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An obsessive-compulsive personality disorder is defined as a continuous fixation with orderliness, perfectionism, and control (with little to no room for flexibility), which slows or prevents the completion of tasks. They are often perceived as uncooperative, stubborn, stingy and self-righteous.

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What is Obsessive-Compulsive Personality Disorder? | Comprehensive Review

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Acting confined or restricted with emotions.

Inflexible to rules

Organizing and making lists for tasks

Desire to have control over relationships.

Inability to feel empathy for people and create/keep relationships.

Overly committed to their profession

Difficulty with self-identity and direction

Difficulty relinquishing control and assigning duties

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The Surprising Symptoms of Obsessive Compulsive Personality Disorder (OCPD)

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Children may show signs of OCPD, but do not receive a diagnosis until they are in their late or early adolescence. Children may feel as tho they need to be perfect or perfectly obedient. This carries on to adulthood.

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A family history of either personality disorders, anxiety, or depression

Childhood trauma, such as child abuse, that causes you to feel like being "perfect" is the only way to get by.

Having a prior mental health issue, particularly an anxiety disorder

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Cultivating self-compassion

Practicing meditation

Identify self-soothing techniques.

Seeking professional help

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Sever social inhibition, inadequacy, and sensitivity to negative criticism and rejection are all characteristics of avoidant personality disorder.

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Avoidant Personality Disorder.. What is it?

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Dependent Personality Disorder is a form of anxious personality disorder. DPD patients frequently feel powerless, subservient, or unable to care for themselves. They may find it difficult to make simple decisions.

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overly sensitive to criticism or rejection and can quickly be harmed by them.

They have few, if any, close friends and are hesitant to get engaged with people unless they are confident that they will be appreciated.

In social situations and interactions, they experience great anxiety and fear, prompting them to avoid activities or employment that need them to interact with others.

Since they are afraid of making a mistake or being embarrassed, they are shy, awkward, and self-conscious in social situations.

They have a tendency to exaggerate possible issues.

They rarely try new things or take risks.

They have low self-esteem and believe they are inadequate and inferior.

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6 Signs of Avoidant Personality Disorder

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Personal responsibility is avoided.

It's difficult to be alone.

When partnerships fail, there is a fear of abandonment and a sense of helplessness.

Intolerance of criticism.

Pessimism and a lack of trust in oneself.

Making day-to-day decisions is difficult.

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Avoidant Personality Disorder can only be diagnosed in people above the age of 18. They may experience many symptoms before they reach maturity. A child who tries to avoid any obligations that need them to interact with others may be more than shy.

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DPD usually starts in childhood or by age 29. Children and adolescents may have trouble concentrating in class, feel anxious, fear separation from caregiver/parents etc.

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Having a psychological problem such as depression or anxiety

A history of depression, anxiety, or personality disorders in your family

Abuse, trauma, or neglect as a child

Trauma can include experiencing a severe episode of humiliation or rejection as a child.

A physical illness, trauma, or genetics that alter your look beyond societal norms

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Abusive relationships

Childhood trauma

Family history of DPD or a different anxiety disorder

Certain cultural and religious or family behaviours

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Adapting new ways to cope with difficult situations

Cognitive behavioural therapy

psychotherapy

Taking prescribed antidepressants.

Getting a better understanding of dependent personality disorder

Having adequate support to help you feel better.

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Talking to a professional

Taking medication

Attending therapy i.e Individual talk therapy, occupational therapy, cognitive-behavioural therapy and other forms of therapy

Educate yourself to be aware of your condition.

Taking part in support groups

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this video talks about what it is like to live with/have OCPD

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OCPD | Living with Obsessive Compulsive Personality Disorder

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This website gives information about the signs, symptoms and treatment options for obsessive compulsive personality disorder.

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This video answers some question you may have about OCPD

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Question and Answer - Obsessive Compulsive Personality Disorder - OCPD explained

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Borderline Personality Disorder is a mental illness that affects people's ability to regulate their emotions. Loss of emotional regulation can have a significant impact on how people with BPD interact with others. Increases impulsivity as well as how they feel about themselves. BPD is often viewed as moody, self-destructive, impulsive, unstable, and dissociated.

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What is Borderline Personality Disorder?

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Self-Harming such as cutting themselves

A cycle of intense or unstable relationships with family loved ones and friends

Recurring thoughts about suicidal behaviours or threats

Feelings of unreality or confusion

Unstable self-image or body image

Impulsive or dangerous behaviours such as spending, unsafe sex, drinking, and reckless driving

Feelings of abandonment

Feelings of emptiness

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A child may experience some signs of borderline personality disorder. The signs of BPD that are found in children are mood swings, finding it hard to express or control their emotions, intense moments of anger, depression and quickly changing from loving someone to admiring someone else to disliking them. In adolescence, some signs of BPD are distorted or dysfunctional self-image; a damaged identity, A persistent fear of abandonment and rejection, and mood changes without a clear cause that are lasting. BPD can be diagnosed as early as 12 years old if symptoms are constant and can be diagnosed later on in adulthood.

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Environmental, cultural, and social factors such as being exposed to conflicts or unstable relationships

Experiencing traumatic life events

Functional changes within the brain

Family interaction or history such as if other family members have BPD or are at higher risk of being diagnosed

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Dialectical Behaviour Therapy

Cognitive Behavioural Therapy

Practicing and learning different breathing exercises to cope with anxiety

Seek professional help such as psychotherapy

Practicing meditation

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https://www.nimh.nih.gov/health/topics/borderline-personality-disorder#part_2248

This is an article about borderline personality disorder, traits, symptoms, the signs that people with BPD experience, and the treatments that are commonly appropriate for this diagnosis.

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National Institute of Mental Health (NIMH)

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Learn about borderline personality disorder, including signs and symptoms, risk factors, treatments and therapies, and tips for family and caregivers.

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https://www.verywellmind.com/the-bpd-family-425215

This following website explains the factors of how BPD can have a negative impact on people's lives and their families. It also describes the different aspects of BPD, how it hurt the people around them, what might be the best decision and how to approach it with a treatment option that will help the family and people with BPD.

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Borderline personality disorder (BPD) is a devastating mental health condition that doesn't just impact the person with BPD. It also impacts everyone they share relationships with, including friends, family, and romantic partners.﻿﻿

Since there are so many family issues that are directly impacted by borderline personality symptoms and behaviors, the entire family of a person with borderline personality may suffer.﻿﻿ These are some of the most common effects of BPD on the family and how to find help as a family.

Stress on the Family

Watching a loved one with BPD suffer and dealing with very difficult relationship symptoms of BPD are extraordinarily stressful for family members. Family members often feel helpless while watching their loved one with BPD engage in self-destructive behaviors. This may be particularly true for parents or caregivers of adolescents with BPD, who may seem out of control.﻿﻿

In addition to the chronic stress of caring for a loved one with BPD, many members of the BPD family will experience very severe psychological trauma due to some of the high-risk behaviors associated with BPD.﻿﻿ For example, many people with BPD engage in self-harm behaviors, such as cutting or burning. These behaviors can become so severe that they can lead to accidental death. In addition, people with BPD have a very high rate of suicide.

Family members are often the ones to manage these high-risk behaviors (e.g., driving their loved one to the emergency room after a suicide attempt) and may experience psychological trauma (which can, in severe cases, lead to problems such as post-traumatic stress disorder).﻿﻿

Guilt and Responsibility

Many family members of people with BPD describe very difficult struggles with feelings of guilt.﻿﻿﻿﻿ Research on the causes of BPD suggests that childhood maltreatment in the form of abuse or neglect may be related to the development of BPD.

There is also evidence of a strong genetic component. These findings lead many family members, especially parents, to blame themselves or feel guilty, even if the development of their loved one's BPD was outside of their control.

Some families try to be supportive but are concerned that if they are too supportive they will reward some of the BPD-related behavior, such as self-harm. Others want to be supportive but feel angry at the person with BPD about their behavior.

Finally, some have difficulty being supportive because of their own psychiatric issues. For example, because BPD does tend to run in families, other people in the family may also have BPD.

Struggles Families Experience

The stress of dealing with a loved one's BPD symptoms is compounded by the stress of managing their treatment.﻿﻿ Often, clinicians rely on the BPD family to help organize the family member's treatment, which can involve multiple providers and teams and many different levels of care (including outpatient treatment and occasional partial or inpatient hospitalization).

Family members may be called upon to notice changes in their loved one's status (e.g., is their mood lower than usual or have they stopped taking their medications as prescribed?), provide transportation to appointments or coordinate searches for new treatment options. Negotiating these details and the larger mental health system is no easy task and can place another burden on an already stressed BPD family system.

Broader Effects

Unfortunately, the stress, struggles and support issues involved with having a person with BPD in the family can have consequences on both the immediate and extended family.﻿﻿﻿ Parents of adolescents and adults with BPD describe the intense stress that caring for a child with BPD can introduce into the marriage relationship.

In addition, siblings are affected in many ways. Some siblings may also be pulled in to a caregiving role, while others may distance themselves from the family in order to protect themselves (or their own marriages, children, etc.) or to avoid the emotional distress involved in being in a close relationship with someone with BPD.

Extended family may also be affected; grandparents, aunts, uncles and other relatives are part of the BPD family support network, and they can also feel the strain of caring for a person with BPD.﻿﻿﻿

Getting Help

It is not always easy for loved ones to find the help and support they need to care for their family member with BPD. If you are committed to getting help, though, there are options and resources available. First, if you suspect that your loved one has BPD, and they are not yet in treatment, you can encourage them to get the help they need.

There are also resources specifically available for family members. For example, the National Alliance for Borderline Personality Disorder (NEA-BPD) offers the Family Connections Program throughout the United States.

This program is a 12-week class designed to offer education, skills training and support to family members of people with BPD.﻿﻿﻿﻿﻿ To learn more about the program, visit the Family Connections page of the NEA-BPD website.

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How BPD Can Negatively Impact and Hurt Your Family

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Borderline personality disorder (BPD) is a devastating mental health condition that doesn't just impact the person with BPD. It also impacts everyone they share relationships with, including friends, family, and romantic partners.﻿﻿ Since there are so many family issues that are directly impacted by borderline personality symptoms and behaviors, the entire family of a person with borderline personality may suffer.﻿﻿ These are some of the most common effects of BPD on the family and how to find help as a family.

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https://childmind.org/guide/quick-guide-borderline-personality-teens-young-adults/

This is a quick guideline for BPD in children, adolescence and adults. It explains how BPD can not only start in early childhood but may have a long-term effect on adults as well during adulthood and ways they can reach out for help and how they can cope.

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Lo sentimos, la página que usted busca no se ha podido encontrar. Puede intentar su búsqueda de nuevo o visitar la lista de temas populares.

What is borderline personality disorder?

Borderline personality disorder (BPD) is a mental health condition that comes with extreme emotions, intense challenges with self-esteem, and difficulty forming strong, stable relationships with others. Teenagers with BPD are often angry, impulsive, and quick to believe that other people have wronged them.

Young people with BPD often harm themselves and they have a high risk of suicide. Symptoms of BPD usually show up in the teenage years. Early treatment can help people with BPD manage the disorder better.

What are the symptoms of BPD?

Symptoms of BPD include:

Unrealistic or unstable sense of self

Believing they're worthless

Regularly feeling angry, empty, or hopeless

Mood swings

Finding it hard to control emotions, especially anger

Brief, intense periods of anxiety or depression

Fear of being abandoned and desperate attempts to avoid it

Paranoid thinking

Quickly changing from loving or admiring someone to disliking or criticizing them

Impulsive behavior, such as risky driving, unsafe sex, or alcohol and substance abuse

Self-harm

Attempting suicide

A mental health professional must diagnose BPD. To be diagnosed with BPD, a person must have at least five of the symptoms listed above by the time they're a young adult.

What are the risk factors for BPD?

Kids are more likely to have BPD if they have a parent or sibling who also has BPD.

Experts view BPD as a combination of two big factors. The first is a natural tendency to get upset very easily. The second is growing up in a household that doesn't help kids learn to handle big emotions. Without support as children, young people who experience especially strong emotions may develop unhealthy ways of coping.

What is the treatment for BPD?

The best therapy for BPD is dialectical behavioral therapy (DBT). DBT teaches patients skills to manage their emotions and stop harming themselves. It's called "dialectical" because it's about learning to balance two concepts that seem like opposites: the need for acceptance and the need for change. Long-term studies show that DBT works well for BPD.

There are no medications to treat BPD. However, medication can sometimes help specific symptoms of BPD, including depression, impulsive behavior and anxiety.

Teens with BPD who are in danger of suicide are sometimes hospitalized for treatment.

It is common for people with BPD to have other mental health disorders at the same time. Disorders that often show up with BPD include depression, bipolar disorder, substance use disorder and eating disorders.

People with BPD are also at risk of suicide. If you think your child or teenager is suicidal, you can call the National Suicide Prevention Lifeline at 1-800-273-8255 or 911 if there is an emergency. Don't wait - the risk of suicide in children and teenagers is very real.

We have over 60 guides and 700 articles available to help you (in Spanish too!).
Subscribe and get a curated selection weekly.

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Quick Guide to Borderline Personality Disorder - Child Mind Institute

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Lo sentimos, la página que usted busca no se ha podido encontrar. Puede intentar su búsqueda de nuevo o visitar la lista de temas populares. Borderline personality disorder (BPD) is a mental health condition that comes with extreme emotions, intense challenges with self-esteem, and difficulty forming strong, stable relationships with others.

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Antisocial personality disorder is a mental health disorder characterized by a long history of manipulating, exploiting, or violating the rights of others. This is commonly criminal behaviour. Antisocial personality disorder is often perceived as putting on an act as witty or charming, breaking the law repeatedly, often angry or annoyed and demonstrates no sign of remorse or guilt.

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Antisocial Personality Disorder, Causes , Signs and Symptoms, Diagnosis and Treatment.

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Disregard for right and wrong

Using charm or wit to manipulate others for personal gain or personal pleasure

Arrogance, a sense of superiority and being extremely opinionated

lack concern, regret or remorse about other people's distress

have difficulty sustaining long-term relationships

be unable to control their anger

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Family history of ASPD or other personality disorders

Unstable, violent or chaotic family life during childhood

Mental health disorders

Being subjected to abuse or neglect during childhood

Chemistry of the brain and structure

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The signs of antisocial personality disorder may present in childhood and adolescence. ASPD cannot be diagnosed before the age of 18, but it is recommended that assessments about the diagnosis should begin before the age of 15. Identifying antisocial personality disorder early can help improve long-term benefits.

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This website provides information on the symptoms, treatment and complications of APD

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Social Impact of Avoidant Personality Disorder

Avoidant personality disorder causes a fear of rejection that often makes it difficult to connect with other people. You may be hesitant to seek out friendships, unless you are certain that the other person will like you. When you are involved in a relationship, you may be afraid to share personal information or talk about your feelings. This can make it difficult to maintain intimate relationships or close friendships.

According to the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-5), a person diagnosed with avoidant personality disorder needs to show at least four of the following criteria:

Avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval, or rejection.

Is unwilling to get involved with people unless they are certain of being liked.

Shows restraint within intimate relationships because of the fear of being shamed or ridiculed.

Is preoccupied with being criticized or rejected in social situations.

Is inhibited in new interpersonal situations because of feelings of inadequacy.

Views self as socially inept, personally unappealing, or inferior to others.

Is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing.

Avoidant behavior may commonly be seen in children or adolescents, but a diagnosis of a personality disorder cannot be made in childhood because shyness, fear of strangers, social awkwardness, or being sensitive to criticism are often a normal part of child and adolescent development.

A mental health professional can assess your symptoms, make an accurate diagnosis, and suggest the appropriate treatment options.

Avoidant Personality Disorder Treatments

As with other personality disorders, a mental health professional will design a treatment plan that is appropriate for you. Avoidant personality disorder treatments vary, but they will likely include talk therapy. If a co-existing condition, such as depression or anxiety disorder, is also diagnosed, appropriate medications may also be used.

Avoidant Personality Disorder and Other Conditions

Other mental health disorders can occur along with avoidant personality disorder. Treatments in these cases will be designed to help with the symptoms of each disorder. A few of the conditions that most frequently occur with avoidant personality disorder include:

Social phobia, in which a person experiences overwhelming anxiety and self-consciousness in common social situations.

Dependent personality disorder, in which people rely excessively on others for advice or to make decisions for them.

Borderline personality disorder, in which people have difficulties in many areas including social relationships, behavior, mood, and self-image.

Many avoidant personality disorder symptoms are commonly shared among these other conditions, particularly in the case of generalized social phobia. Because of this, the disorders can be easily confused. It may take some time for a mental health professional to make a clear diagnosis and choose the appropriate treatments for you.

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Avoidant Personality Disorder: Symptoms, Treatments, and Complications

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Avoidant personality disorder causes a fear of rejection that often makes it difficult to connect with other people. You may be hesitant to seek out friendships, unless you are certain that the other person will like you. When you are involved in a relationship, you may be afraid to share personal information or talk about your feelings.

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This video provides viewers with traits one can look out for in order to sport APD

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7 Signs of Avoidant Personality Disorder

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This video looks at what it is like to live with APD. the speaker in he video is diagnosed with ASP, they talk about what's its like for them.

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Safe environment such as home, school, family gatherings

Practice coping skills for emotions and behaviour

Learn new ways of working through relationships with others

Practice being more alert

Practice having a positive mindset and attitude toward lifestyle

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https://www.mayoclinic.org/diseases-conditions/antisocial-personality-disorder/diagnosis-treatment/drc-20353934

This website helps you understand the conditions and treatments of ASPD in terms of educating those with this diagnosis or the family of those with ASPD. It provides a wide range of information on what the diagnosis is like and how to cope with it and who can be a high risk of it.

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Diagnosis

People with antisocial personality disorder are unlikely to believe they need help. However, they may seek help from their primary care provider because of other symptoms such as depression, anxiety or angry outbursts or for treatment of substance misuse.

People with antisocial personality disorder may not provide an accurate account of signs and symptoms. A key factor in diagnosis is how the affected person relates to others. With permission, family and friends may be able to provide helpful information.

After a medical evaluation to help rule out other medical conditions, the primary care provider may make a referral to a mental health professional for further evaluation.

Diagnosis of antisocial personality disorder is typically based on:

A psychological evaluation that explores thoughts, feelings, relationships, behavior patterns and family history

Personal and medical history

Symptoms listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association

Though typically antisocial personality disorder isn't diagnosed before age 18, some signs and symptoms may occur in childhood or the early teen years. Usually there is evidence of conduct disorder symptoms before age 15.

Identifying antisocial personality disorder early may help improve long-term outcomes.

Treatment

Antisocial personality disorder is difficult to treat, but for some people, treatment and close follow-up over the long term may be beneficial. Look for medical and mental health professionals with experience in treating antisocial personality disorder.

Treatment depends on each person's particular situation, their willingness to participate in treatment and the severity of symptoms.

Psychotherapy

Psychotherapy, also called talk therapy, is sometimes used to treat antisocial personality disorder. Therapy may include, for example, anger and violence management, treatment for alcohol or substance misuse, and treatment for other mental health conditions.

But psychotherapy is not always effective, especially if symptoms are severe and the person can't admit that he or she contributes to serious problems.

Medications

There are no medications specifically approved by the Food and Drug Administration to treat antisocial personality disorder. Doctors may prescribe medications for conditions sometimes associated with antisocial personality disorder, such as anxiety or depression, or for symptoms of aggression. Certain drugs are usually prescribed cautiously because they have the potential for misuse.

Coping and support

Skills for family members

People with antisocial personality disorder often act out and make other people miserable - with no feeling of remorse. If you have a loved one with antisocial personality disorder, it's critical that you also get help for yourself.

A mental health professional can teach you skills to learn how to set boundaries and help protect yourself from the aggression, violence and anger common to antisocial personality disorder. He or she can also recommend strategies for coping.

Seek a mental health professional who has training and experience in managing antisocial personality disorder. Ask your loved one's treatment team for a referral. They may also be able to recommend support groups for families and friends affected by antisocial personality disorder.

Preparing for your appointment

If a medical evaluation rules out physical causes for your behavior, your primary care provider may make a referral to a mental health professional, such as a psychiatrist or psychologist.

Take a family member or friend along to your appointment, if possible. With your permission, someone who has known you for a long time may be able to answer questions or share information with the doctor that you don't think to bring up.

What you can do

Before your appointment, make a list of:

Any symptoms you or your family noticed, and for how long

Key personal and medical information, including current physical or mental health conditions, personal or family history of mental illness, traumatic experiences, or major stressors

All medications you take, including the names and doses of any medications, herbs, vitamins or other supplements

Questions you want to ask your doctor to make the most of your appointment

Some basic questions to ask your doctor include:

What is likely causing my symptoms?

What are other possible causes?

What treatments are most likely to be effective for me?

How much can I expect my symptoms to improve with treatment?

How often will I need treatment, and for how long?

Are there medications that can help? Is so, what are the possible side effects?

Is there a generic alternative to the medication you're prescribing?

Are there any printed materials I can have? What websites do you recommend?

Don't hesitate to ask any other questions during your appointment.

What to expect from your doctor

Your doctor is likely to ask you a number of questions, such as:

What are your symptoms?

When did you or your family first notice these symptoms?

How are your symptoms affecting your life?

Have relatives or friends expressed concern about your behavior?

Do you have any close relationships?

If you're not satisfied with work, school or relationships, what do you think is causing your problems?

Have you ever thought about harming yourself or others? Have you ever actually done so?

Have any of your blood relatives, such as a parent or sibling, been diagnosed with or treated for mental illness?

Be ready to answer these questions to reserve time to go over points you want to spend more time on.

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People with antisocial personality disorder are unlikely to believe they need help. However, they may seek help from their primary care provider because of other symptoms such as depression, anxiety or angry outbursts or for treatment of substance misuse.

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https://nacac.org/resource/helping-your-child-move-from-anti-social-to-pro-social-behaviors/

These are resources on how to cope with helping parents with teaching their children how to practice social skills and become more active in having prosocial behaviours. This gives a clear understanding of the diagnosis and how parents or guardians can become aware of their child’s behaviours and how to approach them throughout the process.

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The North American Council on Adoptable Children

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Helping Your Child Move from Anti-Social to Pro-Social Behaviors - The North American Council on Adoptable Children

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We all enter the world ready to attach because this is how we get our most basic and primary needs met. The human infant, like other high functioning mammals, is completely dependent on their primary caregivers to get all of their needs met—survival, safety, food, shelter, stimulation, comfort. For…

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https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4167848/

This is an article that gives an extended amount of information based on antisocial personality disorder, traits, conditions, symptoms, treatments and statistics about people with ASPD. This website is used to educate others about this diagnosis and what other terms can be used to describe it and what ways to best approach it.

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Cochrane Database Syst Rev. Author manuscript; available in PMC 2014 Sep 19.

Published in final edited form as:

Abstract

Background

Antisocial personality disorder (AsPD) is associated with a wide range of disturbance including persistent rule-breaking, criminality, substance use, unemployment, homelessness and relationship difficulties.

Objectives

To evaluate the potential beneficial and adverse effects of psychological interventions for people with AsPD.

Search methods

Our search included CENTRAL Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, PsycINFO, ASSIA, BIOSIS and COPAC.

Selection criteria

Prospective, controlled trials in which participants with AsPD were randomly allocated to a psychological intervention and a control condition (either treatment as usual, waiting list or no treatment).

Data collection and analysis

Three authors independently selected studies. Two authors independently extracted data. We calculated mean differences, with odds ratios for dichotomous data.

Main results

Eleven studies involving 471 participants with AsPD met the inclusion criteria, although data were available from only five studies involving 276 participants with AsPD. Only two studies focused solely on an AsPD sample. Eleven different psychological interventions were examined. Only two studies reported on reconviction, and only one on aggression. Compared to the control condition, cognitive behaviour therapy (CBT) plus standard maintenance was superior for outpatients with cocaine dependence in one study, but CBT plus treatment as usual was not superior for male outpatients with recent verbal/physical violence in another. Contingency management plus standard maintenance was superior for drug misuse for outpatients with cocaine dependence in one study but not in another, possibly because of differences in the behavioural intervention. However, contingency management was superior in social functioning and counselling session attendance in the latter. A multi-component intervention utilising motivational interviewing principles, the 'Driving Whilst Intoxicated program', plus incarceration was superior to incarceration alone for imprisoned drink-driving offenders.

