Attachment, mentalization and antisocial personality disorder: The possible contribution of mentalization-based treatment

Impact of congenital heart disease on personality disorders in adulthood

AIMS

Adults with congenital heart disease (ACHD) constitute an ever-growing patient population characterized by high risks for cardiovascular- and mental disorders. Personality disorders (PDs) are associated with adverse physical and mental health. Studies assessing PD prevalence in ACHD are lacking.

METHODS AND RESULTS

Personality disorder point prevalence was assessed in 210 ACHD by Structured Clinical Interview for Axis-II Personality Disorders (SCID-II) and compared to meta-analytical data from the general population (GP). Depression and anxiety were measured by self-report (Hospital Anxiety and Depression Scale, HADS) and clinician rating (Montgomery-Åsberg depression rating scale, MADRS). Childhood maltreatment was assessed with the Childhood Trauma Questionnaire and quality-of-life (QOL) with the World Health Organization QOL Scale. PD prevalence was markedly higher in ACHD compared to GP (28.1 vs. 7.7%). Particularly borderline (4.8 vs. 0.9%) and cluster C (i.e. anxious or fearful; 17.1 vs. 3.0%) PDs were overrepresented. PD diagnosis was associated with a surgery age ≤12 years (χ²(1) = 7.861, ϕ = 0.195, P = 0.005) and higher childhood trauma levels (U = 2583.5, Z = -3.585, P < 0.001). ACHD with PD reported higher anxiety (HADS-A: U = 2116.0, Z = -5.723, P < 0.001) and depression (HADS-D: U = 2254.5, Z = -5.392, P < 0.001; MADRS: U = 2645.0, Z = -4.554, P < 0.001) levels and lower QOL (U = 2538.5, Z = -4.723, P < 0.001).

CONCLUSION

Personality disorders, particularly borderline- and cluster C, are significantly more frequent in ACHD compared to GP and associated with depression, anxiety, and decreased QOL. Data from the GP suggest an association with adverse cardiometabolic and mental health. To ensure guideline-based treatment, clinicians should be aware of the increased PD risk in ACHD.

Mentalization based treatment for a broad range of personality disorders: a naturalistic study

BACKGROUND

Several studies have observed that mentalization-based treatment (MBT) is an effective treatment for borderline personality disorder (BPD), but its effectiveness for other personality disorders (PDs) has hardly been examined. Additionally, the evidence supporting the claim that MBT improves mentalizing capacity is scarce. The present study examined whether (i) patients with a broad range of PDs enrolled in an MBT program would improve on several outcome measures (ii) mentalizing capacity would improve over time; (iii) patients with BPD would improve more than those with non-borderline PDs.

METHOD

Personality disorders, psychiatric symptoms, social functioning, maladaptive personality functioning and mentalizing capacity were measured in a group of individuals with various PDs (n = 46) that received MBT. Assessments were made at baseline and after 6, 12, and 18 months of treatment. The severity of psychiatric symptoms, measured using the Outcome Questionnaire 45, was the primary outcome variable.

RESULTS

Overall, enrollment in the MBT program was associated with a decrease in psychiatric symptoms and an improvement of personality functioning, social functioning for a mixed group of PDs (all p's ≤ .01). Bigger effect sizes were observed for BPD patients (n = 25) than for patients with non-BPD (n = 21), but the difference failed to reach statistical significance (p = 0.06). A primary analysis showed that the decrease in psychiatric symptoms was significant in BPD patients (p = 0.01), not in non-BPD (p = 0.19) patients. However, a sufficiently powered secondary analysis with imputed data showed that non-BPD patients reported a significant decrease in psychiatric symptoms too (p = 0.01). Mentalizing capacity of the whole group improved over time (d = .68 on the Toronto Alexithymia Scale and 1.46 on the Social Cognition and Object Relations System).

DISCUSSION

These results suggest that MBT coincides with symptomatic and functional improvement across a broad range of PDs and shows that MBT is associated with improvements in mentalizing capacity. As the study is not experimental in design, we cannot make causal claims.

CONCLUSION

Mentalization-based treatment may be an effective treatment for patients with a broad range of PDs.

TRIAL REGISTRATION

The study design was approved by the Leiden University Ethical Committee.

