Antisocial Personality Disorder: A Mentalizing Framework

Antisocial personality disorder (ASPD) is classified in the DSM-IV (1) as an axis II personality disorder under cluster B, together with borderline, histrionic and narcissistic personality disorder. ASPD is characterized by failure to conform to social norms with respect to lawful behaviors, as indicated by repeatedly performing acts that are grounds for arrest; deception, as indicated by repeatedly lying, use of aliases, or conning others for personal profit or pleasure; impulsiveness or failure to plan ahead; irritability and aggressiveness, as indicated by repeated physical fights or assaults; reckless disregard for safety of self or others; consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations; and lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another. For a formal diagnosis there must be evidence of conduct disorder with onset before age 15 years.

ASPD is a common condition with the general population prevalence in men ranging from 1%−2% (2, 3) to 6% (4). Prevalence rates are consistently higher in men compared with women and, as would be expected, ASPD becomes increasingly common in mental health services, the judicial system, and prison settings (5). It is associated with considerable comorbidity (6), especially with other personality disorders, substance misuse (7), and other axis I conditions (8) (9) and also with increased mortality, particularly at a young age, largely because of reckless behavior (10).

ASPD has major public health implications. Treatment for those affected by violence costs an estimated 3%−6% of the health budget in the U.K. (11), primarily due to the association with drug abuse, suicide, early unnatural death, violent crime, unemployment, homelessness, and family violence (12, 13). The disorder has a broad impact on families, relationships, and social functioning but also people with ASPD make heavy demands on social services, mental health services, and the judicial system. The disorder has a significant association with high level of imprisonment. In the U.K. prison population, the prevalence of people with ASPD has been identified as 63% male remand prisoners, 49% male sentenced prisoners, and 31% female prisoners (5). Consequently, it has a great economic cost (14).

Despite the recognition of its high prevalence and level of psychiatric morbidity, there is evidence that those with ASPD continue to be rejected from services because clinicians believe that treatment is ineffective. Patients with ASPD have mental health needs and present to general mental health services and the criminal justice system but receive only brief intervention or, more likely, punishment. Crawford et al. (15) found that 96% of a study sample met criteria for anxiety disorder and 64% had evidence of alcohol misuse; 50% presented to emergency medical services and 21% were admitted to a mental health inpatient unit during the following year. Despite this, few were provided with follow-up care from mental health services when they presented. Of those that were offered some treatment, levels of alcohol and drug misuse were significantly lower over follow-up, suggesting that general psychiatric support can be useful.

People with ASPD who commit offenses may enter forensic psychiatric services only to be discharged to general mental health services where no treatment is available. More emphasis is needed to avert patients with ASPD being managed in more secure settings and to prevent patients being inappropriately rejected from mainstream services. If a relatively brief and effective treatment can be offered to people with ASPD living in the community, this may reduce contact with the criminal justice system, have the potential to improve the lives of people with ASPD, improve access to services, and also reduce health and nonhealth service costs. These are the aims of a treatment program adapting mentalization-based treatment for people with ASPD, which is the topic of this paper.

Mentalizing is the implicit or explicit perception or interpretation of the actions of others or oneself as intentional, that is, mediated by mental states or mental processes (16). It is a multidimensional construct, and breaking it down into dimensional components is helpful in understanding mentalization-based treatment (MBT) (17). Broadly speaking, mentalization can be considered as four intersecting dimensions: automatic/controlled or implicit/explicit; internally/externally based; self/other oriented; and cognitive/affective process (Table 1). Each of these dimensions possibly relates to a different neurobiological system (“Broadening the scope of the mentalization based approach to psychopathology: mentalization as a multi-dimensional construct.” Unpublished study of Luyten P, Fonagy P, Mayes LC, Vermote R, Lowyck B, Bateman A). The key to successful mentalizing is the integration of all the dimensions into a coherent whole. None of us manage to integrate all components of mentalizing all of the time, and nor should we. Normal people will, at times, move from understanding their own motives and those of others according to their consideration of what is in the mind, to explanations based on the physical environment (“I must have wanted to because I did it”; “If they behave like that, they obviously want to spoil everything”). This move from an evaluation of mental process to a focus on physical actions as an explanation is particularly true in powerful affective states when our cognitive processes fragment in the face of a wave of emotion.