Authors' conclusions

Results suggest that there is insufficient trial evidence to justify using any psychological intervention for adults with AsPD. Disappointingly few of the included studies addressed the primary outcomes defined in this review (aggression, reconviction, global functioning, social functioning, adverse effects). Three interventions (contingency management with standard maintenance; CBT with standard maintenance; 'Driving Whilst Intoxicated program' with incarceration) appeared effective, compared to the control condition, in terms of improvement in at least one outcome in at least one study. Each of these interventions had been originally developed for people with substance misuse problems. Significant improvements were mainly confined to outcomes related to substance misuse. No study reported significant change in any specific antisocial behaviour. Further research is urgently needed for this prevalent and costly condition.

Medical Subject Headings (MeSH) Aggression [psychology], Antisocial Personality Disorder [*therapy], Cocaine-Related Disorders [therapy], Cognitive Therapy [methods], Psychotherapy [*methods], Randomized Controlled Trials as Topic, Reward

MeSH check words: Adult, Female, Humans, Male

BACKGROUND

Description of the condition

Antisocial personality disorder (AsPD) is one of the ten personality disorder categories in the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; APA 2000). DSM-IV defines personality disorder as: ' an enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the person's culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment'. General criteria for personality disorder according to DSM-IV are given in Table 1 below.

Table 1

1. An enduring pattern of inner experience and behaviour deviating markedly from the expectations of the individual's culture as manifested in two (or more) of the following areas:

cognition (perception and interpretation of self, others and events);

affect (the range, intensity, lability and appropriateness of emotional response);

interpersonal functioning;

impulse control.

2. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations

3. The enduring pattern leads to clinically significant distress or impairment in social, occupational or other important areas of functioning

4. The pattern is stable and of long duration and its onset can be traced back at least to adolescence or early adulthood

5. The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder

6. The enduring pattern is not due to the direct physiological effects of a substance (e.g. a drug of abuse, a medication) or a general medical condition (e.g. head trauma)

AsPD is identified by traits that include irresponsible and exploitive behaviour, recklessness, impulsivity, high negative emotionality and deceitfulness. In order to be diagnosed with AsPD, according to the DSM-IV, a personmust fulfil criteria A, B, C and D shown in Table 2 below as well as fulfilling general criteria for a personality disorder as outlined above.

Table 2

1. At least three of the following criteria must be met:

1. failure to conform to social norms with respect to lawful behaviours, as indicated by repeatedly performing acts that are grounds for arrest;

2. repeated deceitfulness, as indicated by repeatedly lying, use of aliases, or conning others for personal profit or pleasure;

3. impulsivity or failure to plan ahead;

4. irritability and aggression, as indicated by repeated physical fights or assaults;

5. reckless disregard for the safety of self or others;

6. consistent irresponsibility, as indicated by repeated failure to sustain consistent work behaviour or honour financial obligations;

7. lack of remorse, as indicated by being indifferent to or rationalising having hurt, mistreated, or stolen from another.

2. Current age at least 18 years.

3. Evidence of conduct disorder with onset before age of 15 years

4. Occurrence of antisocial behaviour must not be exclusively during the course of schizophrenia or a manic episode

The focus of this review is antisocial personality disorder, although this condition is also often classified using the International Classification of Diseases - tenth edition (ICD-10; WHO 1992) as dissocial personality disorder (F60.2). AsPD and dissocial personality disorder are often used interchangeably by clinicians and they describe a very similar presentation. While there is considerable overlap between these two diagnostic systems, they differ in two respects. First, DSM-IV requires that those meeting the diagnostic criteria also show evidence of conduct disorder with onset before the age of 15 years and there is no such requirement when making the diagnosis of dissocial personality disorder using ICD-10 criteria. However, a study by Perdikouri et al ( Perdikouri 2007) did not find any clinically important differences when they compared subjects meeting the full criteria for AsPD with those who otherwise fulfilled criteria for AsPD but who did not demonstrate evidence of childhood conduct disorder. Second, dissocial personality disorder focuses more on the interpersonal deficits (for example, incapacity to experience guilt, a very low tolerance of frustration, proneness to blame others) and less on antisocial behaviour. Table 3 below shows the diagnostic criteria for diagnosing dissocial personality disorder. Second, it has been argued that the criteria in ICD-10 are more reflective of the core personality traits of the antisocial with less emphasis on criminal behaviour.

Table 3

1. The general criteria for personality disorder (F60) must be met

2. At least three of the following must be met:

1. callous unconcern for the feelings of others;

2. gross and persistent attitude of irresponsibility and disregard for social norms, rules and obligations;

3. incapacity to maintain enduring relationships, though with no difficulty in establishing them;

4. very low tolerance to frustration and a low threshold for discharge of aggression, including violence;

5. incapacity to experience guilt, or to profit from adverse experience, particularly punishment;

6. marked proneness to blame others, or to offer plausible rationalisations for the behaviour that has brought the individual into conflict with society.

Whilst estimates of the prevalence of AsPD in the general population vary across studies and countries, most studies report a prevalence of between 2% and 3% in the general population ( Coid 2006; Moran 1999). Prevalence rates are consistently higher in men compared with women ( Dolan 2009). For instance, the lifetime prevalence in two North American studies was 4.5% among men and 0.8% among women ( Robins 1991) and 6.8% among men and 0.8% in women ( Swanson 1994). However, two European studies found lower prevalence rates (i.e. of 1.3% in men and 0% in women ( Torgensen 2001) and 1% in men and 0.2% in women ( Coid 2006)). As would be expected AsPD is especially common in prison settings. In the UK prison population, the prevalence of people with AsPD has been identified as 63% in male remand prisoners, 49% in male sentenced prisoners and 31% in female prisoners ( Singleton 1998).

The condition is associated with a wide range of disturbance and is associated with greatly increased rates of criminality, substance use, unemployment, homelessness and relationship difficulties. Antisocial personality disorder is generally associated with a negative long-term outcome. Many adults with AsPD are imprisoned at some point in their life. Although follow-up studies have demonstrated some improvement over time, particularly in rates of re-offending ( Grilo 1998; Weissman 1993), men with AsPD who reduce their offending behaviour over time may nonetheless continue to have major problems in their interpersonal relationships ( Paris 2003). Black found that men with AsPD aged less than 40 years had a strikingly high rate of premature death and obtained a value of 33 for the Standardised Mortality Rate (the age-adjusted ratio of observed deaths to expected deaths - meaning that they were 33 times more likely to die than similar males of the same age without this condition) ( Black 1996). This increased mortality was due not only to an increased rate of suicide, but was also associated with reckless behaviours such as drug misuse and aggression. Follow-up studies in forensic-psychiatric settings suggest a similarly concerning picture. For example, Davies 2007 reported that 20 years after discharge from a medium secure unit almost half of the patients were reconvicted, with reconviction rates higher in those with personality order compared to mentally ill patients.

Description of the intervention

1. psychoanalytic psychotherapy;

2. cognitive behavioral;

3. therapeutic community; and

4. nidotherapy.

Traditionally, psychoanalytically-based psychological therapies held sway but latterly these have been replaced by more cognitive behavioral therapy-based approaches ( Cordess 1996).

It is important to consider all relevant studies without restriction on the type of psychological therapy and to consider psychological interventions where drugs are also given as an adjunctive intervention.

How the intervention might work

Psychoanalytic therapies (which include dynamic psychotherapy, transference-focused psychotherapy, mentalisation-based therapy and group psychotherapy) aim to help the patient understand and reflect on his inner mental processes and make links between his past and his current difficulties. To our knowledge, no randomised trials have been published assessing the efficacy of dynamic psychotherapies specifically for AsPD but there are a small number of trials which examined the effectiveness of psychoanalytic therapies for personality disorder in general. Limited evidence for the efficacy of psychodynamic psychotherapy comes from Bateman 2001, Chiesa 2003, Piper 1993 and Winston 1994.

Cognitive behavioural therapy (CBT) based treatments place emphasis on encouraging the patient to challenge their core beliefs and to gain insight into how their thoughts and feeling affect their behaviour. A review of the evidence for this form of intervention concluded that " the overall evidence in favour of cognitive behavioural therapy in the treatment of personality disorder is therefore relatively slim, with much of the evidence coming from one research group, but it has involved more patients than any other form of treatment" ( Bateman 2004).

Therapeutic community treatments involve patients (also known as residents) not only having therapy together but also working and living together in a shared, therapeutic environment. This provides them with an opportunity to " explore intrapsychic and interpersonal problems and find more constructive ways of dealing with distress" ( Campling 2001). Therapeutic community treatment is the only single treatment modality for severe personality disorder (which is likely to encompass AsPD and some other forms of personality disorder) that has been subject to a meta-analysis of randomised controlled trials. This demonstrated the effectiveness of therapeutic community treatment ( Lees 1999) but several of the included studies did not specifically identify the participants as suffering from AsPD.

Nidotherapy is a formalised, planned method for achieving environmental change to minimise the effect of the patient's disorder upon themselves and others. The effectiveness of this treatment has not yet been established. Unlike most other therapies it aims to fit the immediate environment to the patient rather than change the patient to cope in the existing environment ( Tyrer 2007). Whilst the eventual outcome of nidotherapy is environmental manipulation, it may be regarded as a psychological intervention in that it relies upon first developing a psychological understanding of the person's strengths and difficulties. From this psychological formulation there follows goal setting from which flows the necessary changes in the person's physical and social environment ( Tyrer 2005a).

Why it is important to do this review

AsPD is closely associated with criminal offending and any intervention that seeks to improve the outcome of AsPD is also likely to impact upon this offending. Aos 2001 reported that " for some crimes (especially those involving violence), the cost benefits in favour of intervention are often considerable as the costs of these types of crimes are often very high ".

Despite this, there is currently a dearth of evidence on how best to treat people diagnosed with AsPD, and to date the few reviews that have been carried out have been inconclusive and hampered by poor methodology. These issues were highlighted in Dolan and Coid's ( Dolan 1993) extensive review of the treatment of psychopathic and antisocial personality disorders. Unfortunately the challenge to produce high quality research in this area does not appear to have been fully taken up by the research community. This led a recent Review of Treatments for Severe Personality Disorder by the United Kingdom's Home Office ( Warren 2003) to wryly comment that " Despite the 1,600 copies of Dolan and Coid's review having been purchased by clinicians, academics and institutions the methodological issues which were clearly set out in that review appear not to have been taken on board by the scientific community or those who fund research". Similarly the recently published NICE clinical guidelines on the treatment of AsPD ( NIHCE 2009, p.5) commented that there were " significant limitations to the evidence base, notably a relatively small number of randomised controlled trials (RCTs) of interventions with few outcomes in common ".

It is hoped that there will now have been additional good quality studies to address this important topic. Furthermore, a Cochrane Review of psychological treatments for AsPD will highlight areas where more work is needed and hopefully stimulate research interest.

OBJECTIVES

This review aims to evaluate the potential beneficial and adverse effects of psychological interventions for people with antisocial personality disorder.

METHODS

Criteria for considering studies for this review

Types of studies

Controlled trials in which participants have been randomly allocated to an experimental group and a control group, where the control condition is either treatment as usual, waiting list or no treatment. We included all relevant randomised controlled trials, with or without blinding of the assessors, and published in any language.

Types of participants

Men or women 18 years or over with a diagnosis of antisocial personality disorder defined by any operational criteria such as DSM-IV, or dissocial personality disorder as defined by operational criteria such as ICD-10. We included studies of people diagnosed with comorbid personality disorders or other mental health problems other than the major functional mental illnesses (i.e. schizophrenia, schizoaffective disorder or bipolar disorder). The decision to exclude persons with co-morbid major functional illness is based on the rationale that the presence of such disorders (and the possible confounding effects of any associated management or treatment) might obscure whatever other psychopathology (including personality disorder) might be present and make it more difficult to evaluate the potential effect of any intervention. We placed no restrictions on setting and included studies with participants living in the community as well as those incarcerated in prison or detained in hospital.

Types of interventions

We included studies of psychological interventions, both group and individual-based. This included, but was not limited to, interventions such as:

1. behaviour therapy;

2. cognitive analytic therapy;

3. cognitive behavioural therapy;

4. dialectical behaviour therapy;

5. group psychotherapy;

6. mentalisation-based therapy;

7. nidotherapy;

8. psychodynamic psychotherapy;

9. schema focused therapy;

10. social problem-solving therapy; and

11. therapeutic community treatment.

Psychological interventions were subclassified into single modality and complex psychological interventions. Single modality psychological interventions are those that only involve one specific type of intervention. Such interventions include cognitive analytic therapy and cognitive behavioural therapy. Complex psychological interventions are those that involve more than one modality of treatment (for example, group therapy plus individual therapy) and include dialectical behaviour therapy and psychodynamic psychotherapy with partial hospitalisation ( Campbell 2000).

We included studies of psychological interventions where medication was given as an adjunctive intervention, but reported separately any studies where the comparison is between a psychological and a pharmacological intervention.

Studies comparing two or more different therapeutic modality groups but without a control group are not included in the review.

Types of outcome measures

Primary and secondary outcomes are listed below in terms of single constructs. We anticipated that a range of outcome measures would have been used in the studies included in the review (for example, aggression may be measured by a self-report instrument or by an external observer).

Primary outcomes

Aggression

reduction in aggressive behaviour or aggressive feelings; continuous outcome, measured through improvement in scores on the Aggression Questionnaire (AQ; Buss 1992), the Modified Overt Aggression Scale (MOAS; Malone 1994) or similar validated instrument; or as number of observed incidents.

Social functioning

continuous outcome, measured through improvement in scores on the Social Adjustment Scale (SAS-SR; Weissman 1976), the Social Functioning Questionnaire (SFQ; Tyrer 2005b) or similar validated instrument.

Secondary outcomes

Anger

self-reported improvement in anger expression and control; continuous outcome, measured through reduction in scores on the State-Trait Anger Expression Inventory-2 (STAXI-II; Spielberger 1999) or similar validated instrument.

Whilst acknowledging that the nature of the disorder can lead to difficulty in long-term follow up of individuals with AsPD, we aimed to report relevant outcomes without restriction on period of follow up. We aimed to divide outcomes into immediate (within six months), short-term (> 6 months to 24 months), medium term (> 24 months to five years) and long-term (beyond five years) if there were sufficient studies to warrant this.

Search methods for identification of studies

Electronic searches

The following electronic databases were searched to September 2009:

MEDLINE (from 1950);

EMBASE (from 1980);

CINAHL (from 1982);

the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library 2009, issue 3);

PsycINFO (from 1872);

Cochrane Schizophrenia Group's register of trials related to forensic mental health;

ASSIA;

BIOSIS;

COPAC;

Dissertation Abstracts;

ISI-Proceedings;

ISI-SCI (Science Citation Index);

ISI-SSCI (Social Sciences Citation Index);

OpenSIGLE;

Sociological Abstracts;

ZETOC;

National Criminal Justice Reference Service Abstracts;

UK Clinical Trials Gateway*;

ClinicalTrials.gov*;

Action Medical Research*;

King's College London (UK)*;

ISRCTN Register*;

The Wellcome Trust Register*;

NHS Trusts Clinical Trials Register*;

NHS R & D Health Technology Assessment Programme Register (HTA)*; and

NHS R & D Regional Programmes Register*.

*Searched using the meta Register of Controlled Trials ( http://www.controlled-trials.com/mrct/).

Searching other resources

We searched the reference lists of included and excluded studies for additional relevant trials. We examined bibliographies of systematic review articles published in the last five years to identify relevant studies. We contacted authors of relevant studies to enquire about other sources of information and the first author of each included study for information regarding unpublished data.

Data collection and analysis

Selection of studies

Because this review is part of a larger series of reviews of personality disorders, the selection of studies was carried out in two stages. In the first stage, titles and abstracts were read independently by two review authors (JS and NH) against the inclusion criteria to identify all studies carried out with participants with personality disorder, regardless of any specific personality disorder(s) diagnosed. In the second stage, full copies of studies identified in stage one were assessed against the inclusion criteria by two review authors independently (SG and BV). This second stage assessment identified not only trials with participants diagnosed with antisocial or dissocial PD, but also trials with participants having a mix of PDs for which data on a subgroup with antisocial or dissocial PD might be available.

Studies with two treatment conditions in which the relevant participants formed a small subgroup were only included if the trial investigators randomised at least five people with antisocial or dissocial personality disorder. The rationale is that variance and standard deviation cannot be calculated in samples of two or less, and a two-condition study that randomises less than five relevant participants will have at least one arm for which variance or standard deviation cannot be calculated.

Uncertainties concerning the appropriateness of studies for inclusion in the review were resolved through consultation with a third review author (CD).

Data extraction and management

Three review authors (MF, NH and SG) extracted data independently using a data extraction form and entered data into RevMan 5 ( RevMan 2008). Where data were not available in the published trial reports, we contacted the authors and asked them to supply the missing information. We made significant efforts to contact the primary trial investigator for missing data on any subgroup of participants diagnosed with AsPD where this was not published. If these data were made available to us, we included the data in the review. If data were not forthcoming, we attempted to contact at least one of the co-investigators. A reasonable length of time (eight weeks) was allowed for the investigator(s) to supply the missing data before we proceeded with the analysis.

Assessment of risk of bias in included studies

For each included study, two review authors (MF and NH) independently completed the Cochrane Collaboration's tool for assessing risk of bias ( Higgins 2008, section 8.5.1) with any disagreement resolved through consultation with a third review author (SG). We assessed the degree to which:

the allocation sequence was adequately generated ('sequence generation');

the allocation was adequately concealed ('allocation concealment');

knowledge of the allocated interventions was adequately prevented during the study ('blinding'), whilst acknowledging that it is generally not possible to blind participants in trials of this nature;

incomplete outcome data were adequately addressed;

reports of the study were free of suggestion of selective outcome reporting; and

the study was apparently free of other problems that could put it at high risk of bias.

We allocated each domain one of three possible categories for each of the included studies: 'Yes' for low risk of bias, 'No' for high risk of bias, and 'Unclear' where the risk of bias was uncertain or unknown.

Measures of treatment effect

For dichotomous (binary) data, we used the odds ratio with a 95% confidence interval to summarise results within each study. The odds ratio is chosen because it has statistical advantages relating to its sampling distribution and its suitability for modelling, and because it is a relative measure and so can be used to combine studies.

For continuous data, such as the measurement of impulsiveness on a scale, we compared the mean score for each outcome as determined by a standardised tool between the two groups to give a mean difference (MD), again with a 95% confidence interval. Where possible, we made these comparisons at specific follow-up periods: (1) within the first month, (2) between one and six months, and (3) between six and 12 months. Where possible, we presented endpoint data. Where both endpoint and change data were available for the same outcomes, then we only reported the former.

We reported continuous data that are skewed in a separate table, and did not calculate treatment effect sizes to minimise the risk of applying parametric statistics to data that depart significantly from a normal distribution. We define skewness as occurring when, for a scale or measure with positive values and a minimum value of zero, the mean is less than twice the standard deviation ( Altman 1996). We summarised change-from-baseline ('change score') data along-side endpoint data where these were available. Change-from-baseline data may be preferred to endpoint data if their distribution is less skewed, but both types may be included together in meta-analysis ( Higgins 2008, page 270). Where the data were insufficient for meta-analysis, we reported the results of the trial investigators' own statistical analyses comparing treatment and control conditions using change scores.

In any meta-analysis, we intended to use the mean difference (MD) where the same outcome measure was reported in more than one study and the standardised mean difference (SMD) if different outcome measures of the same construct had been reported.

Unit of analysis issues

(a) Cluster-randomised trials

See Table 4 for information about future updates of this review.

Table 4

Issue

Method

Cluster-randomised trials

Where trials use clustered randomisation, study investigators may present their results after appropriately controlling for clustering effects (robust standard errors or hierarchical linear models). If, however, it is unclear whether a cluster-randomised trial has used appropriate controls for clustering, we will contact the study investigators for further information. If appropriate controls were not used, we will request individual participant data and re-analysed these using multilevel models which control for clustering. Following this, effect sizes and standard errors will be meta-analysed in RevMan5 using the generic inverse method ( Higgins 2008). If appropriate controls were not used and individual participant data are not available, we will seek statistical guidance from the Cochrane Methods Group and external experts as to which method to apply to the published results in attempt to control for clustering. If there is insufficient information to control for clustering, outcome data will be entered into RevMan5 using the individual as the unit of analysis, and then sensitivity analysis used to assess the potential biasing effects of inadequately controlled clustered trials ( Donner 2001).

Missing data

The standard deviations of the outcome measures should be reported for each group in each trial. If these are not given, we will impute standard deviations using relevant data (for example, standard deviations or correlation coefficients) from other, similar studies ( Follman 1992) but only if, after seeking statistical advice, to do so is deemed practical and appropriate
Assessment will be made of the extent to which the results of the review could be altered by the missing data by, for example, a sensitivity analysis based on consideration of 'best-case' and 'worst-case' scenarios ( Gamble 2005). Here, the 'best-case' scenario is that where all participants with missing outcomes in the experimental condition had good outcomes, and all those with missing outcomes in the control condition had poor outcomes; the 'worst-case' scenario is the converse ( Higgins 2008, section 16.2.2).
We will report data separately from studies where more than 50% of participants in any group were lost to follow up. Where meta-analysis is undertaken, we will assess the impact of including studies with attrition rates greater than 50% through a sensitivity analysis. If inclusion of data from this group results in a substantive change in the estimate of effect of the primary outcomes, we will not add the data from these studies to trials with less attrition and will present them separately
Any imputation of data will be informed, where possible, by the reasons for attrition where these are available. We will interpret the results of any analysis based in part on imputed data with recognition that the effects of that imputation (and the assumptions on which it is based) can have considerable influence when samples are small

Assessment of heterogeneity

We will consider I ² values less than 30% as indicating low heterogeneity, values in the range 30% to 70% as indicating moderate heterogeneity, and values greater than 70% as indicating high heterogeneity. We will make an attempt to identify any significant determinants of heterogeneity categorised at moderate or high

Assessment of reporting biases

We will draw funnel plots (effect size versus standard error) to assess publication bias. Asymmetry of the plots may indicate publication bias, although they may also represent a true relationship between trial size and effect size. If such a relationship is identified, we will further examine the clinical diversity of the studies as a possible explanation ( Egger 1997).

Data synthesis and length of follow up

We will group outcome measures by length of follow up, and use the weighted average of the results of all the available studies to provide an estimate of the effect of psychological interventions for people with antisocial personality disorder. We will use regression techniques to investigate the effects of differences in study characteristics on the estimate of the treatment effects. We will seek statistical advice before attempting meta-regression. If meta-regression is performed, it will be executed using a random-effects model

Subgroup analysis

We will undertake subgroup analysis to examine the effect on primary outcomes of:

1. comorbid diagnosis (e.g. other personality disorder, substance misuse disorder);

2. setting (inpatient, custodial, outpatient/community);

3. category of intervention;

4. whether intervention was group-based or individual-based; and

5. regression techniques will be used to investigate the effects of differences in study characteristics on the estimate of the treatment effects. We will seek statistical advice before attempting meta-regression; if meta-regression is performed, it will be executed using a random-effects model.

Sensitivity analysis

We will undertake sensitivity analyses to investigate the robustness of the overall findings in relation to certain study characteristics. A priori sensitivity analyses are planned for:

1. concealment of allocation;

2. blinding of outcome assessors; and

3. extent of drop-outs.

(b) Multi-arm trials

All eligible outcome measures for all trial arms were included in this review.

Assessment of heterogeneity

We aimed to assess the extent of between-trial differences and the consistency of results of any meta-analysis in three ways: by visual inspection of the forest plots, by performing the Chi ² test of heterogeneity (where a significance level less than 0.10 is interpreted as evidence of heterogeneity), and by examining the I ² statistic ( Higgins 2008; section 9.5.2). The I ² statistic describes approximately the proportion of variation in point estimates due to heterogeneity rather than sampling error. See Table 4 for information about future updates of this review.