Theory of Mind: A Brief Review of Candidate Genes

Deficits in theory of mind (ToM), known as the ability to understand the other's mind, have been associated with several psychopathological outcomes. The present systematic review aims to summarize the results of genetic studies that investigated gene polymorphisms associated with mentalization performance tasks in children and adults. The systematic review was carried out following PRISMA guidelines, and the literature search was conducted in PubMed and EBSCOhost using the following keywords: 'theory of mind, mentalizing, mindreading' and 'gene, genetic basis'. Nineteen studies met the eligibility criteria for inclusion. Most of the literature focused on the role of DRD4, DAT1, OXTR, OXT, COMT, ZNF804A, AVP, AVPR, SCL6A4, EFHC2, MAO-A, and the family of GTF2I genes in influencing ToM. However, controversial results emerged in sustaining the link between specific genetic polymorphisms and mentalization abilities in children and adults. Available data show heterogeneous outcomes, with studies reporting an association between the same family genes in subjects of the same age and other studies reporting no correlation. This does not allow us to draw any solid conclusions but paves the way for exploring genes involved in ToM tasks.

Antisocial personality disorder and therapeutic pessimism - how can mentalization-based treatment contribute to an increased therapeutic optimism among health professionals?

Antisocial personality disorder (ASPD) is associated with therapeutic pessimism among health professionals. Several variables are associated with obstacles in therapist's willingness to treat ASPD. Variables that are relevant are (i) confusion associated with the term ASPD, (ii) characteristics of the disorder, (iii) attitudes, experiences, and knowledge clinicians possess, and (iv) insufficient management of countertransference. We assume that therapeutic pessimism is related to the lack of evidence-based, effective treatment for individuals with ASPD. This is problematic because ASPD is associated with large socio-economic costs and considerable suffering for the individual and the society. Mentalization-based treatment (MBT) was developed in treating borderline personality disorder (BPD) and is now considered an effective treatment for this group. Mentalization is defined as the process by which individuals make sense of themselves and others in terms of subjective states and mental processes. This ability affects an individual's psychological functioning, mental health, self-organization, and interpersonal relationships. The overall goal of MBT is to strengthen the individual's mentalizing abilities and facilitate more adaptive handling of problematic, internal states. Recently, a version of MBT tailored for individuals with ASPD (MBT-ASPD) has been developed. The purpose of this review is to investigate how MBT-ASPD relates to the major obstacles that contribute to the therapeutic pessimism toward this group. Despite a limited evidence base, preliminary studies indicate promising results for MBT-ASPD. More research is still required, this review suggests MBT-ASPD can contribute to increased therapeutic optimism and demonstrate specific characteristics of MBT-ASPD that contribute to management of therapeutic pessimism.

Establishing an optimal working relationship with patients with an antisocial personality disorder. Aspects and processes in the therapeutic alliance

OBJECTIVE

Developing good interpersonal relationships is one of the main impediments for people with an antisocial personality disorder (ASPD). However, in treatment of psychiatric disorders, establishing a strong therapeutic alliance (TA) is important for effective treatment. Nevertheless, there is little knowledge on how to establish this TA with this challenging patient group. This study investigates which factors are important in TA development.

METHOD

For this study, a qualitative research methodology is applied. In-depth interviews with therapists experienced in treating ASPD were conducted and analysed through thematic analysis.

RESULTS

The analysis revealed six themes important in alliance formation: the patient's needs, regulating interpersonal dynamics, connective attitude, connective skills, treatment process and treatment goals. Each theme is defined including aspects of the recommended therapeutic attitude and required skills for therapists working with patients with ASPD.

CONCLUSIONS

This study determined that, for therapists working with patients with ASPD, several key factors are essential in establishing a strong TA. These factors include the ability to be firm, authentic, non-judgmental and genuinely involved. An attentive presence is crucial, in which the therapist takes initiative in establishing contact and makes the patient feel that he is truly seen as an autonomous and equal person. In doing so, the therapist needs to provide clarity and structure while remaining perceptive to boundary violations. The therapist must be able to set limits using a clear yet kind tone of voice. Furthermore, it was notable that an intensive appeal is made to the therapist's reflective capacity in these treatments.

Acceptability and feasibility of using avatar-based virtual world software as an adjunct to clinical interventions, training, and reflective practice in a medium secure setting: A qualitative interview study

BACKGROUND

Relationships are at the core of recovery, particularly in secure services where patients have usually had difficulties with authority figures and can have mentalisation deficits. Early indications are that avatar-based virtual world software may help facilitate communication and emotional expression.

