Antisocial Personality Disorder (ASPD) is part of the Cluster B disorders described in the DSM-V. The other three in this Cluster are Borderline Personality Disorder (BPD), Histrionic Personality Disorder (HPD), and Narcissistic Personality Disorder (NPD). These four conditions all share similar causes: catastrophic childhood adversity coupled with inherited genetic vulnerabilities. In other words, they are forms of acute generational trauma that produce neurodevelopmental disorders.
This is (comparatively) great news for up to 3% of the general population who have been diagnosed with ASPD because it exonerates them from what the medical field used to think: that people with ASPD were basically just bad people.
To be fair, people with ASPD are diagnosed for engaging in specific antisocial (1) behaviors that remain fairly consistent across a lifetime. They tend to lack respect for the agency and rights of other people, act exclusively for their own interests, engage in deceptive narratives in order to manipulate others, and disregard legal and social rules. This leads to patterns of behavior that easily fall into lifelong criminality: some studies suggest that up to 70% of incarcerated persons are squarely on the ASPD spectrum, and the recidivism rate (going back to prison more than once) is much higher than non-ASPD folks. Many older studies took an interest in ASPD only because of the negative impact of antisocial folks being less likely to work steady jobs or have committed relationships and families, and being far more likely to end up in prison for extended periods of time. Violent crime especially was considered a hallmark of ASPD.
However, far more people with ASPD do not engage in violent or criminal behavior. They still have enormous issues building long-term intimate relationships, and they do not experience typical emotions in the way their non-ASPD counterparts do, but they are not inherently cruel or mean. They often work extra hard to mask and emulate the feelings they see in other people because they themselves just don’t experience the world in the same way, but all that masking and calculating makes for extra stress.
Any time you are not allowed to be and/or are not accepted for being your authentic self, it always creates mental and emotional strain, leading to additional conditions like depression, anxiety, and explosive anger.
Squishy Brain Talk
Neurocognitive development begins even before birth, and it is influenced by a huge range of variables. When someone is born into a situation where the parental figures don’t have or aren’t allowed connection with their child, that directly affects the way the child’s brain develops by reducing the amount of oxytocin produced. Oxytocin is the neurotransmitter responsible for bonding and feeling connections with others, so a reduction in bonding behavior at an early stage decreases the amount of “empathy juice” that the brain is able to make. The epigenetic element of ASPD often starts with one or more parents not having enough “empathy juice” themselves, often because they were subjected to the same lack of bonding as children.
But then, Something Terrible happens. Usually before the age of five, but sometimes it happens as late as ten, the child goes through a specific and traumatic event or series of events.
The brain deals with intense events by activating the amygdala, the structure responsible for fear and threat recognition. When the amygdala responds to a threat, it signals other areas of the brain to get ready for a fight (or a flight or a freeze) and it sends a message to the hippocampus specifically to record the emotions of the event. The more intense the event, the higher priority the hippocampus assigns to it. When a sufficiently intense trauma happens, the brain records that experience as The Most Important Thing Ever, and everything that happens after that is informed by that trauma. When multiple traumas happen, as is often the case with people diagnosed with ASPD, all of those different Most Important Things collide or collude to create a massive neurological mess: In people with ASPD, medical research has shown that there are multiple neurological differences including reduced volume of the amygdala and hippocampus, dysfunction in the frontal cortex, and a whole slew of neurotransmitter imbalances.
Emotionally, the brain is trying to make rational survival-based decisions about how the world works - because, remember, all of these things are happening in early to mid-childhood when the brain is growing cognitive structures fastest. If Survival Logic decides that bonding with people (especially the people that are supposed to provide the most love and protection) is dangerous, then making those bonding chemicals - oxytocin - is deprioritized. Other neurotransmitters - endorphins to moderate pain response, dopamine to activate physical reactions like running, and norepinephrine to pay attention and stay hypervigilant for further threats - are pumped up and produced in greater quantities. The child-self doesn’t know the difference between a want and a need, so that Survival Logic determines additionally that satisfying any want or need must be done at any cost - even lying, stealing, or manipulating.
Because the child-self doesn’t know any better, and the neurological damage being done at that stage makes this Survival Logic decision the Absolute Most Important Thing In The History Of Ever. And once it’s etched permanently in the brain at a formative moment, it’s a heck of a challenge to undo it.
Undoing It
The greatest challenge for anyone living a non-normative existence is that we don’t know that our experience is non-normative. How could we? We only know the world the way we see it.
For people with ASPD, realizing that their experience is non-normative and in what ways usually comes one of two ways. Either someone who cares for them deeply makes them realize that their behaviors are hurting other people, or else the law gets involved and mandates psychiatric evaluation and therapy. The not-great news is that psychiatrists aren’t terribly helpful: there are no medications currently designed for addressing ASPD. There are numerous concurrent conditions that can be treated with medication (depression or anxiety), but these have to be approached cautiously. Most of the time, these extra conditions develop because of the ASPD, not because of a chemical imbalance in the brain. The brain has grown up to work like this, so it doesn’t believe there’s an “imbalance” to be corrected.
The much-better news is that there are multiple types of talk and cognitive therapies that can help a lot. Mentalization-Based Treatment helps people with ASPD become more aware of how their actions and words affect other people, to connect with the Now moment and see consequences more clearly. Metacognitive therapies take a similar approach, exploring the state of the mind in a given moment, engaging in conscious questioning and exploration to choose action and words consciously. Ultimately, any therapy must also include radical acceptance and trauma-informed approaches.
Radical acceptance (2) is the philosophy that you are who you are, and that you can acknowledge what that is without judgment or deciding that parts of you are “good” or “bad”. When we accept ourselves without judgment, we can decide if what we see there helps us (prosocial, friendly, helpful, intimate) or hurts us (antisocial, mean, selfish, isolating).
In the end, it’s up to the person with ASPD to choose how and what they want to change, and why. If the only reason they look for help is to be able to keep an intimate partner or stay out of trouble, there’s nothing wrong with that. Their brain might not let them feel the things other people feel in the same way, but they still have feelings and needs and desires, and those are all valid.
Footnotes
Antisocial is the opposite of prosocial, a word that describes doing things for the greater good of society as a whole. Antisocial behavior is broadly defined as being self-serving and selfish without regard for others.
Radical acceptance is not the same thing as “radical approval”. When you’ve done something wrong or hurt someone, that’s something that you need to acknowledge and work to correct.