RESULTS

Description of studies

Results of the search

We carried out electronic searches over two consecutive time periods to minimise the difficulty of managing large numbers of citations. Searches to December 2006 produced in excess of 10,000 records. From inspection of titles and abstracts we identified 70 citations that appeared to describe randomised studies on psychological interventions for personality disorder. Twenty-one of these appeared to include participants with a diagnosis of antisocial or dissocial personality disorder (PD). Searches from December 2006 to September 2009 produced 6398 records. After excluding studies that focused exclusively on borderline PD, we identified 38 citations that appeared to describe randomised trials on psychological interventions for personality disorder. Twenty-seven of these had the potential to have included participants with a diagnosis of antisocial or dissocial PD. Full copies were obtained of the 48 records of studies where all or part of the sample appeared to meet diagnostic criteria for antisocial or dissocial PD.

Included studies

Of the 48 studies, we identified 11 that fully met the inclusion criteria. Ten included participants with antisocial personality disorder (under DSM criteria). One study ( Tyrer 2004) included participants with dissocial personality disorder (under ICD-10 criteria). Data on participants with antisocial personality disorder (AsPD)were available for five of the 11 studies ( Davidson 2009; Huband 2007; Messina 2003; Neufeld 2008; Woodall 2007) and these are summarised in this review. Data on the subgroup of participants with antisocial (or dissocial) PD from the other six studies ( Ball 2005; Havens 2007; Marlowe 2007; McKay 2000; Tyrer 2004; Woody 1985) were not available at the time this review was prepared.

The 11 included studies involved a total of 14 comparisons of a psychological intervention against a relevant control condition (i.e. treatment as usual, waiting list or no treatment). There were some important differences between the studies. We summarise these differences and the main characteristics below. Further details are provided in the Characteristics of included studies table.

Only three of the included studies addressed the primary outcomes defined in this review. Two studies reported on reconviction ( Marlowe 2007; Woodall 2007) and one reported on aggression ( Davidson 2009).

Design

Ten of the 11 studies were parallel trials with allocation by individual participant, and one ( Havens 2007) was a cluster-randomised trial where the unit of allocation was treatment site. The 10 parallel trials included one two-condition comparison ( Woody 1985) and one three-condition comparison ( Messina 2003) against a control group.

Sample sizes

There was some variation in sample size between studies. Overall, 411 participants with antisocial or dissocial PD were randomised in the nine trials where this allocation was reported unambiguously, with the size of sample ranging from 15 to 100 (mean 45.7; SD 24.8). However, data were available to us for only five of these trials. In these, 276 participants with antisocial or dissocial PD were randomised, and sample size ranged from 24 to 100 (mean 55.2; SD 27.6). The number of participants completing was reported in only four studies where the proportion that completed ranged from 78.8% to 100% (mean 89.1%).

Participants

Participants were restricted to males in three studies ( Davidson 2009; McKay 2000; Woody 1985). The remaining eight studies had a mix of male and female participants. With one exception ( Tyrer 2004), all studies randomised more men than women. The overall mix was 79.9% men as compared to 20.1% women. All eleven studies involved adult participants, with the mean age per study ranging between 25.1 and 43.5 years (average 34.9 years).

Eight studies focused on participants with substance misuse difficulties. For these, inclusion criteria included opioid substance dependence disorder ( Neufeld 2008; Woody 1985), cocaine dependence disorder ( Messina 2003; McKay 2000), sentenced for driving whilst intoxicated ( Woodall 2007), recent alcohol/drug use whilst homeless ( Ball 2005), sentenced for a drug-related offence ( Marlowe 2007), and being an intravenous drug user ( Havens 2007). The remaining three studies did not recruit participants on the basis of substance misuse. For these, the focus was on recurrent self-harm ( Tyrer 2004), violence ( Davidson 2009) and meeting DSM-IV criteria for (any) personality disorder ( Huband 2007).

Only two of the 11 studies focused exclusively on participants with a diagnosis of antisocial PD ( Davidson 2009; Neufeld 2008). For the remaining nine, participants with antisocial or dissocial PD formed a subgroup. The size of this antisocial subgroup ranged from 15 to 52 participants, representing 3.1% to 46.1% respectively of the total sample (mean 28.5%). Data on the antisocial subgroup were available to us for only three ( Huband 2007; Messina 2003; Woodall 2007) of these nine studies.

The precise definition of antisocial personality disorder and the method by which it was assessed varied between the studies. Six used DSM-IV criteria and made assessments using the Structured Clinical Interview for DSM Axis II disorders (SCID-II) ( Davidson 2009; Havens 2007; Messina 2003), an 'antisocial PD interview' developed by the investigators from the SCID-II ( Marlowe 2007), the International Personality Disorder Examination ( Huband 2007), or the Personality Disorder Questionnaire ( Ball 2005). Three studies used DSM-III-R criteria and assessed using the SCID-II ( McKay 2000; Neufeld 2008), or the Diagnostic Interview Schedule ( Woodall 2007). One earlier study used DSM-III criteria and made assessments using the Schedule for Affective Disorders & Schizophrenia and the Maudsley Personality Inventory ( Woody 1985). One study used ICD-10 criteria and assessed using the PAS-Q ( Tyrer 2004).

Ethnicity of participants was not always reported. Where it was, the proportion of the sample described by the investigators as either 'white' or 'Caucasian' ranged from 7% to 67% per study. The total number of white participants randomised expressed as a proportion of total randomised was 58% for those studies where this information was available. Taking just the studies from which data could be extracted for participants with antisocial or dissocial PD, the proportion of the sample described as either 'white' or 'Caucasian' ranged from 31% to 67% per study. Overall, 63% of all participants randomised were described as neither 'white' nor 'Caucasian'.

Interventions

The following types of interventions were represented: behaviour therapy, cognitive behaviour therapy, schema therapy, and social problem-solving therapy. Interventions that were group-based may have included elements of group psychotherapy, depending on how group psychotherapy is defined. None of the 11 studies evaluated psychodynamic psychotherapy, therapeutic community treatment, dialectical behaviour therapy, cognitive analytic therapy, mentalisation-based therapy or nidotherapy.

Table 5

Intervention

Description

Contingency management + standard maintenance
Neufeld 2008
Messina 2003

Neufeld 2008: Contingency-based behavioural programme is a highly structured contingency-based, adaptive treatment protocol comprising counselling sessions and behavioural interventions. Drug abstinence and counselling attendance are rewarded by greater control over methadone management with negative reinforcers being a reduction in methadone dosage and control of the dosage. Standard maintenance comprises standard methadone substitution treatment with two individual counselling sessions per week with bi-weekly reviews; negative drug screens are rewarded with methadone take home doses
Messina 2003: Contingency management + standard maintenance comprises a brief meeting (two to five minutes) with a contingency management technician. Clean urine specimens are rewarded with vouchers of escalating value (to a maximum of $1277. 50 if drug-free for the 16 weeks of the trial) and with praise/encouragement. Positive samples result in the vouchers being with-held but the participant is not rebuked or punished. Participants continue on standard maintenance treatment (including metha-done, mean 62 mg/day)

CBT + treatment as usual
Davidson 2009
Tyrer 2004

Davidson 2009: CBT involves a cognitive formulation of the individual's problems (to promote engagement) and therapy focusing on beliefs about self and others that impair social functioning. Individuals were offered 15 or 30 sessions of CBT (to determine the optimal 'dose') and therapist adherence/competence was assessed for a random selection (30%) of sessions by audio recording and found to be "within competent range".
Tyrer 2004: Manual-assisted cognitive behaviour therapy (MACT) is a treatment for self-harming behaviour where participants are provided with a booklet based on CBT principles plus an offer of five plus two booster sessions of CBT in the first three months

Single modality interventions focused on substance misuse difficulties

Complex interventions focused on substance misuse difficulties

Single modality interventions not focused on substance misuse difficulties

It is important to note that participants allocated to the experimental condition in these studies commonly received some degree of treatment as usual in addition to the intervention under evaluation. It could be argued that the presence of such 'treatment' requires single modality interventions to be reclassified as complex. For example, standard maintenance for participants with opioid dependence commonly includes counselling sessions in addition to methadone maintenance, which could be seen as introducing an additional CBT component. We have, however, chosen to regard single modality interventions as uncontaminated by any 'treatment as usual' providing that similar 'treatment as usual' forms the control condition.

The duration of the interventions (excluding the very short intervention described by Havens 2007) ranged between four and 52 weeks (mean 23.5 weeks; median 24 weeks). Seven studies followed up participants beyond the end of the intervention period by, on average, 30.9 weeks (range four to 104 weeks).

Control conditions

The inclusion criteria required a control condition that was either treatment as usual, waiting list or no treatment (see Types of studies). We considered that all 11 studies had a control condition that could be described as treatment as usual (TAU). This decision was straightforward for six of the 11 studies, as follows. For Davidson 2009 and Tyrer 2004 it was clear that TAU simply comprised whatever treatment the participants would have received had the trial not taken place. For Huband 2007, treatment as usual pertained whilst on a wait-list for the intervention under evaluation. Treatment as usual was incarceration in Woodall 2007, passive referral in Havens 2007 and standard ('unmatched') schedule court hearings in Marlowe 2007.

For the remaining five studies, all of which focused on participants with substance misuse difficulties, we were forced to consider carefully whether the control condition was treatment as usual or an intervention in its own right. In each case we concluded that the control condition could properly be described as TAU because it represented what a treatment-seeking participant with similar substance misuse problems would normally experience had the trial not taken place. The control conditions for these five studies can be summarised:

Ball 2005: up to three sessions per week of group counselling and psychoeducation sessions plus standard methadone maintenance where appropriate, which the trial investigators described as 'standard group substance abuse counselling'.

Messina 2003: one counselling session per fortnight, standard methadone maintenance, case management visits and medical care, which the trial investigators described as 'methadone maintenance only'.

Neufeld 2008: two individual counselling sessions per week with standard methadone maintenance treatment, which the trial investigators described as 'standard methadone substitution treatment'.

Woody 1985: standard drug counselling, which the investigators described as ' a standard individual counselling intervention focused on providing external services rather than dealing with intra-psychic processes ', plus standard methadone maintenance.

McKay 2000: two group therapy sessions per week based on addictions-counselling and 12-step recovery practices, which the trial investigators described as 'standard continuing care treatment'.

Outcomes

Primary outcomes

One study included self-reported aggression as an outcome: Davidson 2009 summarised the number of participants reporting any incident of physical or verbal aggression, as measured with the MacArthur Community Violence Screening Instrument (MCVSI) interview, plus additional questions on four other behaviours (shouting angrily at others; threatening harm to others; causing damage to property; self-harm).

Two studies included reconviction as an outcome: Woodall 2007 reported drink-driving reconviction using data from the New Mexico State Citation Tracking System, and Marlowe 2007 assessed re-arrests and convictions using state criminal justice databases (although with no data available for the subgroup with AsPD).

Adverse effects, which are generally reported only rarely in studies of psychological interventions, were mentioned only by Marlowe 2007 where the investigators noted the absence of any study-related adverse events.

Four studies included self-reported social functioning as an outcome. Both Davidson 2009 and Huband 2007 reported mean scores on the Social Functioning Questionnaire (SFQ). Neufeld 2008 reported composite scores on the family/social domain of the Addiction Severity Index (ASI), and Ball 2005 reported scores using the same measure but with no data available for the subgroup with AsPD. The ASI is a semi-structured interview designed to assess problem severity in seven areas commonly affected by substance misuse difficulties, one of which is termed the family/social domain. Investigators obtained composite scores for this domain ranging from zero to 1.0 and based on problems reported in the last 30 days. Other domains relevant to this review are those concerning alcohol use, drug use and employment problems (see paragraph below on secondary outcomes).

There were five studies that did not report on any of the primary outcomes defined in the protocol for this review ( Havens 2007; McKay 2000; Messina 2003; Tyrer 2004; Woody 1985); of these, only Messina 2003 had data available for participants with AsPD.

Secondary outcomes

Studies varied widely in their choice of secondary outcomes. Seven reported on leaving the study early, measuring this as the proportion of participants discontinuing treatment before endpoint. Three had data available for participants with AsPD ( Davidson 2009; Messina 2003; Neufeld 2008). The remaining four had no data available for the AsPD subgroup ( Ball 2005; Marlowe 2007; McKay 2000; Woody 1985). The mean number of continuing care sessions attended was additionally reported by McKay 2000. Only Davidson 2009 examined satisfaction with treatment as an outcome: the investigators used a semi-structured interview to enquire about 'satisfaction with taking part in study' and rated responses on a Likert scale from 1 to 7.

One study considered employment status: Neufeld 2008 reported mean composite scores on the employment domain of the Addiction Severity Index (ASI).

One study ( Huband 2007) measured self-reported impulsivity using mean scores on the Barratt Impulsiveness Scale (BIS).

Economic outcomes were considered by two studies: Davidson 2009 examined the total cost per participant of healthcare, social care and criminal justice services measured using case records and the Client Service Receipt Inventory (CSRI); Tyrer 2004 calculated as total costs per participant, including costs incurred by all service-providing sectors and productivity losses resulting from time off work due to illness, although with no data available for the subgroup with dissocial PD.

Two studies included a self-reported measure of anger: Davidson 2009 provided mean scores on the NOVACO Scale and Provocation Inventory (NAS-PI), and Huband 2007 provided mean anger expression index scores using the State-Trait Anger Expression Inventory (STAXI-2).

To aid interpretation, 'substance misuse' was considered as two separate outcomes (see section on Differences between protocol and review). Substance misuse (drugs) was examined in six studies using the drug use domain of the Addiction Severity Index (ASI) ( Marlowe 2007; McKay 2000; Neufeld 2008; Woody 1985), using the Cocaine Relapse Interview (CRI) ( McKay 2000), and through urinalysis ( Marlowe 2007; McKay 2000, Messina 2003; Neufeld 2008). Substance misuse (alcohol) was examined by three studies using the alcohol use domain of the Addiction Severity Index ( Neufeld 2008), using the Alcohol Use Disorders Identification Test (AUDIT) ( Davidson 2009), and via the Form 90 (a time-line follow-back self-report method to assess drinking over the previous 90 days) and the Drinker Inventory of Consequences (DrInC-2R) ( Woodall 2007). In addition, Woodall 2007 reported the frequency of drink-driving in 30 days prior to arrest, or in previous 30 days, measured via questionnaire.

The outcome of engagement with services was considered only by Havens 2007 where the investigators report numbers entering into drug addiction treatment services as a key outcome, although with no data available for the AsPD subgroup.

No study reported on quality of life.

Other relevant outcomes

Psychiatric symptoms were measured in several studies: depression scores were reported using the Beck Depression Inventory (BDI) by Woody 1985; both anxiety and depression using the Hospital Anxiety and Depression Rating Scale (HADS) by Davidson 2009; or generally using the Symptoms Checklist (SCL90) ( Woody 1985) or the Brief Symptom Inventory (BSI) ( Ball 2005). Huband 2007 reported on shame using the Experience of Shame Scale (ESS), on dissociation using the Dissociative Experiences Scale (DES), and on social problem-solving ability via Social Problem Solving Inventory-Revised (SPSI-R). Ball 2005 reported on interpersonal problems via the Inventory of Interpersonal Problems (IIP), on severity of PD via the Personality Diagnostic Questionnaire (PDQ), and on schemas via scores on Early Maladaptive Schema Questionnaire-Research (EMSQ-R). Davidson 2009 reported on schemas using the Brief Core Schema Scales (BCSS). Tyrer 2004 reported number of completed suicides and frequency of self-harm episodes via the Parasuicide History Interview (PHI). Finally, therapy retention was measured as total weeks in treatment ( Ball 2005), as adherence to counselling sessions ( Neufeld 2008) or as the proportion therapeutically transferred over to routine care due to poor/partial treatment response in response to ongoing drug use or poor attendance to scheduled services ( Neufeld 2008).

Studies awaiting classification

We identified three studies of psychological treatments for samples with a mixture of personality disorders where it remains unclear whether a subgroup of participants with a diagnosis of antisocial or dissocial PD had been included ( Berget 2008; Evans 1999; Linehan 2006). Clarification has been sought from the trial investigators but no further information was available at the time this review was prepared. Details are provided in the Characteristics of studies awaiting classification table. These may be summarised as follows.

Berget 2008 compared animal-assisted therapy with a control condition in individuals with psychiatric disorders, and may have recruited a subgroup with dissocial PD since 22 of the 90 participants had a disorder diagnosed under sections F60-69 in ICD-10 (disorders of adult personality and behaviour).

Evans 1999 compared manualised cognitive therapy with treatment as usual in adults with recent self-harm and cluster B personality disturbance. The investigators may have recruited a subgroup with dissocial PD since, although formal Axis II diagnoses are not reported, all participants scored on the Personality Assessment Schedule at least to the level of personality disturbance within the flamboyant cluster of ICD-10.

Linehan 2006 compared DBT and community treatment by experts for adults with suicidal behaviour and BPD, and may have recruited a subgroup with AsPD since 11 of the 101 participants (10.9%) had at least one other cluster B personality disorder.

Excluded studies

The remaining 34 studies that failed to meet all inclusion criteria were categorised as excluded studies. Fifteen were excluded because on close inspection, and following translation into English and contact with the investigators where necessary, it became clear that the sample did not include a subgroup with antisocial or dissocial PD. A further six were excluded because there were less than five participants with antisocial or dissocial PD for reasons that are now explained in the Selection of studies section. Five were excluded because participants had not been allocated at random, and a further six because of lack of a relevant control condition. One study was excluded because it was a trial of assessment rather than of psychological treatment, and one because a proportion of the sample had bipolar disorder. Reasons for exclusion of each of these 34 studies are given in the Characteristics of excluded studies table.

We paid particular attention to five of the excluded studies (described in seven separate reports) that compared one psychological treatment against another. Each was excluded because there was no control condition that could be regarded as treatment as usual, waiting list or no treatment. Although none of these studies focused exclusively on AsPD, and none provided data on their AsPD subgroup, each reported information that we considered would be of interest to a clinician who was seeking treatment options for clients with AsPD. Because of this, we have summarised briefly the characteristics of each of these five studies and conclusions drawn by the trial investigators in the Discussion section.

Risk of bias in included studies

There was considerable variation in how the included studies were reported. We attempted to contact the investigators wherever the available trial reports provided insufficient information for decisions to be made about the likely risk of bias, and were successful in respect of four studies.

We summarise below the risk of bias for the 11 included studies. Studies with data that could be extracted for the antisocial or dissocial PD subgroup (n = 5) are summarised separately from those for which data were unavailable (n = 6). This allows the reader to make a separate judgement about possible bias associated with the quantitative data from which conclusions are drawn in this review. Full details of our assessment of the risk of bias in each case are tabulated within the Characteristics of included studies section. Graphical summaries of methodological quality are presented as Figure 1 and Figure 2 .

Allocation

With data (five studies)

We considered the generation of allocation sequence to be adequate in three studies where allocation was by random numbers which were computer-generated ( Davidson 2009; Huband 2007) or derived from a table ( Messina 2003), and in one study where the toss of coin was used ( Neufeld 2008). We classified adequacy of sequence generation as 'unclear' in the remaining study ( Woodall 2007) where the investigators reported that participants had been allocated at random but provided no further information on how this had been achieved. We considered concealment of the allocation sequence adequate for Davidson 2009, Huband 2007, Neufeld 2008 and Messina 2003 where we considered that there was sufficient evidence that the person enrolling participants could not have foreseen assignment. We classified adequacy of sequence concealment as 'unclear' in the remaining study ( Woodall 2007) because the information available was insufficient to allow a judgment to be made.

Without data (six studies)

We classified adequacy of sequence generation as adequate for Tyrer 2004 (computer-generated random numbers) but 'unclear' for the remaining five studies. In each case the investigators reported that participants had been allocated at random but provided no further information on how this had been achieved. We considered concealment of the allocation sequence adequate for Tyrer 2004. We classified adequacy of sequence concealment as 'unclear' in the remaining five studies, again because the information available was insufficient to allow a judgement to be made.

Blinding

We judged that blinding of participants and personnel involved in the delivery of the intervention was not practical in the design of trials of psychological interventions summarised in this review.

With data (five studies)

We considered adequacy of blinding of outcome assessors to be adequate in two studies ( Davidson 2009; Neufeld 2008) and that it was unlikely that this blind could have been broken. In Messina 2003 the outcome assessors were not blinded. We classified two studies as 'unclear' because the information available was insufficient to allow a judgment to be made ( Huband 2007; Woodall 2007).

Without data (six studies)

We judged adequacy of blinding of outcome assessors adequate for Woody 1985, not adequate for McKay 2000 and 'unclear' in the remaining four studies where there was insufficient information to allow a judgement to be made.

Incomplete outcome data

With data (five studies)

We judged none to have adequately addressed incomplete outcome data. We classified all five as 'unclear' because, although numbers balanced approximately between treatment conditions, the reasons for attrition were not available. This generally arose because participants failed to complete endpoint measures without providing a reason. Two of these five studies reported undertaking an intention-to-treat analysis for at least one primary or secondary outcome ( Davidson 2009; Huband 2007) and three provided analysis only for those participants classed by the investigators as 'completers' ( Messina 2003; Neufeld 2008; Woodall 2007).

Without data (six studies)

We classed all six studies as 'unclear' because it was not possible, in the absence of data from the subgroup with antisocial or dissocial PD, to judge the extent and nature of any missing data, and whether the reasons for such missing data balance across intervention groups.

The overall proportion of missing data (treatment and control conditions combined) varied significantly between studies. Missing data rates for the five studies with data were calculated as number with endpoint scores in comparison with number randomised and ranged from 8.3% to 29.2% (mean 18.0%; SD 7.8%; median 17.3%). Mean rates by type of intervention, calculated similarly, were as follows: CBT 18.2% (two studies); contingency management plus standard maintenance 13.0% (two studies); social problem-solving therapy with psychoeducation 29.2% (one study); DWI program with incarceration 17.3% (one study). These percentages should be regarded with caution for studies where the sample size is small.

Selective reporting

With data (five studies)

We judged that all five studies appeared to have reported on all the measures they set out to use and at all time scales in as far as could be discerned from the published reports without access to the original protocols.

Without data (six studies)

We classified all six studies as 'unclear' because it was not possible, in the absence of data from the subgroup with antisocial or dissocial PD, to judge whether there was selective reporting of any relevant data.

Other potential sources of bias

With data (five studies)

Messina 2003 report providing a reduction of $40 per month (representing a discount of between 22% and 29%) in the cost of methadone maintenance treatment as an incentive for participation in the study. Review authors classed this as 'unclear' because of uncertainty whether this could have introduced bias. We judged the remaining four studies free of other potential sources of bias.

Without data (six studies)

We classed Marlowe 2007 as 'unclear' because of uncertainty about possible risk of bias from diagnosis of AsPD using an 'antisocial personality disorder interview' derived from SCID-II by the trial investigators but with no information on its validation. Havens 2007 was classed as 'unclear' because, as the trial investigators acknowledged, selection bias may have been present because only those completing the one-month follow up were eligible for psychiatric assessment and participants in the case management arm were significantly less likely to have been followed up. We judged the remaining four studies free of other potential sources of bias.

Effects of interventions

Comparison 1. Contingency management + standard maintenance versus standard maintenance alone

Two studies were included in this comparison: Neufeld 2008 (outpatients with AsPD and opioid dependence; six months treatment; n = 100) and Messina 2003 (outpatients with cocaine dependence; AsPD subgroup; 16 weeks treatment; n = 26).

1.2 Leaving the study early

Both Neufeld 2008 and Messina 2003 provide data on leaving the study early. Meta-analysis of data from these two studies indicates no statistically significant difference between treatment and control conditions (OR 0.59; 95% CI 0.28 to 1.24, P = 0.16, I ² = 0%; P value for heterogeneity 0.69, Analysis 1.2 ).