AIMS

To establish the feasibility of using avatar-based virtual world software in a medium secure hospital, adjunctive to standard staff-patient interactions during clinical interventions and staff activities including reflective practice and training; to explore patient, staff participant and facilitator experiences using it.

METHODS

Use of the software was offered across an 89-bedded unit as an optional adjunct to clinical interventions, reflective practice and training sessions. Qualitative data were collected using semi-structured interviews and analysed using thematic analysis. Volunteer sampling was used. Five patients volunteered and were matched with an equal number of staff facilitators and participants.

RESULTS

Eighty four sessions were completed using the avatar software with between 1 and 11 participant(s) per session, totalling 347 participant sessions. No adverse events occurred relatable to the sessions. An overarching theme of 'adding value' emerged, encompassing subthemes such as 'concrete visual presence and imagery', 'mentalisation processes' and 'enhanced focus, depth and problem solving'. Experiences of added value were affected by moderators which were 'power and relationship dynamics', the 'ability to use software', 'practical processes' and 'literacy'.

CONCLUSIONS

Avatar software is feasible to implement, acceptable to patients and staff and may offer an opportunity to aid mentalisation and reflection. By definition, everyone engaging in this study was a volunteer, even an enthusiast, so it would now be useful to extend evaluation to those who need some encouragement to use avatar software. Research to quantify benefits and establish the cost impact is now indicated, as our findings show it may offer a novel way of connecting with hard-to-reach patient groups.

Antisocial personality disorder in group therapy, kindling pro-sociality and mentalizing

Patients with antisocial personality disorder (ASPD) are known for being difficult to treat. Treatment for ASPD is debated and lacking evidence. Among several reasons for treatment difficulties concerning ASPD, negative countertransference in health personnel is one central topic. Mentalization based treatment (MBT) is a reasonable candidate treatment for ASPD. From an ongoing pilot-study on MBT with substance using ASPD patients, we explore therapist experiences. Four experienced MBT therapists together with the principal investigator performed a focus group together. The therapists were themselves involved in performing this study and analyses are made as an autoethnographic study, with thematic analyses as methodological approach. As this study involved a qualitative investigation of own practice, reflexivity of the processes was performed. The aim was to explore in depth: therapist experiences and therapist wellbeing in MBT-ASPD. We found four main themes on therapist experiences: i) gaining safety by getting to know them better; ii) gaining cooperation through clear boundaries and a non-judgmental stance; iii) shifting inner boundaries; and iv) timing interventions in a high-speed culture. These four themes point to different therapist experiences one can have in MBT-ASPD. Our findings resonate well with the clinical literature on ASPD, the findings imply that clinical teams should have a focus on therapist countertransference and burnout, ensure that therapists uphold boundaries and open-mindedness in treatment of ASPD and that therapists experience vitalizing feelings in this line of work.

Explaining the willingness of clinicians to work with patients with antisocial personality disorder using the theory of planned behaviour and emotional reactions

Many clinicians seem to experience negative emotions towards patients with antisocial personality disorder (ASPD), resulting in the exclusion of patients in many treatment programmes. The behaviour of individuals with ASPD has a significant impact on society, which affects ASPD patients and their environment, and therefore, the exclusion from programmes is a serious concern. Relatively, little is known about why some clinicians are willing to work with ASPD patients and others are not and what factors contribute to an increase in the motivation to do so. In this study, clinicians (n = 130) working in a regular and forensic mental health service in the Netherlands completed a questionnaire based on the theory of planned behaviour (TPB) and the Feeling Word Checklist and questions about the relevant experience gained and education received. The current study confirms the limited willingness to work with ASPD patients, especially in regular mental health care. Experience working with ASPD patients, education on cluster B personality disorders and having experienced verbal and/or physical violence in clinical practice did not fully explain whether or not clinicians were motivated to provide treatment to ASPD patients. TPB appeared to predict the intention to provide psychological therapy to ASPD patients adequately. The impact of positive emotions towards ASPD patients on providing treatment appeared to be stronger than negative emotions. This study provides more insight into why so few clinicians are willing to work with ASPD patients and what may increase motivation to include this group in treatment programmes.