The link between ASPD and the affective and external components of mentalizing is well established both developmentally and in adults. Marsh and Blair (26) in a meta-analysis of 20 studies showed a robust link between antisocial behavior and specific deficits in recognizing fearful expressions, an external component of mentalizing. This impairment was not attributed solely to task difficulty. Failure to recognize fearful faces implies dysfunction in neural structures such as the amygdala that subserve fearful expression processing. Youths with conduct problems have been shown to have a hypo-activation of their amygdala in response to pictures normally considered emotionally arousing, particularly where a potentially painful aggressive act was depicted (27). Amygdala hyporesponsiveness may indicate a dysfunction in limbic structures leading to reduced responsiveness of the amygdala to fearful faces and consequent impairment in recognizing distress cues in others. This leads to a lack of empathy and deficient control of aggressive behavior, which would normally be inhibited by observation and empathic identification of distress in another (affective/other mentalizing). Alternatively we may see these abnormalities as reduced sensitivity to stimuli indicating threat (fearlessness). Developmentally it is likely that preferential amygdala responses to fearful faces are reserved for the modulation of vigilance primarily in threatening situations rather than subserving recognition of social cues in everyday situations. However, constitutional fearlessness would stop infants from regularly seeking their attachment figure when experiencing distress; this intersubjective experience of relating in an attachment context may be critical for the normal development of mentalizing and social cognition (28). Mentalizing inhibits unwarranted aggression. So there may be a complex interaction between constitutional fearfulness and its effect on the development of the normal inhibitory factors protecting against antisocial interaction.

In contrast amygdala hyper-responsiveness has also been observed in some individuals. They show a hyperactivation of the amygdala on seeing a hand shut in a door or a foot being stamped on (29). Here, amygdala responses in conduct-disordered youths correlated with parents’ ratings of daring behavior and sadism. Increased amygdala response may indicate excitement or enjoyment of others’ pain. The suggestion here is that for some individuals these images may generate an unusual level of enjoyment rather than empathetic concern. In either case, the dysfunction of emotional resonance or empathy appears to be linked to vulnerability for antisocial behavior and the clinical and theoretical exploration of this relationship appears warranted. Examining the role of empathy, the ability to understand and care about the emotions of others, in antisocial individuals Baron-Cohen found that lack of care for others led to antisocial and destructive behaviors possibly due to a partial but fundamental impairment of mentalizing, “mindreading without empathizing” (30).

More recently other researchers (e.g., 31) have suggested that antisocial actions and psychopathy may be associated with abnormal attention to socially relevant cues such as scanning the eyes, and that dysfunction in attentional mechanisms underlies emotion recognition deficits (32, 33). Lack of attention to the eyes implies a more general problem with the external component of mentalizing and loss of association and interest in links to internal mental states. This suggests there may be an extensive reduction in ability to recognize emotions in others rather than a specific diminution in ability to recognize fear. If deficits in processing emotion cues are pervasive, which would be consistent with the idea of reduced external mentalizing, there are likely to be widespread difficulties in those social and interpersonal interactions requiring empathic and emotional responsiveness. Misreading emotion cues, or more likely not even registering them, will make it more difficult to understand the subtleties of others’ perspectives. Certainly the internal affective state, which is a key component of empathy and mentalizing of the other person, will remain a mystery. So, although not recognizing others’ distress cues may be important (34, 35), additional, more wide-ranging problems related to social and emotional functioning may contribute to the problems facing people with ASPD. This has important clinical implications.

Effective treatment offered to patients presenting to mental health services may improve not only the life of patients but also their families by improving social function of patients and reduce costs to the health and criminal justice systems by reducing aggressive acts that bring people with ASPD into contact with the law.

Traditionally there has been a lack of confidence and considerable skepticism from clinicians regarding psychological treatments and management options of patients with ASPD because of the inherent challenges associated with working with this group (36, 37). Interventions for some of the symptoms associated with antisocial personality disorder have been developed, principally for the treatment or management of aggression. However, the relevance of anger management programs may be limited. Anger is not explicitly included in the diagnostic criteria for antisocial personality disorder, and while anger may be related to impulsivity and aggression, reducing anger may not reduce impulsivity and aggression. Equally, when delivered to offenders, anger management interventions may reduce levels of anger without having an impact on offending, aggressive, or violent behaviors if the causes of those behaviors in an individual are unrelated to anger.

Interventions have been developed with the aim of reducing offending behavior. These include a wide range of cognitive and behavioral interventions (38–40) and to a lesser extent therapeutic communities (41). Within the U.K. criminal justice system the use of cognitive and behavioral interventions such as reasoning and rehabilitation (42) and enhanced thinking skills (43) is widespread.