1.3 Substance misuse (drugs)

Messina 2003 report data indicating a statistically significant difference between treatment and the control condition in numbers with cocaine-negative specimens by week 17 (OR 8.56; 95% CI 1.33 to 54.95, P = 0.02, Analysis 1.4 ), by week 26 (OR 11.67; 95% CI 1.53 to 89.12, P = 0.01, Analysis 1.5 ), and by week 52 (OR 10.00; 95% CI 1.44 to 69.26, P = 0.02, Analysis 1.6 ), favouring treatment in each case. Messina 2003 also report skewed summary data (see Table 2 ) indicating a statistically significant greater mean number of cocaine-negative specimens for the treatment compared to the control condition by 16 weeks (P < 0.05; two-way ANOVA with Tukey-Kramer post-hoc test; analysis of completers by the trial investigators). The trial investigators conclude that " ... patients with AsPD were more likely to abstain from cocaine use during treatment than patients without AsPD. The strong treatment effect for AsPD patients was primarily due to the contingency management condition. Regression analyses showed that AsPD remained significantly related to contingency management treatment responsivity while controlling for other factors". (Abstract, p.320, Messina 2003). Neufeld 2008 report data indicating no statistically significant difference between treatment and control conditions in (adjusted) mean composite drug domain scores via the Addiction Severity Index at six months (data presented graphically; hierarchical regression model with variables at one, two, three and six months including condition, time, time-by-condition interaction and polydrug use at baseline; analysis of completers by the trial investigators, see Table 1 ). Neufeld 2008 also report summary data (see Table 3 ) indicating no statistically significant difference between treatment and control conditions at six months for overall percentage of opioid-negative urine specimens (OR 1.31; 95% CI 0.71 to 2.42, P = 0.39), of cocaine-negative urine specimens (OR 1.59; 95% CI 0.86 to 2.96, P = 0.14), of sedative-negative urine specimens (OR 1.82; 95% CI 0.72 to 4.42, P = 0.18) and of negative urine specimens for any drug (OR 1.70; 95% CI 0.94 to 3.07, P = 0.08), each being an analysis of completers carried out by the trial investigators.

1.6 Other outcomes

Neufeld 2008 report summary data (see Table 4 ) indicating a greater, statistically significant, overall number of counselling sessions attended in proportion to the total number of sessions offered for treatment compared to the control condition by six months (OR 4.00, 95% CI 2.39 to 6.70, P < 0.0001; analysis of completers by the trial investigators). The trial investigators concluded that " subjects in the experimental group had significantly better counselling attendance ... compared to the control group. The experimental intervention increased attendance in subjects with low and high levels of psychopathy and with and without other psychiatric co-morbidity." (Abstract, p.101, Neufeld 2008).

Comparison 2. CBT + standard maintenance versus standard maintenance alone

Two studies were included in this comparison: Messina 2003 (outpatients with cocaine dependence; AsPD subgroup; 16 weeks treatment; n = 27) and Woody 1985 (male outpatients with opioid dependence; 24 weeks treatment; n = 50; no data available for control condition for the AsPD subgroup).

2.1 Leaving the study early

Messina 2003 report data indicating no statistically significant difference between treatment and control conditions for leaving the study early (OR 0.38; 95% CI 0.03 to 4.87, P = 0.46, Analysis 4.1 ). Woody 1985 provide data on leaving the study early, but with no data for the AsPD subgroup.

2.2 Substance misuse (drugs)

Woody 1985 provide data on drug domain scores via the Addiction Severity Index, but with no data for the AsPD subgroup.

2.3 Other outcomes

Woody 1985 provide data on psychiatric symptoms via scores on the SCL-90 and on depression via scores on the Beck Depression Inventory, but with no data for the AsPD subgroup.

Comparison 3. Contingency management + CBT + standard maintenance versus standard maintenance alone

One study was included in this comparison: Messina 2003 (outpatients with cocaine dependence; AsPD subgroup; 16 weeks treatment; n = 19).

3.2 Substance misuse (drugs)

Comparison 4. CBT + treatment as usual versus treatment as usual

Two studies were included in this comparison: Davidson 2009 (male outpatients with AsPD and recent verbal/physical violence; six and 12 months treatment; n = 52) and Tyrer 2004 (outpatients with recurrent self-harm; dissocial PD subgroup; up to seven treatment sessions; n = 15; no data available).

4.1 Aggression

Davidson 2009 report data indicating no statistically significant difference between treatment and control conditions from baseline to endpoint at 12 months in the change (reduction) in number reporting any act of verbal aggression (OR 0.94; 95% CI 0.29 to 3.00, P = 0.92, Analysis 2.3 ) or of physical aggression (OR 1.20; 95% CI 0.40 to 3.62, P = 0.75, Analysis 2.5 ). The trial investigators observed, however, that " incidents of any acts of verbal or physical aggression decreased in both groups over the year of the study ". (p.574).

4.4 Leaving the study early

Davidson 2009 report data indicating no statistically significant difference between treatment and control conditions for leaving the study early by three months (OR 0.63; 95% CI 0.19 to 2.13, P = 0.46, Analysis 2.7 ), by six months (OR 0.96; 95% CI 0.31 to 2.96, P = 0.94, Analysis 2.8 ), by nine months (OR 1.84; 95% CI 0.61 to 5.57, P = 0.28, Analysis 2.9 ), or by 12 months (OR 0.88; 95% CI 0.23 to 3.33, P = 0.84, Analysis 2.10 ).

4.6 Economic outcomes

Davidson 2009 provide data on the total cost of health, social work and criminal justice services received over 12 months, and the average cost per participant for NHS services alone over 12 months (see Table 8 ) but with no statistics. Tyrer 2004 provide the total costs per patient over one year for the whole sample, but with no data for the dissocial PD subgroup.

4.8 Other outcomes

Davidson 2009 report skewed summary data (see Table 9 ) indicating no statistically significant difference between treatment and control conditions for mean BCSS (Brief Core Schema Scales) scores at 12 months on the self-as-positive subscale (P = 0.89; mean difference in change from baseline −0.2, 95% CI −3.6 to 3.1), the self-as-negative subscale (P = 0.64; mean difference in change from baseline −0.8, 95% CI −4.3 to 2.7), the others-as-positive subscale (P = 0.10; mean difference in change from baseline −2.6, 95% CI −5.8 to 0.5) and the others-as-negative subscale (P = 0.15; mean difference in change from baseline −2.4, 95% CI −5.8 to 0.9; intention-to treat-analysis by the trial investigators in each case). Tyrer 2004 provide data on number of completed suicides for the whole sample and on frequency of self-harm episodes via the Parasuicide History Interview, but with no data for the dissocial PD subgroup. The trial investigators conclude for the sample as a whole ' Although the results showed no significant difference between those repeating self-harm in the manual-assisted CBT group (39%) compared with the TAU group (46%) (P = 0.20), the treatment was cost-effective [10% cheaper than TAU] and the frequency of self-harm episodes was fewer [50%] in the manual-assisted CBT group. ' (Abstract, p.102).

Comparison 5. Social problem-solving therapy with psychoeducation versus treatment as usual

One study was included in this comparison: Huband 2007 (community living adults with personality disorder; AsPD subgroup; 24 weeks treatment; n = 24). The trial investigators, while providing data on the AsPD subgroup, noted that their trial was not designed to have sufficient power to detect significant change in subgroups of this size, and also that 20 of the 24 had at least one other Axis II diagnosis.

5.5 Other outcomes

Huband 2007 report data indicating no statistically significant difference between treatment and control conditions at six months in mean SPSI social problem-solving ability scores (MD 0.18; 95% CI −2.57 to 2.93, P = 0.90, Analysis 3.2 ), in mean ESS shame scores at six months (MD 14.64; 95% CI −12.70 to 41.98, P = 0.29, Analysis 3.5 ) and in mean DES dissociation scores at six months (MD 4.30; 95% CI −21.19 to 29.79, P = 0.74, Analysis 3.6 ).

Comparison 6. 'Driving Whilst Intoxicated program' + incarceration versus treatment as usual (incarceration alone)

One study was included in this comparison: Woodall 2007 (incarcerated drink-driving offenders with AsPD; 28 days treatment; n = 52).

6.1 Reconviction

Woodall 2007 report data indicating no statistically significant difference between treatment and control conditions in reconviction for drink-driving (Cox regression of re-arrest rates) over 24 months (HR 0.56; 95% CI −0.19 to 1.31, P = 0.15, Analysis 6.1 ). The trial investigators concluded that " although non-significant, AsPD participants in the treatment group were considerably less likely to be re-arrested for DWI than AsPD participants in the control group " (p.985, col 1).

6.2 Substance misuse (alcohol)

Woodall 2007 provide descriptive and graphical summaries (p.983, col 1) of analyses of self-reported alcohol use using the Form90 measure. These showed a statistically significant difference between treatment and control conditions (group × AsPD × time interaction) over the 24-month period for both total standard ethyl-alcohol consumption units and number of drinking days, favouring treatment in each case (P < 0.05; omnibus test; repeated measures ANOVA, mixed factorial design with Geisser-Greenhouse adjustment; analysis of completers by the trial investigators). A similar analysis for average blood alcohol content did not indicate statistically significant differences (P = 0.052).

The trial investigators concluded that " participants randomized to receive the first offender incarceration and treatment [DWI] program reported greater reductions in alcohol consumption from baseline levels when compared with participants who were only incarcerated. AsPD participants reported heavier and more frequent drinking but showed significantly greater decline in drinking from intake to post-treatment assessments." (Abstract, p.974, Woodall 2007).

6.3 Other outcomes

Woodall 2007 report skewed summary data indicating no statistically significant difference between treatment and control conditions for mean number of days driving after drinking in past 30 days (see Table 10 ) and for mean number of days driving after five or more drinks in past 30 days (see Table 11 ) at six, 12 and 24 months post incarceration (P values not provided, but not significant for the group-by-time interaction; ANOVA mixed factorial design; completer analysis by the trial investigators). However, the trial investigators report a significant overall main effect of time for the whole sample (P < 0.001), " indicating a decline in self-reported drinking and driving from intake to post-incarceration assessments" (p.982, col 2) and a " significant AsPD-by-time interaction (P < 0.001) resulting from the fact that, contrary to expectations, the AsPD participants showed a greater improvement over time than the non-AsPD participants on both these self-reports of drinking and driving. " (p.982, col 2).

Comparison 7. Optimal judicial supervision versus treatment as usual (standard judicial supervision)

One study was included in this comparison: Marlowe 2007 (adults drug offenders supervised by pre-adjudication court; AsPD subgroup; average nine months treatment; n = unknown; no data available). This study compares optimal ('matched') judicial supervision with standard judicial supervision (treatment as usual) in adult drug court offenders. Trial investigators used diagnosis of AsPD as one criterion for assignment to high (rather than low) risk category, but no data was available for the AsPD subgroup. Marlowe 2007 provide data on reconviction (to 24 months post-admission), substance misuse (drugs) (self-report via the Addiction Severity Index, and drug screen by urinalysis), leaving the study early and adverse events (descriptively only; " no study-related adverse event was reported to date " (p.56, col 1)), but with no data for the AsPD subgroup.

The trial investigators conclude ... "high risk participants graduated [from the program] at a higher rate, provided more drug-negative urine specimens at 6 months post-admission, and reported significantly less drug use and alcohol intoxication at 6 months post-admission when they were matched to bi-weekly hearings [i.e. optimal judicial supervision] as compared to the usual schedule of hearings [i.e. standard judicial supervision]." (Abstract, p.S4, Marlowe 2007).

Comparison 8. Supportive-expressive psychotherapy + standard maintenance versus standard maintenance alone

One study was included in this comparison: Woody 1985 (male outpatients with opioid dependence; AsPD subgroup; 24 weeks treatment; n = 50; no data available). The trial investigators report on AsPD subgroup with data for the experimental condition, but not for control condition for the AsPD subgroup. Woody 1985 provide data on leaving the study early, substance misuse (drugs) (self-report via the Addiction Severity Index), psychiatric symptoms (scores on the SCL90), and depression (scores on the BDI), but with no data for the AsPD subgroup in the control condition. Trial investigators conclude " Those with opiate dependence plus AsPD alone improved only on ratings of drug use. Patients with opiate dependence alone or with opiate dependence plus depression improved significantly and in many areas. Opiate-dependent patients with AsPD plus depression responded almost as well as those with only depression. AsPD alone is a negative predictor of psychotherapy outcome, but the presence of depression appears to be a condition that allows the patient to be amenable to psychotherapy, even though the behavioural manifestations of sociopathy are present." (Abstract, p.1081, Woody 1985).

Comparison 9. Dual-focus schema therapy versus treatment as usual

One study was included in this comparison: Ball 2005 (homeless adults with substance abuse; AsPD subgroup; 24 weeks treatment; n = 24; no data available). This study describes an RCT comparing dual-focus schema therapy with treatment as usual (TAU) in homeless substance abusers.

Ball 2005 provide data on leaving the study early, therapy retention (as total weeks in treatment), therapy utilisation (number weeks in which sessions attended), psychiatric symptoms (via the Brief Symptom Inventory (BSI)), early maladaptive schemas (scores on the Early Maladaptive Schema Questionnaire-Research (EMSQ-R)), interpersonal problems (scores on the Inventory of Interpersonal Problems (IIP)) and social/family functioning (via the Addiction Severity Index (ASI)) for the whole sample, but with no data for the AsPD subgroup.

Trial investigators concluded " Overall, there was greater utilization of individual dual-focus schema therapy than standard group substance abuse counselling [i.e. treatment as usual]. However, clients with more severe personality disorder symptoms demonstrated better utilization of standard group substance abuse counselling than dual-focus schema therapy." (Abstract, p.371, Ball 2005).

Comparison 10. Case management versus treatment as usual (passive referral)

One study was included in this comparison: Havens 2007 (intravenous drug-using outpatients; AsPD subgroup; four weeks treatment; n = unknown; no data available). This study describes a cluster RCT and compares participants with and without AsPD. Havens 2007 provide data on engagement with services (as entry into treatment) for the whole sample, but with no data for the AsPD subgroup.

The trial investigators concluded for the whole sample " In a multivariate intention-to-treat model (i.e. ignoring the amount of case management actually received), those randomised to case management were more likely to enter treatment within 7 days. Additional 'as treated' analyses revealed that participants who received 30 min or more of case management within 7 days were 33% more likely to enter treatment and the active ingredient of case management was provision of transportation." (Abstract, p. 225, Strathdee 2006).

Additionally, investigators concluded " Compared to those without AsPD, intravenous drug users with comorbid AsPD who spent 25 or more minutes with their case manager prior to their treatment entry date were 3.51 times more likely to enter treatment than those receiving less than 5 minutes, adjusting for interventions status, race, and treatment site (98% confidence interval 1.04 to 11.89). Providing case management services to intravenous drug users with comorbid AsPD may facilitate treatment entry and reduce negative consequences of drug abuse." (Abstract, p.267, Havens 2007).

Comparison 11. Individualised relapse prevention versus treatment as usual (standard continuing care treatment)

One study was included in this comparison: McKay 2000 (male outpatients with cocaine dependence; AsPD subgroup; 20 weeks treatment; n = 46; no data available). McKay 2000 provide data on substance misuse (self-report via the Addiction Severity Index (ASI) and the Cocaine Relapse Interview, and drug screen by urinalysis) for the whole sample, but with no data for the AsPD subgroup.

The trial investigators concluded that " a diagnosis of AsPD was not a predictor of differential response to the two continuing care interventions in the study. However, AsPD patients had worse medical and psychiatric problem severity than non-AsPD patients at entrance to continuing care and during follow-up. These results suggest that cocaine patients with AsPD who are in the continuing care phase of outpatient rehabilitation might benefit from additional medical and psychiatric treatment services." (Abstract, p.287, McKay 2000).

DISCUSSION

As described in the introduction, antisocial personality disorder (AsPD) is a prevalent condition associated with considerable personal and societal adverse consequences. It also has major negative economic consequences as it is associated with poor occupational productivity and increased criminal justice costs. Consequently, one might expect that the identification of interventions that might reduce this impact would be a research priority. Unfortunately, the conclusion of this review is similar to many that preceded it in that there is little good quality evidence as to what might (or might not) be effective for this condition. As only 11 studies could be included in the review, the first point to make therefore is how few studies there were to consider.

The second refers to the design and methodological quality of the few studies that could be included. Disappointingly few of the included studies addressed the primary outcomes defined in this review. While the underlying personality structure of AsPD comprises dissociate traits such as impulsivity, lack of remorse and irritability, its most common behavioural manifestation is persistent rule-breaking. Although the focus on behaviour, rather than on the underlying personality structure, has been frowned upon by some commentators (e.g. Livesley 2007), we argue that persistent rule-breaking is akin to a final common pathway manifestation of the underlying personality structure. If one accepts this argument, it is disappointing that only two of the included studies ( Marlowe 2007; Woodall 2007) had reconviction as their primary outcome. Another ( Davidson 2009) used self-reported aggression. In the light of the important adverse cost consequences of the condition and likely need for complex and expensive interventions, it was also disappointing that only two studies ( Davidson 2009; Tyrer 2004) considered the economic impact of their intervention.

Furthermore, the majority of the included studies were trials to reduce substance misuse. As many within the sample of substance misusers also satisfied criteria for AsPD, there was an opportunity to report on these separately. Hence, strictly speaking, these were not interventions for AsPD; rather, they were interventions to reduce substance misuse in a sample, some of whom also satisfied criteria for AsPD. While these studies were not without their limitations, there is evidence that contingency management is effective in reducing substance misuse in this population. While this finding is similar to the recent NICE guidance on opioid detoxification ( NIHCE 2007) in general, it suggests that this principle of intervention is also effective in those with AsPD.

Summary of main results

A proportion of the quantitative data available from the studies included in this review met our criteria for skewed data as described in the section on Measures of treatment effect. Consequently, in the absence of raw data from the trial investigators, we have presented all skewed data as Additional tables and have reported statistics on comparisons between conditions as calculated by the trial investigators rather than performing our own analysis. We did not carry out any synthesis of primary or secondary outcome data via meta-analysis (other than for the outcome of leaving the study early) because (a) data for an outcome was available from only one study, or (b) we wanted to minimise the risk of applying parametric statistics to skewed data that was not normally distributed. The summaries that follow below are therefore essentially descriptive. The focus of this review is relatively broad since it seeks evidence on effectiveness of any psychological intervention in the treatment of antisocial or dissocial personality disorder. We found considerable differences between the studies in terms of participants, size of sample, intervention modality and choice of outcome measures.

We found only three interventions (contingency management with standard maintenance; CBT with standard maintenance; 'Driving Whilst Intoxicated program' with incarceration) which were effective, compared to the control condition, in terms of improvement in at least one outcome in at least one study. Each of these interventions had been developed for people with substance misuse problems. No study reported significant change in any specific antisocial behaviour, such as offending, aggression or impulsivity.

For the 'contingency management' intervention, two studies produced contrasting results in terms of drug misuse ( Messina 2003 and Neufeld 2008). The Addiction Severity Index (ASI) results in Section 1.10 a: Substance misuse (drugs) and in Section 1.10b: Substance misuse (alcohol) favoured the intervention over control in the Messina 2003 study but not the Neufeld 2008 study. However, contingency management was superior in terms of social functioning and counselling session attendance in Neufeld 2008. These differences may have arisen because of differences in the nature of the behavioural intervention. Both studies describe 'contingency management', but the positive reinforcements available in the Messina study for participants who stayed drug-free seem considerably more attractive. For example, a participant in the Messina study who managed to stay drug-free for the whole 16 weeks of the trial could earn redeemable vouchers worth a total of $1277. In contrast, the positive reinforcement in the Neufeld 2008 trial comprised greater control over methadone clinic attendance and dosage in reward for drug abstinence and attendance at counselling sessions.

A note on the five excluded trials that compared one psychological intervention against another

We excluded five studies (described in seven separate reports) that compared one psychological treatment against another because there was no control condition that could be regarded as treatment as usual, waiting list or no treatment. Although none of these five studies focused exclusively on AsPD, and none provided data on their AsPD subgroup, each reported information that we consider to be of interest to a clinician seeking treatment options for this client group. Because of this, we now summarise briefly the characteristics of each of these five studies and the conclusions drawn by the trial investigators.

Ball 2007 conducted a randomised trial comparing dual-focus schema therapy (DFST) with 12-step facilitation therapy (12FT) in 30 opioid-dependent outpatients who were receiving methadone maintenance. The investigators note that DFST focuses on achievable goals such as improving self-esteem, relationships and exposure to substance abuse, but does seek to achieve full remission. Both therapies were manual-guided and were delivered for six months. All participants had at least one DSM-IV personality disorder diagnosed using the SCID-II.

AsPD was the most common diagnosis (n = 19) followed by borderline, avoidant and dependant personality disorder (PD), although the trial investigators did not report results from the AsPD subgroup separately. For the whole sample, the investigators report no significant differences between the two therapies on retention, utilisation or reduction in psychiatric symptoms or psychosocial impairment. However, participants allocated to DFST showed more rapid decrease in the frequency of substance use over six months in comparison with those allocated to 12FT. DFST was also associated with a stronger therapeutic alliance between therapists and participants, whereas 12FT showed a better reduction of dysphoric affect.

Easton 2007 describe a study aggregating results of two controlled trials: Carroll 2004 in outpatients with cocaine dependence, and Carroll 1998 in outpatients with cocaine and alcohol dependence. The first trial ( Carroll 2004) randomised to four conditions to allow comparison between CBT and interpersonal therapy (IPT), both with and without disulfiram. The other trial ( Carroll 1998) involved five conditions: CBT plus disulfiram, 12-step facilitation plus disulfiram, supportive psychotherapy plus disulfiram, CBT plus no medication and 12-step facilitation plus no medication. Treatment duration was 12 weeks in each case. Both trials had a subgroup with AsPD (pooled n = 79), although neither study nor Easton 2007 analyse results from the AsPD subgroup separately. Carroll 2004 report that, for their whole sample (of which 41% had AsPD), those allocated to CBT reduced their cocaine use significantly more than those allocated to IPT. Carroll 1998 report that, for their whole sample (of which 25% had AsPD), those allocated to CBT and 12-step facilitation significantly reduced their cocaine use over time compared with the supportive psychotherapy condition. Taking the results of the two trials together, there were no significant differences between participants with and without criminal justice involvement in frequency of substance use during treatment or the one-year follow up ( Easton 2007).

Longabaugh 1994 conducted a randomised trial comparing CBT with relationship enhancement therapy for 229 outpatients with alcohol abuse problems. Treatment was for 20 sessions in each case and was completed in four to six months. A subgroup (n = 48) met criteria for DSM-III AsPD via the Diagnostic Interview Schedule, of which 31 were used in the investigators' analysis. At 13 to 18 months following start of treatment, the investigators report that participants with AsPD averaged more abstinent days than those without AsPD. In addition, participants with AsPD who were allocated to CBT drank less per drinking day than did either those without AsPD who were allocated to CBT or those with AsPD allocated to relationship enhancement therapy. The investigators conclude that, irrespective of drinking index, participants with AsPD responded poorly with high post-treatment support for abstinence, whereas those without AsPD responded better with support.

Vinnars 2005 compared manualised supportive-expressive dynamic psychotherapy with non-manualised community-delivered dynamic psychotherapy for 156 outpatients with any DSM-IV personality disorder, assessed using the SCID-II. A small subgroup (n = 12) met criteria for AsPD, although the investigators did not analyse these data separately. For the whole sample, investigators report global level of functioning as improved in both treatment conditions. They also report decreases in number of participants fulfilling criteria for a PD diagnosis, PD severity, and psychiatric symptoms, but with no significant difference in effect between treatments. The investigators conclude that manualised supportive-expressive psychotherapy was as effective as non-manualised community-delivered psychodynamic therapy conducted by experienced clinicians. Vinnars 2007 and Vinnars 2009 report further analysis of data from the same trial, exploring significant predictors of reduction in psychiatric symptoms and in personality pathology. No additional information on the small AsPD subgroup is provided. For the whole sample, the investigators found both treatments equally effective at reducing personality pathology and the largest improvement was found in quality of object relations.

