Antisocial personality disorder

Background

• A pervasive pattern of disregard for and violation of the rights of others

Clinical Features

• Three (or more) of the following criteria, occurring since age 15 years:
  • Failure to conform to social norms with respect to lawful behaviors, as indicated by repeatedly performing acts that are grounds for arrest.
  • Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure.
  • Impulsivity 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.
  • Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another.
• The individual is at least age 18 years
• There is evidence of conduct disorder with onset before age 15 years
• The occurrence of antisocial behavior is not exclusively during the course of schizo­phrenia or bipolar disorder

Differential Diagnosis

• Substance use disorders
• Schizophrenia and bipolar disorder
• Other personality disorders and personality traits
• Criminal behavior not associated with a personality disorder

Evaluation

• A clinical diagnosis; however if entertaining other organic causes may initiate workup below

General ED Psychiatric Workup

• Point-of-care glucose
• CBC
• Chem 7
• LFTs
• ECG (for toxicology evaluation)
• ASA level
• Tylenol level
• Urine toxicology screen/Blood toxicology screen
• EtOH
• Urine pregnancy/beta-hCG (if female of childbearing age)
• Consider:
  • Ammonia (see Hepatic encephalopathy)
  • TSH (hypo or hyperthyroidism may mimic mental illness)
  • CXR (for Tb screen or rule-out delirium in older patient)
  • UA (for rule-out delirium in older patients)
  • Head CT (to rule-out ICH in patients with AMS)
  • Lumbar puncture (to rule-out meningitis or encephalitis)

Management

• Set clear boundaries and expectations
• Referral for outpatient psychiatric treatment, although difficult to treat with psychotherapy. Antipsychotics, antidepressants and mood stabilizers can be used to control symptoms such as aggression and impulsivity

Disposition

• Discharge

See Also

• Personality disorders