How the Good Lives Model Can Complement Mentalization-Based Treatments for Individuals Who Have Offended With Anti-Social Personality Disorder and General Forensic Mental Health Needs: Practice Update

Limited research to date has focused on strengths-based rehabilitative approaches, such as the Good Lives Model (GLM) and the additive benefits such approaches have in ameliorating mental health needs of those in contact with forensic services. Mentalization-based therapies (MBTs) may be an effective treatment in forensic settings. This article aims to provide an overview of how GLM theory can integrate MBT within forensic settings. The review provides a conceptual overview of the many commonalities between GLM and MBT principles and provides information about how MBT can be embedded within forensic communities adhering to GLM principles. The article closes by offering an overview of the evidence of MBT approaches for individuals with anti-social personality disorder (ASPD) and those in contact with forensic services.

Psychological interventions for antisocial personality disorder

BACKGROUND

Antisocial personality disorder (AsPD) is associated with poor mental health, criminality, substance use and relationship difficulties. This review updates Gibbon 2010 (previous version of the review).

OBJECTIVES

To evaluate the potential benefits and adverse effects of psychological interventions for adults with AsPD.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, 13 other databases and two trials registers up to 5 September 2019. We also searched reference lists and contacted study authors to identify studies.

SELECTION CRITERIA

Randomised controlled trials of adults, where participants with an AsPD or dissocial personality disorder diagnosis comprised at least 75% of the sample randomly allocated to receive a psychological intervention, treatment-as-usual (TAU), waiting list or no treatment. The primary outcomes were aggression, reconviction, global state/functioning, social functioning and adverse events.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

This review includes 19 studies (eight new to this update), comparing a psychological intervention against TAU (also called 'standard Maintenance'(SM) in some studies). Eight of the 18 psychological interventions reported data on our primary outcomes. Four studies focussed exclusively on participants with AsPD, and 15 on subgroups of participants with AsPD. Data were available from only 10 studies involving 605 participants. Eight studies were conducted in the UK and North America, and one each in Iran, Denmark and the Netherlands. Study duration ranged from 4 to 156 weeks (median = 26 weeks). Most participants (75%) were male; the mean age was 35.5 years. Eleven studies (58%) were funded by research councils. Risk of bias was high for 13% of criteria, unclear for 54% and low for 33%. Cognitive behaviour therapy (CBT) + TAU versus TAU One study (52 participants) found no evidence of a difference between CBT + TAU and TAU for physical aggression (odds ratio (OR) 0.92, 95% CI 0.28 to 3.07; low-certainty evidence) for outpatients at 12 months post-intervention. One study (39 participants) found no evidence of a difference between CBT + TAU and TAU for social functioning (mean difference (MD) -1.60 points, 95% CI -5.21 to 2.01; very low-certainty evidence), measured by the Social Functioning Questionnaire (SFQ; range = 0-24), for outpatients at 12 months post-intervention. Impulsive lifestyle counselling (ILC) + TAU versus TAU One study (118 participants) found no evidence of a difference between ILC + TAU and TAU for trait aggression (assessed with Buss-Perry Aggression Questionnaire-Short Form) for outpatients at nine months (MD 0.07, CI -0.35 to 0.49; very low-certainty evidence). One study (142 participants) found no evidence of a difference between ILC + TAU and TAU alone for the adverse event of death (OR 0.40, 95% CI 0.04 to 4.54; very low-certainty evidence) or incarceration (OR 0.70, 95% CI 0.27 to 1.86; very low-certainty evidence) for outpatients between three and nine months follow-up. Contingency management (CM) + SM versus SM One study (83 participants) found evidence that, compared to SM alone, CM + SM may improve social functioning measured by family/social scores on the Addiction Severity Index (ASI; range = 0 (no problems) to 1 (severe problems); MD -0.08, 95% CI -0.14 to -0.02; low-certainty evidence) for outpatients at six months. 'Driving whilst intoxicated' programme (DWI) + incarceration versus incarceration One study (52 participants) found no evidence of a difference between DWI + incarceration and incarceration alone on reconviction rates (hazard ratio 0.56, CI -0.19 to 1.31; very low-certainty evidence) for prisoner participants at 24 months. Schema therapy (ST) versus TAU One study (30 participants in a secure psychiatric hospital, 87% had AsPD diagnosis) found no evidence of a difference between ST and TAU for the number of participants who were reconvicted (OR 2.81, 95% CI 0.11 to 74.56, P = 0.54) at three years. The same study found that ST may be more likely to improve social functioning (assessed by the mean number of days until patients gain unsupervised leave (MD -137.33, 95% CI -271.31 to -3.35) compared to TAU, and no evidence of a difference between the groups for overall adverse events, classified as the number of people experiencing a global negative outcome over a three-year period (OR 0.42, 95% CI 0.08 to 2.19). The certainty of the evidence for all outcomes was very low. Social problem-solving (SPS) + psychoeducation (PE) versus TAU One study (17 participants) found no evidence of a difference between SPS + PE and TAU for participants' level of social functioning (MD -1.60 points, 95% CI -5.43 to 2.23; very low-certainty evidence) assessed with the SFQ at six months post-intervention. Dialectical behaviour therapy versus TAU One study (skewed data, 14 participants) provided very low-certainty, narrative evidence that DBT may reduce the number of self-harm days for outpatients at two months post-intervention compared to TAU. Psychosocial risk management (PSRM; 'Resettle') versus TAU One study (skewed data, 35 participants) found no evidence of a difference between PSRM and TAU for a number of officially recorded offences at one year after release from prison. It also found no evidence of difference between the PSRM and TAU for the adverse event of death during the study period (OR 0.89, 95% CI 0.05 to 14.83, P = 0.94, 72 participants (90% had AsPD), 1 study, very low-certainty evidence).

