Antisocial Personality Disorder And Addiction: Challenges And Treatment Strategies

Antisocial personality disorder (ASPD) is a mental health condition typically impacting how a person acts in society and toward other people. People with antisocial personality disorder often display a lack of empathy or remorse toward others and may experience frequent run-ins with the law. Those with ASPD may struggle to maintain meaningful long-term interpersonal relationships. While most individuals with this disorder may not be inclined to seek professional support, a combination of therapy, lifestyle adjustments, and medication may reduce symptoms.

Individuals with ASPD may also experience a higher rate of substance use disorders, which may include the misuse of legal substances, illegal substances, or alcohol. It can be important to note that the terms “substance abuse,” “alcohol abuse,” and “drug abuse” are no longer recognized in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V), and all of these are typically referred to as “substance use disorder.” Treating a personality disorder in combination with substance use disorder or addiction often requires comprehensive support from licensed mental health professionals with experience in both areas.

Experiencing ASPD and substance use disorder?

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Defining antisocial personality disorder

Antisocial personality disorder is one of 10 identified personality disorders in the DSM-V. According to the American Psychiatric Association, ASPD can be seen as an often misunderstood and underdiagnosed disorder in which an individual may act without empathy or regard for others or the rules of society. 

The diagnostic criteria for ASPD include the following: 

• Disregard for social norms or laws: A person living with ASPD may not believe that laws or rules apply to them, and they may have frequent arrests or run-ins with the legal system.
• Consistent lying: An individual with ASPD may frequently engage in deceit, lies, or manipulation for personal gain.
• Impulsivity: A failure to plan ahead or think about the consequences of their actions can be a characteristic of ASPD. A person with ASPD may make spontaneous decisions without concern for the future. 
• Aggressive behavior: Irritability and aggressive behavior may lead to physical or verbal altercations or assaults. 
• Disregard for safety: A person with ASPD may act with reckless regard for their own safety and that of others.
• Irresponsible behavior: A person with ASPD may struggle to honor promises and fulfill obligations, both at work and at home. 
• Lack of remorse: ASPD usually involves a lack of empathy or remorse, which can mean that a person with this disorder usually does not feel bad for hurting others physically or emotionally. 

In general, to be diagnosed with ASPD, a person must present at least three of the characteristics listed above, and they also must have experienced symptoms of conduct disorder, a precursor to ASPD, before age 15. 

It can be crucial to note that ASPD exists on a spectrum, and that some may experience symptoms more frequently or intensely than others. ASPD may also co-occur with many other mental health conditions, but it appears to be particularly linked to mood disorders and substance use disorders. 

The link between ASPD and addiction

In both ASPD and SUD, individuals may experience a higher rate of impulsivity and risk-taking behavior. For individuals living with SUD, this may be particularly true while using substances or alcohol, as they can lower inhibitions and impact decision-making. 

In the scientific community, it is commonly believed that the disregard for safety and self-medication for additional stress associated with ASPD may be two reasons for the increase in the misuse of substances and alcohol. There may also be a genetic link between the two disorders, and the genes involved in reward sensitivity and decision-making may impact both ASPD and SUD. 

Challenges in treating co-occurring ASPD and addiction

Managing and treating comorbid ASPD and substance use can be challenging. In many cases, it takes a team of mental health professionals with expertise in both ASPD and addiction treatment. For therapists, it can be challenging to build rapport and develop trust with these individuals due to the nature of both disorders. Those with substance use disorder may not consistently attend sessions, and non-attendance may be further exacerbated in people living with ASPD. 

In addition to challenges around rapport and attending sessions, individuals living with both ASPD and addiction may display resistance toward authority figures. The increased rate of criminal behavior often associated with untreated SUD and ASPD may lead individuals to be wary of trusting someone in a perceived position of power, such as a doctor or a therapist. This can lead to them refusing treatment or frequently starting and stopping therapy sessions. 

An effective therapy model may require honesty from both the client and the therapist. Individuals with ASPD may engage in manipulation or deceit, such as lying about their symptoms or behavior, which can make it difficult to move forward during therapy. Although it can be challenging to treat comorbid ASPD and SUD, licensed therapists may be able to use evidence-based strategies to address both disorders.

Treatment strategies

Due to the nature of both substance use disorder and antisocial personality disorder, several treatment approaches may be required to reduce symptoms and improve quality of life. These strategies may include a combination of medication, lifestyle changes, and therapy. 

Integrated treatment approach

Substance use disorder and ASPD symptoms may be closely linked and are often treated simultaneously. Using an integrated treatment approach, a team of professionals, which may include medical doctors, therapists, and social workers, can provide multiple treatments, such as therapy techniques and medication, to manage symptoms. It can be crucial for individuals to consult their prescribing providers before starting, stopping, or changing the way they take medication.

Pharmacotherapy

Pharmacotherapy is an approach that uses medication to manage symptoms. While pharmacotherapy is not typically used for managing personality disorders like ASPD, it can be effective at reducing symptoms of addiction. Substance use disorder may involve a physical dependence on alcohol or other substances, and prescribed pharmaceuticals can reduce the physical cravings associated with substance use. Reducing the physical dependence on a substance can increase the effectiveness of other therapeutic techniques. 

While taking medication for substance use disorder, it can be important to have open and honest communication with the doctor regarding symptoms and side effects. A doctor may monitor an individual’s progress over time and adjust the dosage as needed to better suit an individual’s needs. It may be important to note that a therapist cannot prescribe medication, and they may work with a medical doctor or psychiatrist to develop a pharmacotherapy plan.  

Motivational interviewing

Motivational interviewing is a therapeutic technique generally designed to motivate individuals who may otherwise display ambivalence toward treatment. The motivational interviewing process may begin with a therapist building rapport with a patient before shifting to the patient verbalizing their resistance to change. With ASPD and SUD, motivational interviews may be given during the early stages, and they may improve attendance and buy-in during other interventions.

Peer support and group therapy

Group therapy and peer support options can be effective tools for treating substance use disorder. Individuals living with comorbid ASPD and SUD may also find peer support and group therapy effective. Being in a group can build a sense of belonging and may help a person living with addiction sense they are supported. A group dynamic can also provide strategies and support systems for others who are experiencing the same concerns. 

For individuals experiencing both SUD and ASPD, it may be important to set up sessions with a licensed therapist who understands personality disorders. The symptoms of ASPD may make it challenging to authentically work with a group due to deceitful behavior and a lack of empathy. However, a therapist can help individuals effectively navigate these challenges.

Behavioral therapies

Various therapy options may be beneficial for individuals living with ASPD and SUD, including cognitive behavioral therapy (CBT) and dialectical behavior therapy (DBT). Both CBT and DBT strategies can help a person identify negative thought patterns and replace them with more productive ones, positively impacting their emotions and behavior.

Experiencing ASPD and substance use disorder?

Receive support in online therapy

Living with ASPD and SUD can make it challenging to attend regular, in-person therapy sessions. Online therapy sessions can be attended from anywhere with a device and internet connection, which may make it easier for individuals to consistently attend sessions. With online therapy options, people can search outside of their local areas to find therapists who fit their personal needs and goals.

For individuals with ASPD and SUD, online therapy can be an effective way to manage comorbid disorders. In an online setting, a therapist may provide CBT or DBT while also looking at a patient's complete mental health picture. A therapist may provide support for making lifestyle changes and managing these comorbid disorders over the long term.