Findings from these five excluded trials (importantly, with no specific data from the AsPD subgroup), suggest that CBT may be more effective than interpersonal therapy, and dual-focus schema therapy may be more effective than 12-step facilitation therapy for those with opioid dependency, and also that CBT may be more effective than relationship enhancement therapy for those with alcohol dependency.

Overall completeness and applicability of evidence

The evidence obtained from the included studies is relevant to the review question, but is incomplete for the following reasons:

Although 11 different psychological interventions were compared, none of the studies evaluated psychodynamic psychotherapy, therapeutic community treatment, dialectical behaviour therapy, cognitive analytic therapy, mentalisation-based therapy or nidotherapy.

The majority of studies did not primarily focus on the treatment of antisocial personality disorder, and in only two recruited samples did all participants have this diagnosis.

Eight studies focused on participants with substance misuse difficulties. Although drug/alcohol misuse is often relevant to people with AsPD, having a substance abuse problem is not part of the diagnostic criteria for AsPD.

The findings in two studies may not fully generalise to the population of interest: the sample in Woodall 2007 was drawn mainly from a Native American community; Marlowe 2007 found that women were significantly over-represented in their sample, and that individuals with more severe drug problems and less severe criminal histories were significantly more likely to have participated.

Quality of the evidence

We identified 11 studies that met the criteria for inclusion in this review, involving a total of 411 participants with AsPD. Of these, only five provided usable data, involving 276 participants with AsPD. We judged the overall quality of the evidence from these trials to be relatively poor for the following reasons:

The review relies on data from only five of the 11 included studies, despite attempts to contact the trial investigators for information on the AsPD subgroups.

The study samples were heterogeneous; they encompassed, for example, both prisoners and outpatients. In addition, AsPD was diagnosed under three similar but not identical rubrics (DSM-III, DSM-III-R, and DSM-IV).

Where the completion rate was reported, it was high (mean 89.1%). This may be misleading because of the custodial element of some interventions. For example, Woodall 2007 had a 100% completion rate which might be expected given that one component of the intervention was incarceration.

There was inconsistency in the way primary and secondary outcomes were measured and reported.

The authors consider that the body of evidence summarised in this review is insufficient to allow any conclusion to be drawn about the use of psychological interventions in the treatment of antisocial personality disorder.

Potential biases in the review process

We were aware of a potential for bias that might be seen as arising because two of the review authors (CD and NH) were investigators in one of the studies included in this review ( Huband 2007). We minimised this risk by ensuring that neither author took part in the extraction of data or in summarising the risk of bias for this trial. When it became necessary to request additional data from this study's lead investigator, correspondence was handled via the Cochrane Developmental, Psychosocial and Learning Problems Group in Bristol. These requests were referred by NH to the trial's research committee who responded via Cochrane in Bristol.

Agreements and disagreements with other studies or reviews

The most relevant recent review with which to compare our findings is that carried out in the development of the NICE clinical guideline on antisocial personality disorder ( NIHCE 2009). In reporting their systematic review, the NICE guideline authors observed that there had been little formal development of psychological interventions specifically for the treatment of AsPD, whereas there had been " very considerable development of interventions aimed at reducing offending behaviour" ( NIHCE 2009, section 7.2.1, p.191). In recognition of this, they chose to consider not only interventions which targeted AsPD itself, but also those which targeted the symptoms or behaviours associated with the diagnosis (such as anger, impulsivity and aggression) as well as interventions specifically for offenders regardless of diagnosis. The review described by NIHCE 2009 thus is much broader than our current review which focuses solely on studies of participants with a diagnosis of antisocial or dissocial PD.

Although the two reviews identified the same four studies targeting treatment of AsPD ( Davidson 2009) and treatment of comorbid disorder in people with AsPD ( Messina 2003; McKay 2000; Woody 1985), there were several differences.

The current review identified one study ( Neufeld 2008) that was a later and more complete summary of the trial initially reported by Brooner 1998 which was included in the NICE review.

The current review identified two additional studies with data that were not included in the NICE review ( Huband 2007; Woodall 2007).

NIHCE 2009 considered three additional studies that were excluded from the current review: Wolwer 2001 on cognitive behavioural therapy (CBT) versus coping skills training versus treatment as usual (TAU) in alcohol dependence, which we excluded because too few participants had AsPD; Hesselbrock 1991 on hospitalisation for alcohol dependence, which we excluded because it was not a randomised trial and had no control condition; and Vannoy 2004 on anger-management versus waiting list TAU in offenders, which we excluded because no participant had AsPD.

NIHCE 2009 additionally considered a further 21 studies of treatments for offending behaviour in young people (n = 11), in adults (n = 5) and in offenders with substance misuse problems (n = 5). These studies would not have been eligible for inclusion in the current review because the participants had no formal diagnosis of antisocial or dissocial PD.

In their conclusions, NIHCE 2009 considered that the evidence for the psychological treatment of antisocial personality disorder was limited to one community trial, that the quality of the evidence was low to moderate, and that the limited economic evidence from that trial suggested that CBT may not be cost-saving in the short term. They considered, however, that there was modest evidence for the effectiveness of cognitive and behavioural interventions, primarily delivered in groups, in reducing offending for adults with substance misuse problems, and that this effect has been found in variety of settings including institutional, outpatient and probation settings.

The current review concludes that good quality evidence favouring any psychological intervention for AsPD is virtually non-existent, but that contingency management appears to be effective for those that have AsPD comorbid with substance misuse difficulties.

AUTHORS' CONCLUSIONS

Implications for practice

The results from this review are that there is insufficient trial evidence to justify using any psychological intervention for those with a diagnosis of AsPD. We acknowledge, however, that 'absence of evidence is not evidence of absence of effect' and that this is a group with complex needs that may present to healthcare professionals for help with their difficulties. Professionals will therefore have to rely on their clinical experience in responding, but recognise that good quality evidence supporting whatever intervention is chosen is virtually non-existent. Clinicians should also recognise the difficulty of retaining this group in treatment so that data showing that contingency management is effective for those with AsPD and substance misuse suggest that rewarding them may overcome their treatment-resistant characteristics.

Implications for research

​

Psychological treatments for people with antisocial personality disorder

Antisocial personality disorder is a condition that leads to persistent rule-breaking, criminality, and drug or alcohol misuse. It causes a great deal of hardship for the person concerned, as well as for the person's immediate family and society in general. This review systematically examines the evidence for the effectiveness of psychological treatments used to help people with antisocial personality disorder.

We considered 11 studies, but were unable to draw any firm conclusions from the evidence available. Although several studies looked at treatments to reduce drug or alcohol misuse in people with antisocial personality disorder, few studies focused on treating the disorder itself. Only three studies reported outcome measures that were originally defined in the review protocol as being of particular importance in this disorder (reconviction and aggression). Nonetheless, there was some evidence that a type of treatment known as contingency management (which provides rewards for progress in treatment) could help people with antisocial personality disorder to reduce their misuse of drugs or alcohol.

Further research is urgently needed to clarify which psychological treatments are effective for people with this disorder. This research is best carried out using carefully designed clinical trials. Such trials should focus on the key features of antisocial personality disorder. To be informative, they need to be carried out with samples of participants of sufficient size.

ACKNOWLEDGEMENTS

We gratefully acknowledge: Jo Abbott (Cochrane Developmental, Psychosocial and Learning Problems Group) for running the electronic searches, Renate Reniers for translation of a paper from Dutch, and Cathy Bennett for advice and helpful comments on an early draft of this review.

SOURCES OF SUPPORT

Internal sources

Nottinghamshire Healthcare NHS Trust, UK.

German Federal Ministry of Education and Research, grant no. 01KG0812, Germany.

External sources

CHARACTERISTICS OF STUDIES

Characteristics of excluded studies [ordered by study ID]

Study

Reason for exclusion

Characteristics of studies awaiting assessment [ordered by study ID]

Berget 2008

Interventions

Two conditions: animal-assisted therapy plus treatment as usual/treatment as usual
Details of conditions: AAT comprised farm visit for 3 hours twice a week for 12 weeks to work with farm animals.
TAU comprised 'standard therapy' and stable medical treatment
Duration of intervention: 12 weeks
Duration of trial: 9 months
Length of follow up: participants were followed up for 6 months after end of treatment

Outcomes

Primary outcomes
None
Secondary outcomes
Leaving the study early: proportion of participants discontinuing treatment
Quality of life: scores on the Quality of Life Scale (QOLS-N)
Other outcomes
Self-efficacy: scores on the Generalised Self-Efficacy Scale
Coping ability: scores on the Coping Strategies Scale

Evans 1999

Interventions

Two conditions: brief manual assisted cognitive behavioural therapy (MACT)/treatment as usual (TAU)

Details of conditions: MACT lasted 2 to 6 sessions, with first chapter of manual given by therapists and remaining 5 chapters sent by post. TAU was standard psychiatric treatment
Duration of intervention: between 2 and 6 sessions
Duration of trial: to 6 months post-treatment
Length of follow up: participants were followed up for 6 months after end of treatment

Outcomes

Primary outcomes
Social functioning: scores on the Social Functioning Questionnaire
Secondary outcomes
Leaving the study early: proportion of participants discontinuing treatment
Economic outcomes: cost of care
Other outcomes
Time to next parasuicidal act, rate of parasuicidal acts per month, anxiety/depression symptoms

Linehan 2006

Interventions

Two conditions: dialectical behaviour therapy (DBT)/community treatment by experts (CTBE)
Details of conditions: DBT is standard manualised dialectical behaviour therapy. CTBE was developed to maximise internal validity by controlling for sex of therapist, availability, expertise, allegiance, training and experience, consultation availability and institutional prestige
Duration of intervention: 12 months
Duration of trial: 12 months
Length of follow up: participants were followed up for 12 months after end of treatment

Outcomes

Primary outcomes
None
Secondary outcomes
Leaving the study early: proportion of participants discontinuing treatment
Other outcomes
Number and severity of self-harm incidents; level of suicidal ideation, reasons for living, depression

ADDITIONAL TABLES

Table 7

Study

Outcome

CBT(baseline)
Mean (SD)

n

CBT(last)
Mean (SD)

n

Difference
(95% CI)

TAU(baseline)

n

TAU(last value)

n

Difference
(95% CI)

Comparison of difference
(95% CI)

Notes

Table 9

Study

Outcome

CBT(baseline)
Mean (SD)

n

CBT(last)
Mean (SD)

n

Difference
(95% CI)

TAU(baseline)

n

TAU(last value)

n

Difference
(95% CI)

Comparison of difference
(95% CI)

Notes

Appendix 4. COPAC search strategy

We searched the Consortium of University Research Libraries joint catalogue in September 2009 using the following terms:

randomi* OR ((double OR single OR triple OR treble) and blind) OR prospective OR (clinical and trial)

We then downloaded results into a Procite5 database and searched again using the terms:

(antisocial* OR asocial* OR avoidant OR borderline OR dependent OR depressive OR dissocial OR dissocial* OR histrionic OR moral OR multi-impulsive OR multiple* OR narcissistic OR parano* OR passive-aggressive OR psychopath* OR sadis* OR schizotypal OR self-defeating OR sociopath*)

DIFFERENCES BETWEEN PROTOCOL AND REVIEW

The review differs from the original protocol in four ways:

1. An additional restriction was added to the Selection of studies section to apply to studies where participants with antisocial or dissocial personality disorder formed a small subgroup. This required that studies included in the review should have randomised at least five people with antisocial or dissocial personality disorder. The rationale is that variance and standard deviation cannot be calculated in samples of two or less, and so a two-condition study randomising less than five (relevant) participants will have at least one arm for which standard deviation cannot be calculated.

2. The outcome of substance misuse (as specified a priori in the section on Secondary outcomes in the protocol) was modified so that a reader would find it easier to differentiate drug misuse outcomes from alcohol misuse outcomes. It has been replaced by two separate categories: substance misuse (drugs) and substance misuse (alcohol).

3. Skewed data are reported in separate tables as specified in the original protocol (see Measures of treatment effect). However, where the trial investigators provide results of their own statistical analysis on such data, we report their results descriptively within the section on Effects of interventions.

4. Where investigators did not provide standard deviations for a continuous outcome, these were calculated where possible from standard errors, confidence intervals, t-values, F values or P values using the method described in the Cochrane Handbook for Systematic Reviews of Interventions, section 7.7.3.3 ( Higgins 2008)).

The review omits six analyses specified in the original protocol because of insufficient data (see Table 4 ). These were:

1. subgroup analysis of effect on primary outcomes of comorbid diagnosis, setting, category of intervention, and whether group-based or individual-based;

2. sensitivity analysis to investigate the robustness of findings concerning concealment of allocation, blinding of outcome assessors, and extent of drop-outs;

3. assessment of the extent to which the results of the review could be altered by the missing data by sensitivity analysis based on consideration of 'best-case' and 'worst-case' scenarios;

4. sensitivity analysis of the impact of including studies with high attrition rates (25% to 50%);

5. drawing of funnel plots of effect size versus standard error to assess for possible publication bias; and

6. grouping of outcome measures by length of follow up.

Footnotes

DECLARATIONS OF INTEREST

Conor Duggan: Chair, UK National Institute of Clinical Excellence Committee on antisocial personality disorder; advisor to a current randomised controlled trial of schema focused therapy at Ashworth High Secure Hospital, UK; investigator in a completed randomised controlled trial of social problem-solving therapy plus psychoeducation for people with personality disorder ( Huband 2007).

Nick Huband: investigator in a completed randomised controlled trial of social problem-solving therapy plus psychoeducation for people with personality disorder ( Huband 2007); because this study was included in this review, NH and CD excluded themselves from data extraction and summarising the risk of bias for this trial.

Klaus Lieb: Chair, Department of Psychiatry and Psychotherapy, University Medical Center, Mainz; advisor to a planned randomised controlled trial of inpatient schema therapy in patients with personality disorders.

References to studies included in this review

Havens 2007 {published data only}  . *

McKay 2000 {published data only}  . *

References to studies excluded from this review

Arnevik E, Wilberg T, Urnes O, Johansen M, Monsen JT, Karterud S. Psychotherapy for personality disorders: short-term day hospital psychotherapy [ Arnevik 2009 {published data only} . versus outpatient individual therapy - a randomized controlled study. European Psychiatry. 2009;24(2):71-8. [ PubMed] Google Scholar]

Kool S, Schoevers R, Duijsens IJ, Peen J, Van AAlst G, De Jonghe F, et al. Treatment of depressive disorder and comorbid personality pathology: combined therapy [ Kool 2007 {published data only} . versus pharmacotherapy [Dutch] Tijdschrift voor Psychiatrie. 2007;49(6):361-72. [ PubMed] Google Scholar]

Vinnars B, Barber JP, Noren K, Gallop R, Weinryb RM. Manualized supportive-expressive psychotherapy [ Vinnars 2005 {published data only} . versus nonmanualized community-delivered psychodynamic therapy for patients with personality disorders: bridging efficacy and effectiveness. American Journal of Psychiatry. 2005;162(10):1933-40. [ PubMed] Google Scholar]

References to studies awaiting assessment

Additional references

Weissman MM. The epidemiology of personality disorders: a 1990 update. Journal of Personality Disorders. 1993;(Suppl):44-62. [ Weissman 1993 . Google Scholar]

* Indicates the major publication for the study

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Cochrane Database Syst Rev. Author manuscript; available in PMC 2014 Sep 19. Published in final edited form as: Antisocial personality disorder (AsPD) is associated with a wide range of disturbance including persistent rule-breaking, criminality, substance use, unemployment, homelessness and relationship difficulties. To evaluate the potential beneficial and adverse effects of psychological interventions for people with AsPD.

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One of several personality disorders is Narcissistic personality disorder (NPD), characterized by an overinflated sense of one’s self and a need for excessive attention. People with NPD are seen as self-absorbed, selfish, entitled, and do not value the feelings of others.

https://www.youtube.com/watch?v=Ax4FecKK1xk

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Narcissistic Personality Disorder (NPD).. What is it?

# data[].attributes.body
Upset other people often

Unstable relationships with others or struggling to keep one

Always putting themselves first

They think they know the “right” way every time

Have a hard time taking the feelings of others into consideration or seriously

Have a wide range of fast mood swings

Set unrealistic expectations and goals

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Some signs within children are normal parts of child development. The signs that can be often seen are children showing related signs to their behaviours such as getting an attitude at school, how they play independently and with other children within their age group. In adolescence, some signs of NPD are lack of friends or relationships with others, excessive social media posting of themselves, often checking themselves in mirrors and setting unrealistic goals. NPD cannot be diagnosed until the age of 18.

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Environment, including parent-child relationships

Genetics

Trauma and abuse

Excessive praise and judgment by parents

Chemistry of the brain and structure

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Individual psychotherapy

Cognitive Behavioural Therapy

Family or couples therapy

Become healthy and productive

Create a safe space for them to allow acceptance

Encourage in helping the family become healthy in ways that will benefit them

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https://emedicine.medscape.com/article/1519417-treatment

The purpose of this website is to ensure that others understand the treatment options for people with NPD and to provide insight into the considerations to take into account before using medication. It also explains the various therapeutic treatments or methods that can be used.

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Narcissistic Personality Disorder Treatment & Management: Approach Considerations, Psychotherapy, Pharmacologic Therapy

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Narcissistic personality disorder (NPD) is 1 of the 10 clinically recognized personality disorders listed in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders,
Fifth Edition (DSM-5). It belongs to the subset of cluster B personality disorders, which are tho…

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https://lifecarecounselling.in/blog/do-i-have-narcissistic-personality-disorder/

Using the expertise of professionals, this website provides resources from a counselling center that is well versed in the diagnosis of NPD and works closely with people to help find what works genuinely well for them.

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Do I Have Narcissistic Personality Disorder? Symptoms & Treatments

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Do I Have Narcissistic Personality Disorder? Determine whether you or someone you know may be a narcissist exhibiting symptoms of mild narcissism or a more severe case of Narcissistic Personality Disorder (NPD). Read more

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https://www.verywellmind.com/types-of-therapy-2795753

In the following link, you will learn about the main types of therapy and how they can be used to help people gain insight into their options and ways the therapy types can help their mental health.

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The popular conception of therapy is that of the classic talk therapy; a client, a couch and a psychologist with a notepad and pencil in hand. While some approaches do utilize this method, there are numerous types of therapy that can be used to help a client overcome problems. In all cases, the goal of therapy is to provide a nonjudgmental environment that allows the client and therapy provider to work together towards a mutually agreed upon set of goals.

The following are just a few of the many different types of therapy available.

Psychoanalytic Therapy

Psychoanalytic therapy is one of the most well-known treatment modalities, but it is also one of the most misunderstood by mental health consumers. Founded by Sigmund Freud, psychoanalytic therapists generally spend time listening to patients talk about their lives, which is why this method is often referred to as "talk therapy." The therapy provider will look for patterns or significant events that may play a role in the client's current difficulties. Psychoanalysts believe that childhood events and unconscious feelings, thoughts and motivations play a role in mental illness and maladaptive behaviors.

While this type of therapy has many critics who claim that psychoanalytic therapy is too time-consuming, expensive and generally ineffective, this treatment has several benefits as well. The therapist offers an empathetic and nonjudgmental environment where the client can feel safe in revealing feelings or actions that have led to stress or tension in his or her life. Oftentimes, simply sharing these burdens with another person can have a beneficial influence.

Cognitive-Behavioral Therapy

Cognitive-behavioral therapists tend to focus on specific problems. These therapists believe that irrational thinking or faulty perceptions cause dysfunctions. A cognitive therapist may work with a client to change thought patterns. This type of therapy is often effective for clients suffering from depression or anxiety.

Behavioral therapists work to change problematic behaviors that have been trained through years of reinforcement. A good example of behavioral therapy would be a therapist working with a client to overcome a fear of heights. The therapist would encourage the client to gradually face their fear of heights through experience. The client might first imagine standing on the roof of a tall building or riding an escalator. Next, the client would slowly expose themselves to greater and greater levels of their fear until the phobia diminishes or disappears entirely.

Cognitive and behavioral approaches can be highly effective when treating specific problems. Oftentimes, cognitive and behavioral approaches are combined when treating a disorder. A therapist treating a client with social anxiety may help the client form more accurate thinking patterns as well as focusing on specific behaviors, such as social avoidance.

Group Therapy

Group therapy is a form of psychotherapy where two or more clients work with one or more therapists or counselors. This method is a popular format for support groups, where group members can learn from the experiences of others and offer advice. This method is also more cost-effective than individual psychotherapy and can be effective for certain types of problems.

It is common for those suffering from a mental illness or problem behavior to feel alone, isolated or different. Group therapy can help clients by providing a peer group of individuals that are currently experiencing the same symptoms or who have recovered from a similar problem. Group members can also provide emotional support and a safe forum to practice new behaviors.

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The popular conception of therapy is that of the classic talk therapy; a client, a couch and a psychologist with a notepad and pencil in hand.

# data[].attributes.body
Individuals with histrionic personality disorder have an unwavering need to be noticed and often act dramatically or inappropriately to gain attention. Their self-esteem is based on the approval of others, rather than real self-worth.

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Histrionic personality disorder, Causes, Signs and Symptoms, Diagnosis and Treatment.

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Make rash decisions

Not think before acting

Be self-centered

Rarely show concerns for others

Threaten or attempts of suicide to get attention

Constantly seeks reassurance of approval

Low tolerance for frustration

Gets easily bored by routine

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In childhood, a child can experience these signs of HPD from a family member or a parent that might repeat a learning behaviour such as lack of criticism, punishment, and unpredictable attention given by the parent. Adolescents can experience attachment disorders, difficulty functioning in school or social settings, may become involved with inappropriate people and engage in risky behaviour like self harming, alcohol, drugs.

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Genetics

Environmental - severe childhood trauma such as abuse, neglect, abandonment, lack of caregiver attention

Neurochemical

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Talking to a professional and seeking psychodynamic psychotherapy

Resolving underlying, unconscious conflicts that drive unhealthy behaviours

Mindfulness Meditation

Mindfulness-based stress reduction

Taking medication for any other mental health conditions

Join support groups and focus on developing better communication skills

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https://www.verywellhealth.com/histrionic-personality-disorder-hpd-5111948#toc-treatment

In the following link, you will learn about the different traits, causes, diagnosis, treatment, and coping skills of HPD and help people with this diagnosis find out the different approaches to healing and what treatment works the best for them. It also explains the different viewpoints of emotional patterns and thoughts.

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Histrionic Personality Disorder: Definition, Traits, Causes, Treatment

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Histrionic personality disorder (HPD) is defined by excessive, theatrical attention-seeking behaviors. Learn more about common traits and treatment.

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https://traceymaxfield.com/histrionic-personality-disorder-in-children-and-teenagers/

This website provides an overall understanding of how HPD occurs in children and adolescents. It provides a clear structure and information about where this personality disorder could come from and the treatments to cope with it.

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Histrionic Personality Disorder in Children and Teenagers

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https://www.goodtherapy.org/learn-about-therapy/types/psychodynamic

The following link provides an understanding of a treatment option called psychodynamic and the different types of methods within the same context. It also includes any outstanding information for those with HPD and how they can reach out to professionals and start with it.

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Psychodynamic therapy is the psychological interpretation of mental and emotional processes. Rooted in traditional psychoanalysis, it draws from object relations, ego psychology, and self psychology. It was developed as a simpler, less-lengthy alternative to psychoanalysis.

Psychodynamic therapy aims to address the foundation and formation of psychological processes. In this way, it seeks to reduce symptoms and improve people's lives.

Core Principles of Psychodynamic Therapy

In psychodynamic therapy, therapists help people gain insight into their lives and present-day problems. They also evaluate patterns people develop over time. To do this, therapists review certain life factors with a person in therapy:

Recognizing recurring patterns can help people see how they avoid distress or develop defense mechanisms to cope. This insight may allow them to begin changing those patterns.

