This chapter focuses on brain and behavioural correlates of psychopathy and antisocial personality that inform us about their motivational and emotional underpinnings. Findings related to the three components of the triarchic psychopathy model – boldness, meanness and disinhibition – are reviewed. An important distinction is drawn between ‘primary’ and ‘secondary’ variants of psychopathy, which should not be viewed as a unitary construct.

The nosological background is outlined, with particular reference to the fifth edition of the American Psychological Association's Diagnostic and Statistical Manual and the International Classification of Disease's eleventh iteration. Categorical diagnoses of antisocial personality disorder are critiqued. The question of what motivates people to engage with others, and how this may be lacking in antisocial individuals, is addressed. It is emphasised that to understand what people are like and why they behave the way they do, we need to look at both traits and values – the latter being goals that people find desirable and use as guides for their behaviour across different situations. The importance of motivation for an understanding of personality pathology is outlined in the context of a schema that re-describes PD in terms of an ‘approach vs withdrawal’ dimension that is fundamental to human motivation. Finally, the question ‘How does personality become pathological?’ is raised.

This chapter considers treatment of those with ASPD from the perspective of (1) higher levels of integration of the personality than in previous chapter and (2) managing clients at the more severe end of the ASPD spectrum (i.e., those with violent behaviour detained within secure settings). In respect of item (1) we make specific reference to and describe the phases of exploration and integration in Livesley’s Integrated Modular Treatment. As this requires an emotional maturation in the client (as compared with the establishment of emotional stability in Chapter 6), extra demands are placed on both client and therapist. In the latter case, the ‘fit’ between therapist and therapy is explored. As regards managing those with violent behaviour (including those with psychopathic traits), the principles of the two major criminological interventions (i.e., risk-needs-responsivity [RNR] and the Good Lives Model [GLM]) are compared and contrasted. There is a discussion on those who may be beyond treatment and where interventions can actually lead to harm. Finally, the differences between a forensic case formulation and a case formulation are discussed, with the former focusing on the risk that the individual may pose.

This chapter reviews what is known about the developmental antecedents of adult antisocial personality. It addresses the question of why it is that, while many people may have personality difficulties, a minority develop a severe and persistent dysfunction of personality that is more or less life-long, leading them into a pattern of chronic antisocial behaviour. Findings reviewed in this chapter suggest that the route to adult antisociality is marked by a cascade of developmental roadblocks and insults arising during childhood and adolescence. The authors emphasise the importance of adolescence as a period when things can go seriously awry and personality can deviate from a normal track. They further emphasise the critical importance of substance abuse, particularly the misuse of alcohol, in the genesis of life-course-persistent antisociality. Two possible developmental pathways are described, one predominantly male, the other predominantly female, through which adult antisociality results from adverse circumstances in childhood and adolescence.

Using recently published general population studies, this chapter updates an earlier Moran review on the epidemiology of ASPD. It examines the prevalence, comorbidity, psychosocial functioning, impact on health services and cultural differences of those with ASPD and, to a lesser extent, of those with psychopathy and on prisoners. It finds that the prevalence of ASPD ranges between 0.6% and 4.3% in men (which is significantly higher than in women). It has multiple comorbidities – both with other mental disorders (especially with substance misuse and affective disorder) together with other Cluster B PDs. Despite significant mental health and psychosocial impairment, those with ASPD rarely seek treatment for their disorder. There are marked cultural differences in the prevalence of ASPD with studies in the United States showing significantly higher rates than in Europe or in Asia. The prevalence of ASPD among prisoners is c. 55% among men and 31% among women with community prevalence rates for psychopathy ranging from 0.6% in the United Kingdom and 1.0% in the United States. Both ASPD and psychopathy have a positive association with both increased mortality and suicidality, suggesting that, together with their other impairments, they are a group that require mental health interventions.