Only a small number of careful research studies have been conducted among people with ASPD, so the evidence base for the treatment and management of this patient group is limited (44, 45). Most studies have been done in the context of penal programs, and few have been undertaken in general mental health settings. An early review by Vennard et al. (46) concluded that CBT methods combined with training in social skills and problem solving gave the most positive results with both juvenile and adult offenders, in terms of recidivism. However, even this complex intervention did not achieve large reductions in reoffending with mixed groups of offenders. Therapeutic communities were found to have the lowest success rate (47). There is some more recent but limited evidence for the effectiveness of cognitive behavioral therapy (CBT) alone. Data from a pilot randomized controlled trial in a general mental health setting of individual CBT among men with ASPD suggested that psychological treatments may have a role to play in helping to reduce the likelihood of reoffending (48).

More specific targeting of the emotional deficits found in ASPD may be more appropriate. If the deficits are restricted to fear and sadness this suggests interventions focused on increasing understanding and internalization of these specific emotions. However the current finding of more pervasive deficits suggests training of all emotions is likely to be useful, and indeed a recent study (49) has found emotion recognition training (ERT) across emotions and modalities to be effective for reducing problematic behaviors in children with high-callous unemotional traits.

Trials of MBT have shown it to be effective for BPD. These trials have included patients with ASPD. In a trial comparing MBT with structured clinical management (SCM) for patients with BPD, a subanalysis of the data showed that MBT was more effective than SCM in patients with ASPD (Unpublished [2012] study of Bateman, A and Fonagy, P). While the effectiveness of both treatments was attenuated in people with ASPD, this suggests that people with ASPD may benefit from a more focused program on their mentalizing problems. This study also suggested that MBT was superior to SCM in patients with comorbid axis II personality disorder. If MBT is more beneficial for patients whose BPD is embedded in other personality problems, how can we explain the paradox that treatment specifically designed for BPD may be beneficial for those with additional problems beyond the target of the therapy and, if so, could it be adapted appropriately for patients with different mentalizing problems such as those outlined for ASPD. We have limited data to answer this question. We may hypothesize that first, while MBT was designed for BPD, it may have broader scope. Mentalizing is a key component of self-identity and a central aspect of interpersonal relationships and social function. Thus, improvements in mentalizing may have an impact on a range of disordered mental processes whatever the source of pathology. If PD is conceptualized as a serious impairment in interpersonal relationships, intimacy, identity, and self-direction (50), enhancing mentalizing might benefit PD as a whole, regardless of subtype.

MBT integrates cognitive and relational components of therapy and has a theoretical basis in attachment theory. MBT was developed for people with borderline personality disorder and therefore focused on mentalizing problems associated with high emotional arousal in the context of attachment relationships. Adaptation of this basic model is necessary for people with ASPD not only because their mentalizing problems differ from those found in BPD but also for a number of other descriptive reasons. First, people with ASPD are more likely to demonstrate over-control of their emotional states within well-structured, schematic attachment relationships rather than under-control in chaotic attachment relationships, which are more commonly found in people with BPD. Second, people with ASPD tend to seek relationships that are organized hierarchically, with each person knowing his or her place, whereas people with BPD tend to struggle to reach consensus and shared respect. Third, it is specifically threats to the hierarchical order of relationships that lead to arousal within the attachment system in people with ASPD; this triggers an inhibition of mentalizing that in turn leads to fears of inability to control internal states. It has been suggested that the internal state most feared by people with ASPD are threats to self-esteem (51). Patients with ASPD inflate their self-esteem by demanding respect from others, controlling the people around them, creating an atmosphere of fear. This maintains pride, prestige, and status. Loss of status is devastating as it potentially reveals shameful internal states that threaten to overwhelm, so any threat of loss of status becomes firmly rooted as a dangerous reality that has to be dealt with by physical force. Momentary inability to mentalize, to see behind the threats to what is in the mind of the person apparently threatening them, means they have no way of keeping out a rapidly lowering self-esteem and loss of position. Emotional capacities such as guilt and love toward others and fear for the self may protect from engaging in violent behavior but the loss of mentalizing and the embryonic ability of these patients to experience such feelings prevent mobilization of these inhibitory mechanisms. Fourth, if the reduction in ability to recognize others’ emotions is more pervasive than being restricted to fear and sadness, then a focus in treatment on recognition of all emotions in others is essential. Finally fear for the self is often absent and violent impulses are uninfluenced by the emotional expressions of others, which go unrecognized. Indeed the consequences and dangers of aggression become secondary.

MBT for ASPD is based on a mentalizing understanding of the psychological problems of people with ASPD. The clinical interventions follow from this theoretical framework. Whether it will be effective in helping a neglected group of patients remains to be seen and it is currently the subject of a randomized controlled trial.