AUTHORS' CONCLUSIONS

There is very limited evidence available on psychological interventions for adults with AsPD. Few interventions addressed the primary outcomes of this review and, of the eight that did, only three (CM + SM, ST and DBT) showed evidence that the intervention may be more effective than the control condition. No intervention reported compelling evidence of change in antisocial behaviour. Overall, the certainty of the evidence was low or very low, meaning that we have little confidence in the effect estimates reported. The conclusions of this update have not changed from those of the original review, despite the addition of eight new studies. This highlights the ongoing need for further methodologically rigorous studies to yield further data to guide the development and application of psychological interventions for AsPD and may suggest that a new approach is required.

Attachment and Personality Disorders Among Child Molesters: The Role of Trust

The present study investigated multivariate associations between attachment styles and personality disorders (PDs)-and the mediating role of trust-in a sample of child molesters ( n = 84) and a matched control group from the general community ( n = 80). Among child molesters, canonical correlation analysis revealed that two variates resembling avoidant and anxious attachment dimensions were associated with PD traits. Attachment avoidance was related to schizoid, schizotypal, and avoidant PDs, with a marginal contribution of antisocial PD. Attachment anxiety was related to borderline and histrionic PDs, with a marginal contribution of obsessive-compulsive PD. Paranoid and dependent PDs contributed to both variates. In the control group, a more general association between attachment insecurity and PDs emerged. Finally, mistrust significantly explained the associations between attachment and PDs in both samples. Future studies should examine whether treatment for PDs in child molesters could benefit from a focus on attachment and trust.

Beyond diagnosis: Mentalization and mental health from a transdiagnostic point of view in adolescents from non-clinical population

An increasing volume of evidence suggests that mentalization (MZ) can be an important factor in the transition from mental health to mental illness and vice versa. However, most studies are focused on the role of MZ in specific disorders. This study aims to evaluate the relationship between MZ and mental health as a trans-diagnostic process. A sample of 172 adolescents aged 12 to 18 years old (M = 14.6, SD = 1.7; 56.4% of girls) was assessed on measures of MZ, psychopathology and psychological functioning from a multimethod and multi-informant perspective. Contrary to predictions, MZ was not associated with general psychopathology and comorbidity, even when explored from a broad, trans-diagnostic perspective. However, we observed a robust association linking MZ to functioning and well-being across many dimensions, involving social, role and several psychological indicators of adjustment and mental health. These results suggest that MZ may contribute to mental health beyond symptoms, not so much associated with psychopathology, but rather resilience and well-being.

Treatment of antisocial personality disorder: Development of a practice focused framework

There is little to no evidence of effective treatment methods for patients with an antisocial personality disorder (ASPD). One of the reasons could be the fact that they are often excluded from mental healthcare and thus from studies. A treatment framework based on 'state of the art' methods and best practices, offering guidelines on the treatment of ASP and possibilities for more systematical research, is urgently needed. This research involved a literature search and an international Delphi-study (N = 61 experts in research, management and clinical practice focused on ASPD). The results suggested important preconditions with regard to organization of care, healthcare workers and therapy. Conclusions are that there are many ways to coordinate effective treatment and management and work toward the increased availability of evidence based care for persons with ASPD.