The therapeutic relationship is central to psychodynamic therapy. It can demonstrate how a person interacts with their friends and loved ones. In addition, transference in therapy can show how early-life relationships affect a person today. Transference is the transferring one's feelings for a parent, for example, onto the therapist. This intimate look at interpersonal relationships can help people understand their part in relationship patterns. It may empower them to transform that dynamic.

Psychodynamic therapy is available to individuals, couples, families, or groups. It can be used as short-term or long-term therapy. Brief psychodynamic therapy is goal-oriented and can take as many as 25 sessions. Long-term psychodynamic therapy may take two years or more.

Accessing the Unconscious

People tend to develop defense mechanisms. Defense mechanisms may keep painful feelings, memories, and experiences in the unconscious. A few common defense mechanisms include:

Psychodynamic therapists encourage people to speak freely about their emotions, desires, and fears. Being open may help reveal vulnerable feelings that have been pushed out of conscious awareness. According to psychodynamic theory, behavior is influenced by unconscious thought. Once vulnerable or painful feelings are processed, the defense mechanisms reduce or resolve.

Psychodynamic Diagnostic Manual (PDM)

The Psychodynamic Diagnostic Manual (PDM) was released in 2006. Its goal is to offer a conceptual framework for human psychological functioning. It also aims to serve as an alternative to the Diagnostic and Statistical Manual (DSM). The DSM outlines observable symptoms associated with mental health conditions. Meanwhile, the PDM describes subjective experiences.

Improvisational Psychodynamic Music Therapy

One approach to psychodynamic therapy is psychodynamic music therapy. This innovative and creative form of therapy involves exploration of various instruments. Guitars, drums, and pianos a just of few of the instruments used. This kind of music therapy is non-directive. It does not require any musical background. Instead, people are encouraged to improvise and express themselves through music in any way they wish.

Music therapists are highly trained to identify various personality traits and emotional issues. They can do this by observing how a person in therapy creates music. As they build their therapeutic alliance, they also participate in the music making. This can help strengthen their bond and help the therapist access deeper communication tools. For people with high levels of anxiety or fear, the music can be soothing. It may provide an element of release during difficult therapeutic sessions.
References:

1. Knekt, P., Lindfors, O., Härkänen, T., Välikoski, M., Virtala, E., et al. (2008). Randomized trial on the effectiveness of long- and short-term psychodynamic psychotherapy and solution-focused therapy on psychiatric symptoms during a 3-year follow-up. Psychological Medicine, 38(5), 689-703. doi:http://dx.doi.org/10.1017/S003329170700164X

2. Leichsenring, F., Hiller, W., Weissberg, M., & Leibing, E. (2006). Cognitive-behavioral therapy and psychodynamic psychotherapy: Techniques, efficacy, and indications. American Journal of Psychotherapy, 60(3), 233-59. Retrieved from http://search.proquest.com/docview/213135027?accountid=1229

3. Luborsky, Ellen, O'Reilly-Landry, Maureen, and Arlow, Jacob. (2008). Psychoanalysis. In Raymond J. Corsini and Danny Wedding (Eds.), Current Psychotherapies (pp. 15-62). Belmont, CA: Thomson Higher Education

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Psychodynamic therapy is the psychological interpretation of mental and emotional processes. Rooted in traditional psychoanalysis, it draws from object relations, ego psychology, and self psychology. It was developed as a simpler, less-lengthy alternative to psychoanalysis. Psychodynamic therapy aims to address the foundation and formation of psychological processes.

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this video provides the viewers with signs to look out for in DPD

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Dependent Personality Disorder Signs to Looks Out For

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Dependent Personality Disorder (DPD) is one of a cluster of personality disorders. Individuals with dependent personality disorder have an excessive need to be taken care of; it often manifests as 'clinging' behavior, or a fear of separation.

People with dependent personality disorder strongly doubt their own abilities and skills and cultivate an air of helplessness. Their fear of abandonment is strong, and someone with dependent personality disorder may lie about their ability to perform certain tasks in order to get one of their valued people to do it for them. This creates the idea that they cannot do that task without the other person, preventing the other person from leaving them.

Symptoms of Dependent Personality Disorder

Dependent personality disorder shares some symptoms with other personality disorders, but also has a few unique characteristics that define it. If you notice these behaviors in yourself or someone that you love, you should tell your doctor - there are evaluations that your doctor can perform to figure out if you have dependent personality disorder and get you the help that you need. Symptoms of dependent personality disorder include:

Difficulty making decisions without the input or presence of others

Being overly passive or submissive

An inability to disagree with or argue with others

Allowing or preferring other people to handle your personal business

Extreme fear of abandonment, especially by loved ones

Intense sadness and lethargy when a loved one leaves or after a breakup

A willingness to do anything in your power, including putting up with abuse or mistreatment or doing dangerous or illegal things, to please a valued person or keep them near you

Having trouble starting projects or doing things alone

Constantly seeking relationships and cultivating them in order to not be alone, no matter how unhealthy the relationship may be

Causes and Risk Factors for Dependent Personality Disorder

While there are no direct or specific causes of dependent personality disorder, some conditions and circumstances can make a person's likelihood of developing the disorder higher. These include:

Traumatic abandonment in childhood through family circumstances or war

A family history of personality disorders, depression, or anxiety

Surviving childhood abuse, including stifling parenting, withdrawn parenting, or having parents who punished individual thinking

Having a chronic physical illness in childhood

Treatment for Dependent Personality Disorder

You and your doctor can come up with a treatment plan that can help you be more in control of your disorder using medication, therapy, and other tools.

Medication: No medication is approved to treat dependent personality disorder directly, but some medications like anti-anxiety drugs, antidepressants, and mood stabilizers can help control the symptoms.

Therapy: Psychotherapy is often the first line of treatment in helping you gain control over your dependent personality disorder. Cognitive behavioral therapy and other types of psychodynamic therapy can help you learn new behaviors. Find the right care option for you at Sheppard Pratt.

Education: Learning more about dependent personality disorder, personality disorders, and other mental health conditions can help you and your loved ones understand more about the support that you need to thrive. Learn more about mental health through our Knowledge Center.

Support: Having adequate support can help you feel better about your condition and other conditions that may contribute to your dependent personality disorder. See the support groups available at Sheppard Pratt.

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Dependent Personality Disorder | Knowledge Center

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Dependent Personality Disorder (DPD) is one of a cluster of personality disorders. Individuals with dependent personality disorder have an excessive need to be taken care of; it often manifests as 'clinging' behavior, or a fear of separation. People with dependent personality disorder strongly doubt their own abilities and skills and cultivate an air of helplessness.

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this website provides viewers with information on the supports, causes and symptoms of DPD.

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Dependent personality disorder (DPD) is an anxious personality disorder characterized by an inability to be alone. People with DPD develop symptoms of anxiety when they're not around others. They rely on other people for comfort, reassurance, advice, and support.

People who don't have this condition sometimes deal with feelings of insecurity. The difference is that people with DPD need reassurance from others to function. According to the Cleveland Clinic, people with this condition normally first show signs in early to mid-adulthood.

A condition must fall into one of the following clusters to be classified as a personality disorder:

Cluster A: odd or eccentric behavior

Cluster B: emotional or erratic behavior

Cluster C: anxious, nervous behavior

DPD belongs to cluster C. Signs of this disorder include:

People with DPD may require constant reassurance. They can become devastated when relationships and friendships are severed.

When alone, a person with DPD may experience:

Some of these symptoms are the same for people with anxiety disorders. People with medical conditions such as depression or menopause may also experience some of these symptoms. Contact your doctor to receive a specific diagnosis if you experience any of the above symptoms.

It's unknown what causes people to develop DPD. However, experts cite both biological and developmental factors.

Some risk factors that might contribute to the development of this disorder include:

Your doctor will give you a physical exam to see if a physical illness could be the source of symptoms, particularly anxiety. This may include blood tests to check for hormone imbalances. If tests are inconclusive, your doctor will likely refer you to a mental health specialist.

A psychiatrist or psychologist usually diagnoses DPD. They'll take your symptoms, history, and mental state into account during diagnosis.

Diagnosis begins with a detailed history of your symptoms. This includes how long you've been experiencing them and how they came about. Your doctor may also ask questions about your childhood and your present life.

Treatment focuses on alleviating symptoms. Psychotherapy is often the first course of action. Therapy can help you better understand your condition. It can also teach you new ways to build healthy relationships with others and improve your self-esteem.

Psychotherapy is usually used on a short-term basis. Long-term therapy could put you at risk of growing dependent on your therapist.

Medications can help relieve anxiety and depression, but are generally used as a last resort. Your therapist or doctor may prescribe you a medication to treat panic attacks that result from extreme anxiety. Some medications for anxiety and depression are habit-forming, so you may have to see your doctor regularly while taking them to prevent prescription dependence.

Complications that can arise from untreated DPD are:

Early treatment can prevent many of these complications from developing.

The cause of DPD is unknown, which makes it difficult to prevent the condition from developing. However, recognizing and treating symptoms early can prevent the condition from worsening.

People with DPD generally improve with treatment. Many of the symptoms associated with the condition will decrease as treatment continues.

DPD can be overwhelming. As with other personality disorders, many people are uncomfortable seeking help for their symptoms. This can affect quality of life and increase the long-term risks for anxiety and depression.

If you suspect a loved one might have DPD, it's important to encourage them to seek treatment before their condition worsens. This can be a sensitive matter for someone with DPD, especially since they seek constant approval and don't want to disappoint their loved ones. Focus on the positive aspects to let your loved one know they're not being rejected.

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Dependent Personality Disorder: Causes, Symptoms, and Support

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Dependent personality disorder (DPD) is an anxious personality disorder characterized by an inability to be alone. People with DPD develop symptoms of anxiety when they're not around others. They rely on other people for comfort, reassurance, advice, and support. People who don't have this condition sometimes deal with feelings of insecurity.

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Paranoid Personality Disorder is a part of a group of conditions called cluster A. Those personality disorders are disorders that may make people who have them act unusual and odd to others. Paranoid disorder makes a person suspicious of others around them.

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Paranoid Personality Disorder, Causes, Signs and Symptoms, Diagnosis and Treatment.

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If you are a person who has a paranoid personality disorder, the symptoms would be you having a hard time relaxing because you are always super suspicious of people, even families. You think people are going to betray you even if there is no evidence that proves it. You have a hard time opening up to others and sharing personal information because you think people will use that information against you.  A remark or casual look from a person might make you think they are going to hurt you which might make you get mad easily and makes you become controlling in your relationships with others. You will see yourself remembering even small things that people have done to you and having a hard time forgiving people.

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5 Signs of Paranoid Personality Disorder

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Children and Adolescents who have paranoid personality disorder might become defensive, and moody. Says that people are attacking them when the person might be trying to give them simple advice for example teachers, friends,  or parents. Children and adolescents who have paranoid personality disorder will show anxiety, and feel scared when having to be in a social setup, for example not wanting to go to school because there are a lot of people that are against them or can hurt them there. They will not want to be with others and isolate themselves which will last more than 6 months.

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Hillcrest Adolescent Treatment Center - Agoura Hills, California

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How to Handle a Teen with Paranoid Personality Disorder

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Teens and Paranoid Personality Disorder Adolescence can be a stressful time for unprepared parents and their children. At that age, teenagers develop varied interests and acquire diverse personalities. Unfortunately, part of the acquired behavior involves challenging the authority of the parent and an unfettered desire to have more independence.

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 Croll to causes of Paranoid Personality Disorder

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The actual cause of paranoid personality disorder is unknown but some risk factors can be genetics which means you have it from a previous family who had the disorder or other related disorder. Some other risk factors for paranoid personality disorder could be environmental factors that make you develop this disorder. This could be childhood trauma, exposition to physical, sexual and/or emotional abuse from family members, friends or strangers. Those kinds of trauma could lead to a person developing paranoid personality disorder which makes them suspicious of people around them and always thinking people are going to hurt them.

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The Recovery Village Drug and Alcohol Rehab

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Paranoid personality disorder is the fourth most common personality disorder in the United States. Having paranoid personality traits elevates the risk of developing substance use disorders and significantly impacts people's ability to trust others, including family members and friends who might be trying to provide support. People with paranoid personality disorder are more likely to struggle to develop a stable social network.

While people with paranoid personality disorder might be opposed to treatment, they can benefit from targeted interventions that challenge their cognitive distortions and help them establish more trust with professionals and peers.

What Is Paranoid Personality Disorder?

Paranoid personality disorder is one of the three Cluster A personality disorders listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM). Schizoid, schizotypal and paranoid personality disorder have been called the "eccentric" personality disorders and share features in common with psychotic disorder schizophrenia.

Personality disorders differ from other psychiatric disorders in many ways. People who have paranoid personality traits are less likely to view them as symptoms and more likely to perceive them as part of their identity or personality.

While other mental health conditions can develop in later years, childhood influences frequently drive personality disorders, which arise by late adolescence or early adulthood and persist over time. They reflect behaviors that were adaptive in childhood but become maladaptive in adulthood.

Symptoms of Paranoid Personality Disorder

Most paranoid personality disorder symptoms reflect a mistrust in the world and other people.

Paranoid personality disorder is primarily driven by thinking patterns. People with the disorder believe others intend to harm or take advantage of them. Typical behaviors of paranoid personality disorder can range in severity and include:

Being tense

Having difficulty admitting being at fault or wrong

Showing coldness or a lack of emotion

Withdrawing almost entirely from social contact with others

Engaging in excessive tracking, recording or "policing" behavior

Exhibiting a short temper and overreacting to minor or perceived slights

Confronting people in person or over the phone with accusations of betrayal

Signs of Personality Disorder

The signs of paranoid personality disorder are often more apparent to outside observers than to people who have the disorder. People with paranoid personality disorder usually perceive paranoid personality traits as part of who they are.

People who express suspicion of others aren't always paranoid, and paranoid personality disorder can only be accurately diagnosed by identifying symptoms that persist for an extended amount of time, which rules out legitimate causes of mistrust.

For example, people who have been stalked might exhibit paranoia for good reason, though they are likely to heal over time and trust others again. People with paranoid personality disorder tend to maintain the same degree of paranoia over time and for a wide range of relationships even if they have not experienced any recent harm or manipulation.

Paranoid personality disorder examples include a wide range of behavior. One person with the disorder might isolate himself in his house and peer through the blinds at every passerby. Another person might map out an elaborate conspiracy theory using newspaper clippings pasted to their wall.

However, many people quietly suffer from symptoms of the disorder and only signal their paranoia to others with subtle signs like clipped speech or furtive glances. Some sense that others won't believe them and work diligently to keep their suspicions hidden.

Causes of Paranoid Personality Disorder

As with other personality disorders, paranoid personality disorder causes typically fall within one of three categories: genetic, biological or environmental. Paranoid personality disorder is closely linked to a family history of Cluster A personality disorders, schizophrenia or other psychotic disorders.

There is also a strong connection between paranoid personality disorder and childhood abuse. People with the disorder often have histories of childhood trauma combined with family dynamics that were emotionally distant. People with the disorder typically experienced little to no affection growing up and were directly abused or exposed to frequent episodes of violence between their parents.

How Is Paranoid Personality Disorder Diagnosed?

The paranoid personality disorder definition from the DSM characterizes the disorder as "a pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent." To be diagnosed with paranoid personality disorder, a person must exhibit four of the following seven symptoms or traits:

Being reluctant to confide in others due to fear of betrayal

Fixating on doubts about others' loyalty or trustworthiness

Repeatedly accusing a partner of sexual or romantic infidelity

Holding on to grudges and refusing to forgive even minor insults or slights

Perceiving demeaning or threatening meanings in neutral statements or events

Suspecting, without evidence, that others are exploiting, harming or deceiving them

Inaccurately perceiving hostility in others and making quick, aggressive counterreactions

These traits cannot be better explained by or occur during a psychotic, mood or other psychiatric disorder. While schizophrenia and other psychotic disorders are usually more acutely disturbing or disrupting to the people who have them, they are also easier to recognize and treat. People with paranoid personality disorder are affected on a more pervasive level that makes identifying the condition more difficult.

For this reason, people rarely come into treatment to address paranoid personality disorder symptoms. They may receive a paranoid personality disorder diagnosis after a long period of observation by a clinician who has been treating them for related medical or mental health concerns. One way that professionals can make a paranoid personality disorder diagnosis is completing a patient history and determining when a person started thinking and acting in ways characteristic of the disorder. For paranoid personality disorder, the age of onset is typically in late teen or early adult years.

For people who wonder whether they have or someone they know has this mental illness, reading a paranoid personality disorder case study can be helpful. The story of 65-year-old "Mr. J" shows many ways that the disorder can affect a person's life, including causing them to avoid or withdraw from necessary medical care.

Who Is at Risk for Paranoid Personality Disorder?

The most significant risk factor for paranoid personality disorder is a family history of the disease or other related disorders. The genetic factors associated with psychotic and Cluster A personality disorders linked to differences in brain function. Brain activity associated with social interaction, emotional activation, learning and memory differs in people with these conditions.

Aside from genetics, environmental factors are the most significant risk factors for developing paranoid personality disorder. People who experience chaos, abuse or trauma in families with emotionally distant communication styles are at particular risk of developing this personality style. Having experiences of frequent victimization can reinforce a worldview that people in positions of authority can't be trusted.

Paranoid Personality Disorder Statistics

Facts about paranoid personality disorder include the following:

Estimates of how many people in the U.S. have paranoid personality disorder vary, but studies suggest about 4.5 percent of the population, or more than 14 million people, have paranoid personality disorder

The prevalence of paranoid personality disorder in people receiving outpatient mental health treatment is 2 to 10 percent

The rates of paranoid personality disorder among people in psychiatric inpatient units is 10 to 30 percent

A recent study shows that about 10 percent of people receiving treatment for an alcohol use disorder have a co-occurring paranoid personality disorder

Paranoid personality disorder can cause constant stress and drive people to limit their social support systems. This increases their risk of substance abuse and addiction. These comorbid disorders can seem daunting to treat, but there are many options available to help people recover from substance abuse. If you or someone you know is struggling with a co-occurring paranoid personality disorder and substance abuse, contact a representative from The Recovery Village to learn how to start living a healthier life.

Medical Disclaimer: The Recovery Village aims to improve the quality of life for people struggling with a substance use or mental health disorder with fact-based content about the nature of behavioral health conditions, treatment options and their related outcomes. We publish material that is researched, cited, edited and reviewed by licensed medical professionals. The information we provide is not intended to be a substitute for professional medical advice, diagnosis or treatment. It should not be used in place of the advice of your physician or other qualified healthcare provider.

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Paranoid Personality Disorder - The Recovery Village Drug and Alcohol Rehab

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Paranoid personality disorder is the fourth most common personality disorder in the United States. Having paranoid personality traits elevates the risk of developing substance use disorders and significantly impacts people's ability to trust others, including family members and friends who might be trying to provide support.

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Some resilience factors can be therapy, learning how to reduce paranoic thinking, control anger, learning how to relax and getting support from others.

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This video explains 4 ways that could help a person reduce paranoid thinking.

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How To Stop Paranoia - 4 Ways To Help | BetterHelp

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https://www.promisesbehavioralhealth.com/mental-health-treatment-programs/paranoid-personality-disorder-therapy-program/

This website explains the different treatments that exist for Paranoid personality disorder, it also explains what are different therapy programs that exist such as art therapy program and yoga. It also explains how those therapy programs work.

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When someone receives a diagnosis for paranoid personality disorder, it can be a life-changing moment. While this diagnosis can feel challenging at first, it is possible to alleviate and manage the disorder. Through the best paranoid personality disorder treatment program, clients can learn more about their condition and find the right treatments for it.

What Is a Paranoid Personality?

Personality disorders may be quite common, but this does not make them any easier to live with. Paranoid personality disorder (PPD) refers to a group of mental conditions that psychiatrists call eccentric personality disorders. To other people, someone with these conditions appears to be odd, unusual, or peculiar. Once someone realizes they have PPD, paranoid personality disorder therapy may eventually help them live a normal lifestyle.

Individuals with this condition have a suspicion and mistrust of other people without any reasonable justification for these feelings. Many people begin developing PPD during their childhood or teenage years. While it is more common in men, the condition can affect people of both genders. No one knows for sure what causes this condition, but it seems to have genetic, psychological, and biological factors.

People who have PPD think that other people want to harm them, they may not trust others and have a tendency to blame others. These individuals may doubt the trustworthiness and loyalty of the people closest to them. They are unforgiving, hypersensitive, and reluctant to trust others.

How to Get a Diagnosis

People can get a diagnosis through their doctor, a psychiatrist, or a paranoid personality disorder treatment program. Normally, clients first notice that they have symptoms and go to their doctor, who then performs a comprehensive evaluation with a physical exam and a medical history. The doctor may do diagnostic tests to rule out conditions like substance abuse or physical ailments.

After ruling out other causes, the doctor may recommend that the client go to a psychologist or paranoid personality disorder therapy. A mental health professional has training for diagnosing and treating mental health disorders. Once the individual has a diagnosis, they can find the treatment they need.

What Is a Paranoid Personality Disorder Treatment Program?

A paranoid personality disorder treatment program helps clients through therapy, medication, and other options. Clients may benefit from options like cognitive behavioral therapy, dialectical behavior therapy, and schema therapy. Stress management therapy can also help individuals handle tension and learn how to respond healthily to external stimuli.

Sometimes, treatment centers use incentive therapy to help the individual change their behaviors. Although there is not a cure for this mental disorder, a doctor may also use medication to relieve the symptoms of the individual's condition. Some of the most effective medications for PPD include antidepressants, mood stabilizers, and antipsychotics.

Getting the Right Treatment for a Mental Illness

When someone gets treatment for a mental illness, the paranoid personality disorder treatment program may also provide care for other symptoms. Often, a treatment center will look for other mental illnesses, substance abuse problems, and physical ailments. Once the client starts treatment, they can get care for all of these issues.

At the treatment center, clients can find help through options such as:

In the right paranoid personality disorder treatment program, specialists tailor the treatment options to the client's unique needs. This type of program gives clients the best chance of overcoming their mental illness or substance abuse disorder. At Promises Behavioral Health, we offer help for a variety of mental disorders. Discover a healthier, happier outlook on life today by calling us at 844.875.5609.

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Paranoid Personality Disorder Treatment Program

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When someone receives a diagnosis for paranoid personality disorder, it can be a life-changing moment. While this diagnosis can feel challenging at first, it is possible to alleviate and manage the disorder. Through the best paranoid personality disorder treatment program, clients can learn more about their condition and find the right treatments for it.

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This is a website that has a lot of worksheets, tools, exercises and videos that explain and teach how to cope with stress, anxiety and anger.

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The Anger Iceberg represents the idea that, although anger is displayed outwardly, other emotions may be hidden beneath the surface. These other feelings-such as sadness, fear, or guilt-might cause a person to feel vulnerable, or they may not have the skills to manage them effectively.

By exploring what's beneath the surface, clients can gain insight into their anger, such as other possible treatment avenues. For example, a client who realizes their anger is fueled by jealousy may benefit from communication skills, whereas a client who realizes their anger is caused by stress will benefit from developing self-care habits.

The Anger Iceberg worksheet can be used in multiple ways. It works well as a group discussion piece, or as an activity where clients identify and circle their own hidden emotions. Try the following discussion questions to get started:

Imagine a friend is facing a situation that's similar to one of your own anger triggers. What emotions do you think they might feel, other than anger?

In your family, or in the culture you grew up in, what emotions do people freely express? What emotions do they keep to themselves?

Imagine a person who handles difficult emotions-such as sadness, fear, or hurt- effectively. How do they show these emotions? What do they do to cope with them?

Anger is sometimes used mask emotions that make a person feel vulnerable, such as hurt or shame. Can you think of a time you expressed anger in order to conceal another emotion you were feeling?

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Anger Iceberg (Worksheet) | Therapist Aid

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The Anger Iceberg represents the idea that, although anger is displayed outwardly, other emotions may be hidden beneath the surface. These other feelings-such as sadness, fear, or guilt-might cause a person to feel vulnerable, or they may not have the skills to manage them effectively.

