or failure to plan ahead.
  4. Irritability and aggressiveness, as indicated by repeated physical fights or assaults.
  5. Reckless disregard for safety of self or others.
  6. Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations.
  7. Lack or remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another.

B. The individual is at least age 18 years.

C. There is evidence of conduct disorder with onset before age 15 years.

D. The occurrence of antisocial behavior is not exclusively during the course of schizophrenia or bipolar disorder.

Alternative Model

Proposed Diagnostic Criteria

A. Moderate or greater impairment in personality functioning, manifested by characteristic difficulties in two or more of the following four areas:

  1. Identity: Egocentrism; self-esteem derived from personal gain, power, or pleasure.
  2. Self-direction: Goal setting based on personal gratification; absence of prosocial internal standards, associated with failure to conform to lawful or culturally normative ethical behavior.
  3. Empathy: Lack of concern for feelings, needs, or suffering of others; lack of remorse after hurting or mistreating another.
  4. Intimacy: Incapacity for mutually intimate relationships, as exploitation is a primary means of relating to others, including by deceit and coercion; use of dominance or intimidation to control others.

B. Six or more of the following seven pathological personality traits:

  1. Manipulativeness (an aspect of Antagonism): Frequent use of subterfuge to influence or control others; use of seduction, charm, glibness, or ingratiation to achieve one's ends.
  2. Callousness (an aspect of Antagonism): Lack of concern for feelings or problems of others; lack of guilt or remorse about the negative or harmful effects of one's actions on others; aggression; sadism.
  3. Deceitfulness (an aspect of Antagonism): Dishonesty and fraudulence; misrepresentation of self; embellishment or fabrication when relating events.
  4. Hostility (as aspect of Antagonism): Persistent or frequent angry feelings; anger or irritability in response to minor slights and insults; mean, nasty, or vengeful behavior.
  5. Risk taking (an aspect of Disinhibition): Engagement in dangerous, risky, and potentially self-damaging activities, unnecessarily and without regard for consequences; boredom proneness and thoughtless initiation of activities to counter boredom; lack of concern for one's limitations and denial of the reality of personal danger.
  6. Impulsivity (an aspect of Disinhibition): Acting on the spur of the moment in response to immediate stimuli; acting on a momentary basis without a plan or consideration of outcomes; difficulty establishing and following plans.
  7. Irresponsibility (an aspect of Disinhibition): Disregard for - and failure to honor - financial and other obligations or commitments; lack of respect for - and lack of follow-through on - agreements and promises.

C. The impairments in personality functioning and the individual's personality trait expression are relatively inflexible and pervasive across a broad range of personal and social situations.

D. The impairments in personality functioning and the individual's personality trait expression are relatively stable across time, with onsets that can be traced back to at least adolescence or early adulthood.

E. The impairments in personality functioning and the individual's personality trait expression are not better explained by another mental disorder.

F. The impairments in personality functioning and the individual's personality trait expression are not solely attributable to the physiological effects of a substance or another medical condition (e.g., severe head trauma).

G. The impairments in personality functioning and the individual's personality trait expression are not better understood as normal for an individual's developmental stage or sociocultural environment.

Note: The individual is at least 18 years of age.

Specify if:

  • With psychopathic features

Specifiers

A distinct variant often termed psychopathy (or "primary" psychopathy) is marked by a lack of anxiety or fear and by a bold interpersonal style that may mask maladaptive behaviors (e.g., fraudulence). This psychopathic variant is characterized by low levels of anxiousness (Negative Affectivity domain) and withdrawal (Detachment domain) and high levels of attention seeking (Antagonism domain). High attention seeking and low withdrawal capture the social potency (assertive/dominant) component of psychopathy, whereas low anxiousness captures the stress immunity (emotional stability/resilience) component.

In addition to psychopathic features, trait and personality functioning specifiers may be used to record other personality features that may be present in antisocial personality disorder but are not required for the diagnosis. For examples, traits of Negative Affectivity (e.g., anxiousness), are not diagnostic criteria for antisocial personality disorder (see Criterion B) but can be specified when appropriate. Furthermore, although moderate or greater impairment in personality functioning is required for the diagnosis of antisocial personality disorder (Criterion A), the level of personality functioning can also be specified.

Differential Diagnosis

The diagnosis of antisocial personality disorder is not given to individuals younger than 18 years and is given only if there is a history of some symptoms of conduct disorder before age 15 years. For individuals older than 18 years, a diagnosis of conduct disorder is given only if the criteria for antisocial personality disorder are not met.

Substance use disorders

When antisocial behavior in an adult is associated with a substance use disorder, the diagnosis of antisocial personality disorder is not made unless the signs of antisocial personality disorder were also present in childhood and have continued into adulthood. When substance use and antisocial behavior both began in early childhood and continued into adulthood, both a substance use disorder and antisocial personality disorder should be diagnosed if the criteria for both are met, even though some antisocial acts may be a consequence of the substance use disorder (e.g., illegal selling of drugs, thefts to obtain money for drugs).

Schizophrenia and bipolar disorders

Antisocial behavior that occurs exclusively during the course of schizophrenia or a bipolar disorder should not be diagnosed as antisocial personality disorder.

Other personality disorders

Other personality disorders may be confused with antisocial personality disorder because they have certain features in common. It is therefore important to distinguish among these disorders based on differences in their characteristic features. However, if an individual has personality features that meet criteria for one or more personality disorders in addition to antisocial personality disorder, all can be diagnosed

Narcissistic personality disorder

Individuals with antisocial personality disorder and narcissistic personality disorder share a tendency to be tough-minded, glib, superficial, exploitative, and lack empathy. However, narcissistic personality disorder does not include characteristics of impulsivity, aggression, and deceit. In addition, individuals with antisocial personality disorder may not be as needy of the admiration and envy of others, and persons with narcissistic personality disorder usually lack the history of conduct disorder in childhood or criminal behavior in adulthood.

Histrionic and borderline personality disorder

Individuals with antisocial personality disorder and histrionic personality disorder share a tendency to be impulsive, superficial, excitement seeking, reckless, seductive, and manipulative, but persons with histrionic personality disorder tend to be more exaggerated in their emotions and do not characteristically engage in antisocial behaviors. Individuals with histrionic and borderline personality disorders are manipulative to gain nurturance, whereas those with antisocial personality disorders are manipulative to gain profit, power, or some other material gratification. Individuals with antisocial personality disorder tend to be less emotionally unstable and more aggressive than those with borderline personality disorder.

Paranoid personality disorder

Although antisocial behavior may be present in some individuals with paranoid personality disorder, it is not usually motivated by a desire for personal gain or to exploit others as in antisocial personality disorder, but rather is more often attributable to a desire for revenge.

Criminal behavior not associated with a personality disorder

Antisocial personality disorder must be distinguished from criminal behavior undertaken for gain that is not accompanied by the personality features characteristic of this disorder. Only when antisocial personality traits are inflexible, maladaptive, and persistent and cause significant functional impairment or subjective distress do they constitute antisocial personality disorder.

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