Differentiating Community Dwellers at Risk for Pathological Narcissism From Community Dwellers at Risk for Psychopathy Using Measures of Emotion Recognition and Subjective Emotional Activation

The Italian translations of the Pathological Narcissism Inventory (PNI) and Triarchic Psychopathy Measure (TriPM) were administered to 609 community dwelling adults. Participants who scored in the upper 10% of the distribution of the PNI total score were assigned to the group of participants at risk for pathological narcissism, whereas participants who scored in the upper 10% of the distribution of the TriPM total score were assigned to the group of participants at risk for psychopathy. The final sample included 126 participants who were administered the Reading the Mind in the Eyes Test (RMET) and emotion-eliciting movie clips. Participants at risk for pathological narcissism scored significantly lower on the RMET total score than participants who were not at risk for pathological narcissism. Participants at risk for psychopathy showed a significant reduction in the subjective experience of disgust, fear, sadness, and tenderness compared to participants who were not at risk for psychopathy.

A randomised controlled trial of mentalization-based treatment versus structured clinical management for patients with comorbid borderline personality disorder and antisocial personality disorder

BACKGROUND

Antisocial personality disorder (ASPD) is an under-researched mental disorder. Systematic reviews and policy documents identify ASPD as a priority area for further treatment research because of the scarcity of available evidence to guide clinicians and policymakers; no intervention has been established as the treatment of choice for this disorder. Mentalization-based treatment (MBT) is a psychotherapeutic treatment which specifically targets the ability to recognise and understand the mental states of oneself and others, an ability shown to be compromised in people with ASPD. The aim of the study discussed in this paper is to investigate whether MBT can be an effective treatment for alleviating symptoms of ASPD.

METHODS

This paper reports on a sub-sample of patients from a randomised controlled trial of individuals recruited for treatment of suicidality, self-harm, and borderline personality disorder. The study investigates whether outpatients with comorbid borderline personality disorder and ASPD receiving MBT were more likely to show improvements in symptoms related to aggression than those offered a structured protocol of similar intensity but excluding MBT components.

RESULTS

The study found benefits from MBT for ASPD-associated behaviours in patients with comorbid BPD and ASPD, including the reduction of anger, hostility, paranoia, and frequency of self-harm and suicide attempts, as well as the improvement of negative mood, general psychiatric symptoms, interpersonal problems, and social adjustment.

CONCLUSIONS

MBT appears to be a potential treatment of consideration for ASPD in terms of relatively high level of acceptability and promising treatment effects.

TRIAL REGISTRATION

ISRCTN ISRCTN27660668 , Retrospectively registered 21 October 2008.

Mindfulness moderates the relationship between aggression and Antisocial Personality Disorder traits: Preliminary investigation with an offender sample

INTRODUCTION

Poor mentalizing has been described as a characteristic of Antisocial Personality Disorder (ASPD), along with the well-established role of aggressiveness. In the current study, we tested this hypothesis focusing on a specific aspect of mentalization (i.e., mindfulness).

METHOD

We explored the unique and joint contribution of aggression dimensions and mindfulness facets to ASPD traits in an offender sample (N=83).

RESULTS

Mindfulness deficits were associated with ASPD traits, and a significant unique association emerged between difficulties in acting with awareness and ASPD traits. Likewise, physical aggression confirmed its association with ASPD traits. Moderation analyses revealed that mindfulness interacted with aggression in predicting ASPD. Specifically, at low levels of mindfulness, the association between aggression and ASPD dropped to nonsignificance.

CONCLUSIONS

Results suggest that fostering self-mentalizing is a relevant treatment target when treating offenders with ASPD.

Antisocial personality disorder: a current review

The Diagnostic and Statistical Manual of Mental Disorders (DSM 5) classification of antisocial personality disorder (ASPD) describes individuals who engage in repetitive irresponsible, delinquent, and criminal behavior. The diagnosis is highly controversial, with many researchers and clinicians arguing that the category is too heterogeneous, overinclusive, and demonstrates considerable overlap with other disorders. This review focuses on recent studies that have improved our understanding of the characteristics of individuals who fit the ASPD definition by exploring how subtypes differ and how comorbid conditions influence the presentation of ASPD. In addition, we discuss research on the etiology of ASPD that has identified genetic and environmental factors that may contribute to the development and persistence of antisocial behavior, and brain imaging research that has improved our understanding of the relationships between ASPD and other psychopathology. Finally, we discuss promising preliminary research on treatment for this disorder.