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Schizotypal Personality Disorder is part of the Cluster A group of diagnoses. It is present as a need to isolate oneself from others, feeling anxiety in a social environment, and having odd behaviours, thoughts and beliefs.

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What is Schizotypal Personality Disorder?

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If you are a person who has a schizotypal personality disorder, the symptoms would be you have an unusual and different way of thinking and/or beliefs. For example, you might believe in superpowers like telepathy; those beliefs are not related to religion. You can have suspicious thoughts and doubt about people's loyalty. You might feel that you have unusual experiences; for example, you might feel the presence of a person who is missing and having illusions. You can have a different way of speaking. For example, it might be vague or rambling during a conversation. You can have strong anxiety. You might find it better when you are lonely, which might make you have no or few friends outside of family members. You can have difficulties reacting to emotions and find yourself giving inappropriate emotional responses. You might like to dress differently, for example, always wearing unmatched clothing. A person who has schizotypal personality disorder would usually have 5 or more of these symptoms.

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The signs of Schizotypal personality disorder in children and adolescents are unusual preoccupying fantasies, restricted close friends, and getting extremely anxious when being in a social environment. For example, not wanting to go to school. They are usually recluses and lonely. They have difficulty creating relationships with others.

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Abstract

The Problem

For 60 years, there has been growing recognition that some children have a cluster of distressing and unusual social, communication, perceptual, thought, and behavioral difficulties and preoccupations with bizarre fantasies that have a detrimental impact on mental health and well-being. We argue that it is timely, necessary, and sufficient to diagnose this neurodevelopmental psychopathology as Schizotypal Disorder (SD) occurring in Childhood (SDC).

There are disparate historical approaches to the recognition of these psychotic-like perturbations in children. Some do not recognize this disturbance as a disorder because "the character and personality of children is fluid and not persistent,"  or at most a manifestation of childhood reactive emotional states such as depression. Others have conceptualized the diagnosis of these children within either the Schizophrenia or Autism spectra ( figure 1) in the Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Classification of Diseases (ICD) systems by early terms such as "Schizophrenia, childhood type" (DSM-I, DSM-II, ICD-8), "Pervasive Developmental Disorder NOS (PDD-NOS)" (DSM-III, DSM-IV-TR), or "atypical autism" (ICD-10). These diagnoses remained poorly defined and have not been retained in the current editions (DSM-5, ICD-11). Another approach to categorize children with dysfunction in multiple emotional, behavioral and social domains, on the boundary between Schizophrenia and Autism, was to group them under the term "borderline (psychotic) syndrome," a precursor to the distinct DSM-III adult categories of borderline and schizotypal personality disorders. This failed to yield greater diagnostic application in children. Conversely, in the Autism/PDD literature a similar group of children were described with Multiplex Developmental Disorder or Multiple Complex Developmental Disorder. However, these constructs were overinclusive and were not recognized by the DSM and the ICD, which continued with the unsatisfactory category of PDD-NOS.

In the early schizophrenia literature, longitudinal research of psychopathology in children, including high-risk offspring of parents/mothers with schizophrenia, described children with odd behavior, rejection by peers, perceptual and thought disorder, and antisocial behavior. They were also more likely to develop schizophrenia in adolescence/early adulthood. A landmark NIMH longitudinal study of 160 children who screened positive for schizophrenia symptoms described a group of "multidimensionally impaired" children. They presented with transient psychotic symptoms, emotional reactivity, preoccupation with fantasies, difficulties when interacting socially, and cognitive deficits with information processing and visuospatial skills. The similarity of these children with the current criteria for SD within the schizophrenia spectrum is apparent. They belong to a spectrum of recognizable schizotypal characteristics, influenced by neurodevelopmental, genetic, and psychosocial determinants that vary from subtle impairments in functioning, to the fluctuant but persistent clinical disturbance of SD, and at its extremity to the decompensation of schizophrenia.

SD is a complex condition, including cognitive-perceptual impairments, oddness, disorganization, and interpersonal difficulties. In the ICD-11,(6A22) SD is included within the group of Schizophrenia or other primary psychotic disorders. The DSM-5 describes SD in the cluster A group of Personality Disorders,(p655-659) but also includes it within the Schizophrenia Spectrum Disorders (SSD)(p90) given their overlap at the behavioral, neural, and cognitive levels. It is characterized by the presence of 5 or more of the following culturally abnormal symptoms: ideas of reference, odd beliefs and magical thinking (in children bizarre preoccupying fantasies), unusual perceptual experiences including bodily illusions, odd thinking and speech, suspiciousness or paranoid ideation, inappropriate or restricted affect, odd or eccentric behavior or appearance, lack of close friends, and social anxiety beyond reassurance associated with paranoid fears.

SD is usually diagnosed from young adulthood, but "may be first apparent in childhood" (p657) and can be reliably and validly diagnosed in children aged 5-12 years. The prevalence of SDC is not yet established. Population studies in a UK cohort of 2127, 12-year-old twins and 27 000, 11- to 12-year-old Australian children indicated a prevalence of definite psychotic symptoms of 5.9% and 10.2%, respectively, but attribution of symptoms to other causes such as sleep phenomena were not excluded. In a large birth cohort study (Avon longitudinal study of parents and children, ALSPAC), 38.9% of 6455 children aged 11.4-14.3 years (mean 12.9) were reported with one or more psychotic symptoms. Following a structured clinical assessment (Diagnostic Interview Schedule for Children Version IV; DISC-IV), 5.6% were identified with "definite psychotic-like symptoms" and 2.6% remained after eliminating those whose symptoms could be attributed to sleep, fever, organic causes or substance use. Given that the DISC-IV does not specifically identify SDC, it is possible that this 2.6% would meet criteria for SDC.

Potential risk factors for SDC also require investigation, particularly those known to be associated with the development of psychotic symptoms, including genetics, psychosocial and environmental risk factors, childhood psychopathological disorders, and childhood trauma. The maturational pathway of SDC into adulthood and its salience to the onset of psychosis is unclear. Small longitudinal studies suggest that SDC symptoms persist and may develop into schizophrenia or other SSD. There is some evidence for the relative stability of schizotypal traits in children, but given the dynamic nature of brain plasticity and development in children, longitudinal studies are required to discover if SDC may resolve. For example, we reported that brain structural connectivity abnormalities observed in siblings of those with childhood schizophrenia normalized by mid-adolescence. Further research on the developmental course and outcome of SDC is necessary, particularly regarding resilience as well as risk factors for psychosis.

What is the Symptomatology of SDC?

In addition to the DSM-5 and ICD-11 criteria for SD ( box 1 and table 1), clinical features of SDC might include neurodevelopmental delays and deficits in motor functioning, including clumsiness, poor fine graphomotor skills, and limited motor planning. Individual children might have a scatter of intellectual functioning and specific neurocognitive impairments similar to those observed in adolescents with SD, including impaired processing speed, working memory and executive functioning. Impairments in attentional self-control and set-shifting abilities might underlie the child's difficulties shifting from their preoccupation with unusual fantasies and perceptual disturbances in order to attend to external tasks.

Schizotypal disorder: A "pattern of social and interpersonal deficits and cognitive/perceptual distortions and eccentric behavior" (p.655, DSM-5) which begins in childhood, interferes with social and family life, attention, learning, and school participation, and causes emotional and behavioral disturbance; indicated by:

1. Ideas of reference

2. Bizarre fantasies and preoccupations

3. Perceptual disturbance (auditory, visual)

4. Odd thinking and speech

5. Suspicious (paranoid) ideation

6. Disturbed affect

7. Odd behavior

8. Disturbed ability to make and keep friends

9. Anxiety (and mood disturbance with periods of depression, irritability, and difficulty regulating emotions) associated with fearful paranoid preoccupying ideas and perceptions

Not in the course of:

1. Schizophrenia, as perceptual disturbance and paranoia fluctuate with periods of more normal mental state in the absence of negative symptoms.

2. ASD, as they are capable of periods of more normal social interaction, communication, and empathy. They are preoccupied with elaborative inner fantasies that distort their social interactions and play rather than having a focus on detail in the external world and the rigid, concrete interests and rituals apparent in ASD.

In the context of varied cognitive profiles:

Case Study 1 (MARK): wide scatter of average to very low cognitive skills, with relatively better verbal skills and greater difficulty with visuo-motor tasks. Performance compromised by his preoccupation with fantasies impairing his concentration on external tasks and social interactions.

Case study 2 (RUTH): low average-borderline ability compromised by inattention due to distraction by fantasies.

Case Study 3 (TOM): wide scatter of cognitive abilities with high average verbal and perceptual reasoning skills but significant difficulty with working memory and visuo-motor deficits impairing his handwriting. His cognitive performance was inhibited by difficulty shifting attention from his preoccupying thoughts.

Can SDC be Differentiated From Other Neurodevelopmental Disorders?

SDC symptoms fluctuate in severity and are aggravated by stress and anxiety. In contrast, Schizophrenia in childhood presents with progressive, pervasive and disabling negative symptoms, disorganization, and progressively developing hallucinations and delusions. SDC clearly shares some diagnostic criteria with DSM-5 and ICD-11 Autism Spectrum Disorder (ASD), including abnormalities of social communication and interaction, restricted fixated interests, and idiosyncratic behaviors. These well-described similarities have led to diagnostic ambiguity as well as prognostic and therapeutic challenges, resulting in diagnostic overshadowing or substitution of SDC by ASD. This is further complicated by the allocation of funding for educational and disability services for ASD rather than for other diagnoses. Nevertheless, there are key diagnostic criteria for SDC which differentiate it from ASD ( table 1). In particular, SDC is defined by perceptual disturbances, a preoccupation with fantasies and paranoid thinking causing inattention, disturbed speech, social difficulties, and anxiety. A recent structural and functional brain imaging study suggests that the difficulty children with SDC have in shifting from internally focused attention differentiates them from neurotypical children and those with ASD, and might contribute to their abnormal perceptions and reality testing and inattention to external tasks.

A major constraint on clinicians and researchers assessing children with schizotypal symptoms is that current classification systems state that SD "does not occur exclusively during the course of ... ASD" (DSM-5)(p657) or "excludes ASD" (ICD-11).(6A22) Two international guidelines for the diagnosis of ASD, the UK National Institute for Health and Care Excellence (NICE) Clinical Guidelines and the American Academy of Pediatrics (AAP) Practice Guidelines, together with a leading structured diagnostic assessment instrument, the Autism Diagnostic Observational Schedule-Second Edition (ADOS), do not acknowledge SDC as either a possible differential or a comorbid diagnosis. A diagnosis of ASD made in preference to that of SDC or in ignorance of comorbid SDC potentially disqualifies identification of schizotypal symptoms, with implications for etiology, treatment, and outcome. This is despite the evidence suggesting that a comorbid diagnosis of SDC can be identified in around 40% of children with ASD. To address this issue, we developed a novel structured clinical diagnostic tool for SDC, the Melbourne Assessment of Schizotypy in Kids (MASK), that facilitates the recognition of potential comorbidity of SDC with other neurodevelopmental conditions.

Case Studies

The neglect of SDC and the apparent barriers encountered by clinicians and researchers in identifying these children has potential adverse long-term consequences by facilitating misdiagnosis and a lack of research into outcome and treatment. The aim of this paper is to give these children a voice by providing detail of 3 de-identified case studies (with informed parental consent) that illuminate the clinical presentation of SDC. These children were independently diagnosed with DSM-5 criteria for SD by the authors B.J.T. and A.V.B. or R.T. in the process of the development of the MASK. All met the DSM-5 diagnostic formulation for SDC presented in Box 1. Diagnostic features demonstrated by these children are flagged in brackets for each case. The history of biopsychosocial developmental risk factors for each child is presented in table 3, and their longer-term outcome is presented in table 4.

Case Study 1

MARK (5 y) was referred by a Pediatrician requesting an assessment for ASD and Attention-deficit/hyperactivity disorder (ADHD) because of his disruptive behavior at preschool.

Assessment included an interview with mother, school reports, and a school observation. Mark's teacher described him as "at times delightful, caring and sociable but also feared by children and often excluded from class due to aggression, particularly when he is acting as another character." His mother described Mark as "mostly a lovely and kind boy with lots of personality" but who had difficulty playing with peers because he often has "characters from films and who he makes up in his mind" that make him angry and disruptive. She was "at her wit's end" because her son "suddenly switched into a real world for him of angry characters, then you can't reason with him." His preoccupation with his characters made him "excitable, aggressive towards children and inattentive in class activities."

Preschool Observation.

Mark insists on wearing a T-shirt with a graphic image of a skull to preschool every day (odd behavior). Mark was observed participating and conversing happily in a cooperative and imaginative game of blocks with 3 children when suddenly he rushed to another group of children making threatening punching movements, yelling at them to stop talking about him because he was a "superhero" (ideas of reference/paranoia, odd beliefs, social difficulty). Following intervention by the teacher he became aloof, muttering aggressively whilst scribbling on paper. He suddenly ran across the room threatening to "stab" another teacher with play scissors, yelling " Stop talking....it's not me....Evil Mark will kill you. " Later during a group garden walk he wandered off by himself, acting oddly, and talking as if he could see, hear and was being directed by a character called "Mario" (inappropriate affect, paranoid ideation, unusual perceptions with anxiety, social difficulties).

Psychiatric Mental State Examination (Mother Sitting Quietly in the Background).

Mark was wearing his skull T-shirt. He was initially shy but soon made appropriate eye contact and chatted happily as he initiated an interactive and imaginative game with a toy train set. Suddenly he pointed at a red crayon mark on the wooden tracks, became agitated and started making punching movements shouting, " that's evil blood....evil Mark....punch you in the face " (odd behavior, perceptual disturbance, odd fantasies). He became incoherent and distressed and his mother came over and tried to calm him.

Later, he was unable to focus on visual mood scales (happy-sad, anxious-calm, angry-peaceful) but stabbed the sad-happy scale with his finger while saying incoherently, " more bad red.....fighting him...I'll punch him real fast....," then mumbled and appeared anxiously distressed (odd fantasies, paranoia, anxiety).

When invited to draw a dream (DAD task) ( figure 2), his affect changed from flat to agitated as he rapidly drew a dream from the left of the page which demonstrated paranoid ideas, perceptual (auditory/visual) and bodily disturbance, bizarre fantasies, fragmented speech and thoughts, and anxious distress.

He said, "Darkness, I'm afraid, there's this guy wants to kill you." (Clinician comments (C): Kill you?)

He wrote M on the smaller figure of himself. "With a sword." He wrote the word weapon. (C: A weapon?)

"Throws a bomb.... he says I'm bad....makes me a robot."

Mark then drew a picture of himself as "A robot" on the right with a "bomb" on his head. (C: What are you doing?)

"Punch him real fast," further muttering....as if in an internal conversation ( C: Can you hear someone?)
"Yes, talking growling." (C: Talking?)

"Saying Yoshi you'll die." [Yoshi is his soft toy]. (C: Is it your imagination?)

"No, a real traff tragon." (C: A tragon?)

He rapidly did 3 more fragmented drawings with disjointed incoherent comments referring to "little helfs," "evil school things," "scorpions," and "Yoshi died." He was very agitated and internally preoccupied. He took some minutes to calm down with mother's help. Mark turned his attention to a cooking game with his mother, chatting to her and with a smile, shared some "eggs on toast" with his mother and the clinician.

Neurocognitive and Behavioral Assessment and Other Investigations.

A Wechsler Preschool and Primary Scale of Intelligence for Children-Fourth Edition (WPPSI-IV) assessment suggested he was "probably in the borderline-low average range with a wide scatter of abilities" ( table 2, A). He was "difficult to assess due to poor concentration and non-compliance due to daydreaming and preoccupation with imaginary cartoon characters." The Developmental Behaviour Checklist (DBC) completed by mother and teacher revealed a total score of emotional and behavioral problems in the very high clinical range (96th percentile) and a positive screen on the "Psychosis" scale. Neurological and laboratory investigations were normal.

Case Study 2

RUTH (8 y) was referred by a Pediatrician who reported a 2-year history of Ruth unpredictably withdrawing into a fantasy world, laughing and talking to herself and becoming angry, and frightening other children (preoccupations with fantasies, social problems).

The Pediatrician reported that it was "difficult to follow her conversation, which was rambling and off the point." The teacher reported that Ruth "often talked to herself using different voices as if in a conversation with others and required continual reassurance at school" (fantasy preoccupation, anxiety). Ruth's parents described her as often "anxious" believing that other children were hostile towards her (ideas of reference). She had a persistent fear of leopards but insisted on going to school dressed as one (odd behaviors and anxiety). Her mother and teacher described how Ruth "talked nonsense" and was inattentive "in a world of her own" (odd speech, fantasy preoccupation). She had been suspended from school for aggressive behavior. A DSM-IV PDD-NOS diagnosis was made at age 4 due to "abnormal social interactions, irrelevant conversation, and a preoccupation with odd fantasies such as thinking she is an animal."

Psychiatric Mental State Examination (Both Parents Present).

Ruth was dressed oddly in frayed leopard skin patterned clothes and on arrival crawled about, growling, "I'm a leopard" (odd behavior and beliefs). Her eye contact fluctuated, and her affect varied from appropriate to incongruous (inappropriate affect). She engaged in reciprocal conversation to direct questions about home and school, but during free play activities, her thinking became circumstantial and fragmented with self-referenced suspicious ideas and perceptual disturbance. For example, when asked what she liked to play with friends, she responded with animation, "We play cartwheels and splits." (C: With your friends?)

"Yes, outside with A and B." (C: With A and B?)

She became self-preoccupied. "Outside....this girl I loved the most....like 15....she's mixed up....mean." Looking upward as if listening. "You're bad. I know where you live." (C: Who is bad?)

She appeared frightened. "She keeps looking at me." (C: Is she looking at you now?)

"She's just behind me saying creepy things." (C: Saying creepy things?) "Stop talking. I want you to be happy once."

She became agitated and curled up crying on a chair. It took some minutes for her to settle when comforted by her mother. Ruth then played with the doll's house in conversation with the clinician. When asked what she enjoyed playing at home, she responded warmly:

"Leopards and popstars." (C: How do you play Leopards and popstars?)

She became detached and agitated, as if preoccupied with her thoughts. With evidence of paranoid bizarre fantasy, perceptual disturbance, and fragmented thinking she said:

"Something is banging on the door." Ruth looked fearfully towards the closed office door although all was quiet outside.
"It's creeping me out....a red eye.." (C: A red eye?) "Yes. A red eye coming down." (C: Is it real? Where is it coming down?)

She appeared startled, wide-eyed and fearful.

"It is really coming down outside. There are people on the traffic island outside talking to a different girl."

Her mother comforted her telling her they would buy her an ice-cream on the way home, which helped settle Ruth.

Ruth responded happily when asked to do a drawing of a whole person. She drew a picture of herself with a heart-shaped body, lips and head, and repeated oval shapes for legs, but no arms. She added 2 arrow shapes on the head, which she called "spears." Three visual mood scales were drawn, and Ruth was asked to make a mark on the happy-sad, anxious-calm, and grumpy-peaceful scales to indicate where she had mostly felt over the past week.

On the happy-sad scale, she drew a picture of herself stating, "I was so sad playing a game with Sue because he told me to be rude to her." (social difficulties) (C: Who told you to be rude?)

"The angry voice." (C: A voice in your imagination?)
"No, he really told me." ( C: You really heard him tell you?)

She said "yes" as she drew an angry face. "He's angry in here" (pointing to the face that she was drawing). (C: Who is this you're drawing?)

"...That's me." She cried tearfully. "I'm sorry what I'm saying to him." (perceptual disturbance).

Ruth settled when she was asked to show her responses to the worried and grumpy mood scales. Ruth scribbled with a red pencil over the eyes on the mood scale faces saying she was "really worried (and grumpy) for what I'm saying about the angry voice."

She readily responded to the invitation to draw a dream (DAD task), rapidly becoming absorbed in drawing a "Monster" and commenting:

"He's a monster stopping me....a scary guy." Then loudly, "Oh hahahah" (C: Is it your imagination?)

"Oh no....he's real I can see him from inside my eyes." ( C: Is he talking to you?)

She appeared fearful. "He's saying I'm going to destroy you." (perceptual disturbance, paranoia)

She became increasingly agitated, hitting the chair arm and her head with her fist. (C: Is there any way I can help you Ruth?)

She drew another dream (DAD task) ( figure 3) of distressing perceptions of "voices and monsters in her head." She asked the clinician to help by writing on the picture "push them back into thoughts and memories" and "make them not real" (acute discomfort associated with paranoid fears).

Neurocognitive and Behavioral Assessment and Other Investigations.

A Wechsler Intelligence Scale for Children-Fourth Edition (WISC-IV) assessment at age 7 was attempted but incomplete because of "inattention due to preoccupation with irrelevant thoughts." Adaptive behavior, assessed by the teacher, was in the low average range. Total score of emotional and behavioral problems on the DBC completed by mother and teacher was in the very high clinical range (99.8th percentile), with a positive screen on the "Psychosis" scale. Metabolic and chromosome investigations, electroencephalography results and brain scans were normal.

Case Study 3

TOM (9 y) was referred by the family doctor for erratic, impulsive and disruptive behavior, inattention, mood swings, and school refusal.

Mother reported that over the previous 6 months, Tom's mood had been unstable with irritability, angry outbursts, jealousy, and aggression towards his 2 older brothers. He was often preoccupied with "daydreams," had separation anxiety about being alone at home and at bedtime, and was fearful and anxious about falling asleep by himself. At school, Tom's irritability was alienating children, including his long-standing group of friends. He was inattentive, forgetful and disorganized, and had regressed in his learning, particularly in math. He tired more easily at sports and physical activities. Tom's motivation to attend school fluctuated, with some school refusal, distress, and tearfulness.

Psychiatric Mental State Examination.

Tom was first seen together with his mother. He was initially shy and withdrawn with a flat affect but greeted the clinician politely and with appropriate eye contact. Throughout the session, he had a small teddy bear, which he took in and out of his pocket and talked to (odd behavior and fantasy). As his mother was reporting how irritable he could be towards family and friends, Tom became more animated with an incongruous smile, commenting that he was justified being angry because

"Everyone, even Mum is out to get me." (C: Why would that be?) "To ruin my day." (C: Would this just be at home or elsewhere?) "Everywhere." (C: You mean there are others in the community and at school trying to ruin your day?) "Yes, it's obvious. Zombies are everywhere." (C: How do you know this?)
"I can see through things." (Ideas of reference, odd beliefs, and incongruous affect).

Later when seen by himself, Tom was more engaged but fidgety. Initially, he related well and conversed about his friends and activities he enjoyed. He had a "secret" friend, which only he could "see and talk with and who helped him work out his worries" (perceptual disturbances). His mother reported that Tom would become distressed and scream in the car unless she buckled the car seat for his imaginary friend. Tom said that he had fearful, paranoid ideas of " feeling the presence of scary zombies who touch me and talk to me" (paranoid ideas, bodily illusions, auditory hallucinations). He struggled to sleep because at night, "the zombies visited" and could harm him. When asked about the "zombies" he claimed to " feel their presence and ghosts as well," and at times he could " feel people touching me" (bodily illusions). He believed these experiences were " real and not just imaginary." (C: Do these zombies, ghosts or people touching you talk to you or can you see them?)

"No, I can't hear anything but my brain tells me that they are real and to do things." (C: Is it actually your brain that tells you to do things?) (perceptual disturbances, ideas of reference)
"I'm not sure but I think it's the zombies." (C: What sort of things are you told to do?) "Like drown under the water when I'm swimming." (C: Where do you go swimming?).

Tom talked about swimming with his friends but then became distracted, staring at the ceiling, and his speech became vague, disjointed and incomprehensible (odd thinking, inappropriate behavior and affect).

When asked to complete some visual mood scales, Tom had a fixed, silly smile and marked the scales indicating that he had widely fluctuating emotions of anxiety, depression and irritability. He denied suicidal ideas, including ideas of drowning himself when swimming because "That is just my brain or ghosts telling me." These fluctuating emotions related to "kids at school having it in for me" or when he didn't know where his mother "might be at night" or "panic if my brothers are walking behind me" (anxiety related to paranoid perceptions). His picture of a bad dream was of " a ghost chasing me to eat me" and his mother who " couldn't help because she was sad." (A probable reference to the impact of stress of his mother's mental illness on him).