Starting with a discussion of antisocial personality disorder as a diagnostic construct, this chapter argues that models of mental disorders should focus on symptoms (and individual traits) rather than on flawed diagnostic syndromes. It is argued that interpersonal antagonism, callousness and hostility lie at the core of antisocial personality, which is broader than the constructs – ASPD and psychopathy – with which it is traditionally associated. Paranoia and boredom proneness are considered as key elements of antisocial personality. Assessment of antisocial individuals should consider the three aspects of self: self as social actor, self as motivated agent, and self as autobiographical author, as well as their location on the prosocial-antisocial continuum. Arising from the assessment, a case formulation should seek to articulate the central mechanisms that cause and maintain the individual's main problems and to explain how they are related. When an individual shows violent behaviour it is important that the case formulation identifies the type of violence that is shown and the functions it serves. Consistent with the Good Lives Model (GLM), it is important that positive aspects are included in a strength-based case formulation, covering areas such as work, relationships, accommodation, health and leisure activities.

This chapter examines the evidence of efficacy in the pharmacological and psychological treatment of those with ASPD in good-quality trials for those with ASPD and finds that such evidence is lacking. Given the range of impairments in those with ASPD cited in the previous chapter, here we propose a pragmatic approach that relies on the non-specific effects of psychotherapy, together with the judicious use of medication as required. The former focuses on (1) engagement through an explanation of the disorder, (2) the creation of expectations and (3) identifying relevant treatment options. Judicious use of medication, when necessary, is also recommended. This process is organised by a case conceptualisation of the individual which seeks to integrate the nomothetic (i.e., general principles) with the idiographic (i.e., individual) aspects of the case. For those with ASPD, particular attention needs to be paid to managing therapeutic ruptures as the impulsive and paranoid traits in those with ASPD are likely to lead to premature termination. We believe that these principles offer the practitioner not only a sensible and defensible procedure, but one which is within the ambit of most community mental health teams so it has wide applicability.

This introduces some major concerns and themes covered in the book. It is suggested assessment of antisocial personality should combine a nomothetic (trait-based) approach with an idiographic (person-centred) approach. The latter aims to capture, first, the particular motives, values and goals that drive the individual’s antisocial behaviour, and second, the feeling of continuity, coherence and sense of agency expressed in the individual’s life story. The reader is warned against an uncritical acceptance of ASPD as a ‘disorder’.

This chapter reviews what is known about the interpersonal style of people with antisocial personality and psychopathy, concluding that antisocial individuals have a cold, vindictive and hostile interpersonal style and that they lack the motivation to engage in an empathic way with others. The triarchic view of human selfhood– the self as social actor, as motivated agent and as autobiographical author – is introduced as a framework within which the antisocial individual might be understood from a first-person perspective. So-called dark traits are considered, particularly their role in sexual offending and sexual sadism. It is suggested the ‘dark traits’ construct might be expanded to include paranoia, moral disengagement, spitefulness and greed. The concept of ‘emotion goals’ is introduced and considered in relation to a quadripartite typology of violence that sees violence as reflecting appetitive versus aversive motivation interacting with an impulsive versus controlled dimension.

Here, we explore the thorny issue of the involuntary detention of those with ASPD (and those with psychopathic traits) for treatment. We use, as a frame, the recent history in the United Kingdom of attitudes using the changes in the legal designation of ‘psychopathic disorder’ whereby such individuals might be so detained. As there is undeniable evidence that those with the legal designation of psychopathic disorder are at higher risk of re-offending after discharge, psychiatrists were reluctant to admit them for treatment. This filtered down to the community so that those with a PD label were denied treatment. Faced with this dilemma, the government introduced the DSPD programme, whose rationale was underpinned by a defensible notion of both risk and treatability. We believe that, given the wide margin of error associated with both risk estimation and the efficacy of treatment (especially if the latter is imposed rather than consented to), this was unlikely to have a good outcome, and so it proved. We propose an alternative whereby sentencing and treatment of those with PD if convicted are uncoupled, thereby preserving a cordon sanitaire between the custodial and therapeutic realms.