Neurocognitive and Behavioral Assessment.

During 2 assessment sessions, Tom was inattentive and distracted by preoccupying thoughts. His attention to tasks improved when prompted or given the opportunity to discuss what he was thinking about. Basic receptive and expressive language was age-appropriate, but in conversation, his train of thought was pressured and tangential, jumping to topics dominated by his preoccupying anxious thoughts. He fatigued quickly and needed frequent breaks.

WISC-IV assessment revealed a wide scatter of abilities ( table 2, B). He had excellent visual reasoning and construction skills but struggled with tasks of social comprehension and "working" and "long-term" memory, due to executive functioning difficulty in inhibiting and shifting his attention from his preoccupying thoughts. Academically, his spelling was adversely affected by this inattention and working memory difficulty.

Total score on the DBC completed by mother was in the high clinical range (78th percentile), with a positive screen on the "Psychosis" scale.

Discussion of the Case Studies

The Assessment Process.

The clinical assessment of the 3 children included several elements. First, a parent/teacher psychopathology screening tool-the Developmental Behaviour Checklist (DBC, DBC-2)-indicated the possibility of clinically significant emotional and behavioral problems, including flag items for "Psychosis" and a screen for Autism. There are a number of informant behavior checklists that also include questions regarding hallucinations, delusions, odd behaviors, speech/thought disorder, and ideas of reference. These include the Behavior Assessment System for Children 2nd Edition, "atypicality scale" (BASC-2); the DSM oriented Psychotic Symptoms Scale; the Child Behavior Checklist "thought problems" scale; the Screening Questions for Psychotic Symptoms; and the Schizotypal Personality Questionnaire for Children (SPQ-C), which supports a 3-factor structure (cognitive/perceptual, interpersonal, disorganized, plus a general factor). The SPQ-C also has construct validity with respect to gene (family history) environment (childhood abuse) interaction. However, these checklists might have low levels of agreement across multi-informants, do not exclude symptoms attributed to sleep, fever, and substance use, and do not reliably confirm an SDC diagnosis. At best, informant questionnaires indicate the likelihood of SDC requiring further clinical assessment.

Secondly, the diagnosis of SDC was determined by a comprehensive clinical assessment informed by structured interviews-the Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS-PL-DSM-5) including the "Psychosis Supplement," and the Melbourne Assessment of Schizotypy in Kids (MASK)-enhanced by mental state examination and observation conducted by an experienced clinician. Although the K-SADS and other robust structured clinical assessment tools such as the NIMH DISC-IV have diagnostic algorithms for "Psychosis" and Schizophrenia, they do not specify an algorithm for SD. Therefore, with these tools, if the criteria for the diagnosis of Schizophrenia are not met, then the identified psychotic symptoms remain undiagnosed. To date, the MASK is probably the only structured diagnostic interview that specifically elucidates a clinical diagnosis of SDC. In order to improve the recognition of SDC, clinicians should be alert to "atypical thought problems and psychotic symptoms" flagged in parent/teacher behavior checklists or indicated by structured clinical assessment tools, and follow-up with a focused clinical and mental state assessment to confirm that these symptoms meet criteria for SDC.

Comorbidity.

All 3 cases presented a range of associated emotional and behavioral difficulties in addition to their SDC diagnosis. While some of these symptoms can clearly be attributed to the effects on emotions and behavior of the paranoid fears and perceptual and thought disturbances, others might also be regarded as comorbid disorders. For example, they all suffered from generalized anxiety, as well as their anxiety-related schizotypal fears. In a similar way, anxiety is also both inherent and comorbid with other neurodevelopmental disorders such as intellectual disability (ID), ADHD, and ASD. Fluctuating depression (Dysthymia) was experienced by Ruth and Tom. Tom also had a later episode of Major Depression. Developmentally excessive inattention and distractibility were also present in all 3 children associated with their internal preoccupations, thus meeting criteria for ADHD of the Inattentive type. Significant problems with emotion regulation were apparent in all 3 children. Difficulties with the control of emotions are also a feature of other neurodevelopmental disorders such as ASD, ADHD, and ID. A study of 700 children (6-12.9 y) attending mental health outpatient clinics in the United States found 7% screened positive for "Psychosis" using the K-SADS. These children were further identified as suffering a mixture of Major Depression, Bipolar Spectrum Disorder, ADHD, Post-traumatic Stress Disorder, and ASD but not Schizophrenia. Given that the K-SADS does not have an algorithm to identify SDC, and the Psychosis items of the K-SADS are congruent with the symptoms of SDC, then it might be likely that at least some of the 7% identified with "Psychosis," had SDC. The other conditions identified in any of these children would therefore be comorbid disorders. The longer-term association between SDC and comorbid conditions requires further study.

Cognitive Profile.

All 3 children had a wide scatter of cognitive skills, with Ruth and Mark in the intellectually disabled to low average range and Tom in the borderline to high average range. The greatest impairments were identified in the active processing of information in working memory and self-directed attentional control; skills most vulnerable to disruption by preoccupation with internal fantasies. The ALSPAC study found that children (mean age 12.9 y) with low IQ (less than 79-89) were at the highest risk of having "definite psychosis symptoms."  Those children with "higher than average IQ" also had a somewhat increased risk of psychosis.

Inherited Risk.

There was a history of mental illness (psychosis, affective disorder) in the families of the 3 children, emphasizing the potential relevance of genetic influences that require further study. There is evidence that family history might predicate the dysregulation aspects of SDC symptomatology and perhaps its attenuation with development.

Trauma and Stress.

Psychosocial stress and traumatic early life events were experienced at least by Mark and Tom. All 3 children deteriorated in their mental health at times of stressful life events, indicating that the stress response might be both a risk and perpetuating factor of salience to episodes of psychotic decompensation and perhaps predictive of later development of schizophrenia and psychosis. Longitudinal studies are imperative to explore the evidence that suggests that childhood trauma increases the risk of SDC, particularly cognitive/perceptual disturbance, and provide further insights on gene-environment interactions.

Why Diagnose SDC?

When making a diagnosis of SDC, care must be taken to ensure that the symptoms are not transient or a part of "normal developmental variation,"  such as vivid imaginary play and daydreaming. The symptoms must be a cause of distress, disability, and impaired adaptation and cannot be attributed to another cause such as a sleep phenomenon, fever, organic disorder, or substance use. The 3 cases clearly demonstrate that SD can be diagnosed in children and is likely to be a neurodevelopmental disorder. Its symptoms, although fluctuant and reactive to stress, are pervasive, persistent and cause considerable developmental disruption, emotional and behavioral problems and distress to the child and family.

Conclusion

Consistent with evidence that the brain has developmental continuity from childhood, we contend that SDC is a Neurodevelopmental Disorder rather than emerging de novo in later adolescence as a first-episode psychosis. Because SDC is largely unrecognized and under-researched, a number of critical questions remain unanswered regarding phenomenology, epidemiology, etiology, and treatment. Our understanding of diagnostic criteria and comorbidity requires refinement; the developmental trajectory including prevalence and psychosis risk is unclear, although symptoms have been described to persist for 20-30 years; the influence of culture and environment is uncertain; potential etiological factors such as birth trauma, child abuse, psychosis family history, and genetics require further study; and specific features of brain function require confirmation. Neurocognitive assessment, which demonstrates difficulty shifting attention from internal preoccupations and perceptual disturbances, can inform the management of educational, social, and behavioral difficulties and assist with differential diagnosis from other conditions such as ASD, where attention is externally focused. Treatment and management remain speculative but include education for learning and motor difficulties, psychological treatment for stress and anxiety, ecological interventions for family interactions and parenting style, and biological treatments such as the use of neuroleptics. Better recognition of SDC might result in effective early intervention to prevent psychosis in youth. It is critical not to leave children disabled with SDC to languish unrecognized.

Ethics Approval Statement

The project was approved by Monash University Research Ethics Committee (CF08/1420 - 2008000688: Investigation of unusual personality traits in children presenting to a Learning Difficulties Clinic) and Western/Melbourne Health Research Ethics Committee (2009.650: A pilot study investigating brain functioning in children with unusual thinking and atypical personality traits).

Funding

C.P. was supported by a National Health and Medical Research Council (NHMRC) Senior Principal Research Fellowship (ID: 1105825), a Brain and Behavior Research Foundation Distinguished Investigator Award (US; Grant ID: 18722). The work was supported by University of Melbourne-Research Grant Support Scheme (ID: 1452755) and NHMRC Program Grant to C.P. (ID: 1150083).

Acknowledgments

The authors have declared that there are no conflicts of interest in relation to the subject of this study. However, in the last 3 years, C.P. has received honoraria for talks at educational meetings and has served on an advisory board for Lundbeck Australia Pty Ltd.

References

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Schizotypal Disorder in Children-A Neglected Diagnosis

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For 60 years, there has been growing recognition that some children have a cluster of distressing and unusual social, communication, perceptual, thought, and behavioral difficulties and preoccupations with bizarre fantasies that have a detrimental impact on mental health and well-being.

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Risk factors of schizotypal personality disorder could be inherited from previous families members who had mental health disorders.  It could also be from childhood trauma, such as neglect and having a parent who does not show any sign of love to the child throughout their lives.

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What is Schizotypal Personality Disorder?

Schizotypal personality disorder is one of many types of personality disorders. If you have schizotypal personality disorder, others may perceive you as being eccentric or just 'a little bit off.' You may have difficulty forming relationships and interpreting social cues. You may be overly suspicious of others or very superstitious.

People with schizotypal personality disorder do not generally experience hallucinations. However, they do experience delusions. You may experience extreme anxiety or paranoia, especially when in new or social situations. With treatment, medication, and therapy, people with schizotypal personality disorder can get their symptoms under control.

Schizotypal Personality Disorder Symptoms

Your doctor has tests and assessments that can be used for making a schizotypal personality disorder diagnosis. Talk to your doctor if you experience any potential symptoms. Some common symptoms include:

Suspiciousness or paranoia

Delusional thinking that you have special powers or talents

An obsessive focus on religious or occult intervention or power of such things

Strange patterns of speech or word usage

Constant social anxiety

Dressing in odd ways, including being very unkempt or wearing strange costumes as daily clothes

Problems forming or maintaining relationships outside of one's immediate family

Limited emotional responses; flat affect

Schizotypal Personality Disorder Causes and Risk Factors

Schizotypal personality disorder is not caused by any one specific factor. There are a number of risk factors that may make you more inclined to develop this disorder, including:

A family history of schizophrenia disorders or other mental health conditions

Brain malfunction, including brain trauma

Childhood experiences including abuse or neglect

Having a parental figure who is cold or detached from you

Injury or illness before or during birth

A history of psychotic breaks or periods of delusion

Abnormalities in your brain structure or chemistry

Schizotypal Personality Disorder Treatment

With proper treatment and care, you can help lessen the impact schizotypal personality disorder has on your life. You and your doctor can develop a treatment plan and put together a care team to help you get your disorder under control.

Medication: Medications that reduce anxiety, control depression, and help lessen psychosis can be beneficial.

Therapy: Cognitive behavioral therapy, family therapy, cognitive remediation therapy, group therapy, and other types of therapy can help you learn to manage your symptoms and triggers. Find the right therapy option for you at Sheppard Pratt.

Education: By educating yourself about your condition and mental health, you can learn to know when you may need to ask for extra help. Find resources and information from our Knowledge Center.

Support: Support from your family, friends and even a support group can be the key to controlling your condition. Look for a support group at Sheppard Pratt.

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Schizotypal Personality Disorder Symptoms, Causes & Treatment

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Schizotypal personality disorder is one of many types of personality disorders. If you have schizotypal personality disorder, others may perceive you as being eccentric or just 'a little bit off.' You may have difficulty forming relationships and interpreting social cues. You may be overly suspicious of others or very superstitious.

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Some protective factors for Schrizotypal personality disorder are:
support from others, this could be families, friends and teachers
Teaching strategies for anxiety and depression
Getting knowledges on different ways how to socialize with others.

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What is Schizotypal Personality Disorder?

Schizotypal personality disorder is one of many types of personality disorders. If you have schizotypal personality disorder, others may perceive you as being eccentric or just 'a little bit off.' You may have difficulty forming relationships and interpreting social cues. You may be overly suspicious of others or very superstitious.

People with schizotypal personality disorder do not generally experience hallucinations. However, they do experience delusions. You may experience extreme anxiety or paranoia, especially when in new or social situations. With treatment, medication, and therapy, people with schizotypal personality disorder can get their symptoms under control.

Schizotypal Personality Disorder Symptoms

Your doctor has tests and assessments that can be used for making a schizotypal personality disorder diagnosis. Talk to your doctor if you experience any potential symptoms. Some common symptoms include:

Suspiciousness or paranoia

Delusional thinking that you have special powers or talents

An obsessive focus on religious or occult intervention or power of such things

Strange patterns of speech or word usage

Constant social anxiety

Dressing in odd ways, including being very unkempt or wearing strange costumes as daily clothes

Problems forming or maintaining relationships outside of one's immediate family

Limited emotional responses; flat affect

Schizotypal Personality Disorder Causes and Risk Factors

Schizotypal personality disorder is not caused by any one specific factor. There are a number of risk factors that may make you more inclined to develop this disorder, including:

A family history of schizophrenia disorders or other mental health conditions

Brain malfunction, including brain trauma

Childhood experiences including abuse or neglect

Having a parental figure who is cold or detached from you

Injury or illness before or during birth

A history of psychotic breaks or periods of delusion

Abnormalities in your brain structure or chemistry

Schizotypal Personality Disorder Treatment

With proper treatment and care, you can help lessen the impact schizotypal personality disorder has on your life. You and your doctor can develop a treatment plan and put together a care team to help you get your disorder under control.

Medication: Medications that reduce anxiety, control depression, and help lessen psychosis can be beneficial.

Therapy: Cognitive behavioral therapy, family therapy, cognitive remediation therapy, group therapy, and other types of therapy can help you learn to manage your symptoms and triggers. Find the right therapy option for you at Sheppard Pratt.

Education: By educating yourself about your condition and mental health, you can learn to know when you may need to ask for extra help. Find resources and information from our Knowledge Center.

Support: Support from your family, friends and even a support group can be the key to controlling your condition. Look for a support group at Sheppard Pratt.

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Schizotypal Personality Disorder Symptoms, Causes & Treatment

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Schizotypal personality disorder is one of many types of personality disorders. If you have schizotypal personality disorder, others may perceive you as being eccentric or just 'a little bit off.' You may have difficulty forming relationships and interpreting social cues. You may be overly suspicious of others or very superstitious.

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Helping Someone With Schizotypal Personality Disorder 

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This website explains the different recourses and techniques available for a person who has been diagnosed with Schizotypal personality disorder.

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The Recovery Village Drug and Alcohol Rehab

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Editor Camille Renzoni

Schizotypal personality disorder is characterized by odd or eccentric behaviors and difficulty interpreting social cues. Individuals with schizotypal personality disorder frequently have few, if any, close relationships.

This disorder consists of symptoms like:

Failure to understand the impact of behaviors on other people

Misinterpretations of other people's motivations

Deep-rooted distrust of other people

Additionally, many people with schizotypal personality disorder experience other, co-occurring mental health conditions like anxiety and, in some cases, depression. These symptoms can push people away, making schizotypal personality disorder an even more challenging condition to live with.

While treatment is unlikely to cause schizotypal personality disorder to remit, symptoms can be improved with medication, therapy and the support of family members and other caring individuals.

Having a loved one with schizotypal personality disorder can be very trying and exhausting. Because people with schizotypal personality disorder often do not make friends, family members are frequently the only supports available. Parents especially may want to know how to help their child with schizotypal personality disorder and may find themselves gravely disappointed by the responses they usually receive.

While it is unlikely that schizotypal personality disorder will be completely relieved, there is reason to have hope. It is possible for someone to experience symptom improvement with treatment and social support.

If a loved one has schizotypal personality disorder, take the time to learn about the disorder and develop an understanding of its symptoms. Then, you can encourage them to seek treatment, as it is unusual for someone with this disorder to seek help unless they are urged to do so.

Remember, despite sounding similar, schizotypal personality disorder and schizophrenia are not the same. Many people base their assumptions about schizotypal personality disorder on their understanding of schizophrenia. When supporting a loved one, it is important not to have this misconception.

Tips for Supporting Someone With Schizotypal Personality Disorder

While it may be tempting to attempt to control the life of someone with schizotypal personality disorder, this is ultimately more likely to be harmful. Additionally, avoid trying to fix someone's problems and intervene in situations as it is important for a person to believe in their ability to handle difficulties. A factor that may reduce the symptoms of this disorder is experiencing a sense of achievement. Provide challenges and responsibilities for a loved one with schizotypal personality disorder rather than attempting to simplify their life unnecessarily.

Supporting a Loved One Through Treatment for Schizotypal Personality Disorder

Positive family relationships are correlated with better treatment outcomes for schizotypal personality disorder. Families should be engaged in the therapy process and, when appropriate, should seek additional therapy. A therapist can help family members learn how to create a supportive home environment for a person with schizotypal personality disorder.

Other ways to support a loved one can include:

Avoiding enabling behaviors

Offering positive reinforcement for well-handled responsibilities

Giving reassurance that they are worthy of love and friendship

Offering to drive them to therapy appointments

Regularly asking how they are doing to show interest in their life

Where to Find Help for Your Loved One

Schizotypal personality disorder is most frequently treated using a combination of psychotherapy, or talk therapy, and medication.

Therapy can be helpful by building trust with a therapist, which may then help a person be more trusting of other people. Therapy options like cognitive behavioral therapy frequently include challenging faulty thinking, learning adaptive skills and improving trust within family relationships.

Currently, there are no medications approved to treat schizotypal personality disorder, but medications may be used to treat specific symptoms such as anxiety, depression or psychotic episodes.

Compared with the general population, people with schizotypal personality disorder are more likely to have a substance use disorder. When someone has a drug or alcohol addiction and a personality disorder, they have what is called a dual diagnosis, and often need treatment that addresses both conditions at the same time.

If you or a loved one has a substance use disorder and a co-occurring mental health condition like schizotypal personality disorder, The Recovery Village can help. We have facilities across the country to treat substance use and co-occurring disorders. As a first step toward treatment for yourself or a loved one, you can speak with a representative today.

Medical Disclaimer: The Recovery Village aims to improve the quality of life for people struggling with a substance use or mental health disorder with fact-based content about the nature of behavioral health conditions, treatment options and their related outcomes. We publish material that is researched, cited, edited and reviewed by licensed medical professionals. The information we provide is not intended to be a substitute for professional medical advice, diagnosis or treatment. It should not be used in place of the advice of your physician or other qualified healthcare provider.

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Helping Someone With Schizotypal Personality Disorder - The Recovery Village Drug and Alcohol Rehab

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Editor Camille Renzoni Schizotypal personality disorder is characterized by odd or eccentric behaviors and difficulty interpreting social cues. Individuals with schizotypal personality disorder frequently have few, if any, close relationships.

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5 Ways to Deal with Social Anxiety on Your Own https://www.youtube.com/watch?v=dhYF3AqVhgU

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This video shows how a person can try to calm down social anxiety.

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5 Ways to Deal with Social Anxiety on Your Own

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This website gives you advice on how to start a conversation with others and maintain a conversation. It also gives you resources about anxiety.
https://www.futurepathwaysnavigator.org/knowledge-navigators/making-new-friends

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Making New Friends - Future Pathways Navigator

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Learn some tips and tricks to help you make new friends and how to have a conversation with people you don’t even know!

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Schizoid personality disorder is the third personality disorder in cluster A. It is characterized by a lack of social relationships and difficulties showing emotions.

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Symptoms of Schizoid Personality Disorder are:

no interest to have a close relationship, either romantic or friendly, even with family members

Choosing activities that are lonely

Not showing interest and enjoying few or even any activities

Having little or any desire on having sexual experiences with another person

Lack of showing emotions and if someone praise or criticizes you, it does not make any difference for you

A person with Schizoid Personality Disorder can show four or more of these symptoms.

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Personality disorders are characterized by rigid patterns of thinking, feeling and behaving that cause distress or impairment in social, occupational or other areas of functioning. The DSM-5 organizes personality disorders into three groups, including Cluster A, B, and C. Schizoid personality disorder is a Cluster A disorder. Cluster A disorders involve odd or eccentric ways of thinking or behaving.Triebwasser, Joseph et al. 'Schizoid personality disorder.' ¹ Journal of personality disorders vol. 26,6 (2012): 919-2 6: doi:10.1521/pedi.2012.26.6.919

Schizoid personality disorder is characterized by social isolation and indifference towards other people. People with this disorder are often described as cold or withdrawn. They are disinterested in having close relationships, preferring to be alone. Below are symptoms of schizoid personality disorder.

Although many people feel the need to be alone sometimes, most generally enjoy close relationships with other people, whether romantic or platonic. There is also compelling evidence that strong relationships with others contribute positively to both physical and mental well-being.

A person with schizoid personality disorder typically has little interest in forming close relationships with others and will often have difficulty forming healthy interpersonal attachments.Ekselius, Lisa. 'Personality disorder: a disease in disguise.' ² Upsala journal of medical sciences vol. 123,4 (2018): 194-20 4: doi:10.1080/03009734.2018.1526235 Some people with the disorder may have an inner longing for closeness but are hampered by an inability to bond or connect with others on a deep level.

Related Articles

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10 Schizoid Personality Disorder Symptoms

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Schizoid personality disorder is marked by social isolation and indifference towards other people. Do you know what schizoid personality disorder symptoms look like? Discover 10 common schizoid personality disorder symptoms at 10FAQ Health and stay better informed to make healthy living decisions.

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 Teen Schizoid Personality Disorder Symptoms

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The sign in children would be them not wanting to do activities with others at school or outside of school

You might see them not paying attention to school and not showing emotion when teachers or parents are complimenting them or criticize them

You might see them not interested in being friends with others

The symptoms in adolescents are the same as in children one other symptom you will see in adolescents is that you will see them not want to be in any form of romantic and sexual relationship.

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Schizoid Personality Disorder Treatment - Visions Treatment Centers

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Schizoid Personality Disorder Treatment - Visions Treatment Centers Skip to main content At Visions Treatment Centers, we work with specialists and therapists to find different teen schizoid personality disorder treatment modalities to effectively and meet patients' unique recovery needs.

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The actual cause of Schizoid Personality Disorder is unknown but some risk factors could be genetics which means if a family member was diagnosed with a personality disorder that might had play a role and environmental factors can also be a risk factor, for example, child trauma.

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Overview

Schizoid personality disorder is an uncommon condition in which people avoid social activities and consistently shy away from interaction with others. They also have a limited range of emotional expression.

If you have schizoid personality disorder, you may be seen as a loner or dismissive of others, and you may lack the desire or skill to form close personal relationships. Because you don't tend to show emotion, you may appear as though you don't care about others or what's going on around you.

The cause of schizoid personality disorder is unknown. Talk therapy, and in some cases medications, can help.

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Symptoms

If you have schizoid personality disorder, it's likely that you:

Prefer being alone and choose to do activities alone

Don't want or enjoy close relationships

Feel little if any desire for sexual relationships

Feel like you can't experience pleasure

Have difficulty expressing emotions and reacting appropriately to situations

May seem humorless, indifferent or emotionally cold to others

May appear to lack motivation and goals

Don't react to praise or critical remarks from others

Schizoid personality disorder usually begins by early adulthood, though some features may be noticeable during childhood. These features may cause you to have trouble functioning well in school, a job, socially or in other areas of life. However, you may do reasonably well in your job if you mostly work alone.

Schizotypal personality disorder and schizophrenia

Although a different disorder, schizoid personality disorder can have some similar symptoms to schizotypal personality disorder and schizophrenia, such as a severely limited ability to make social connections and a lack of emotional expression. People with these disorders may be viewed as odd or eccentric.

Even though the names may sound similar, unlike schizotypal personality disorder and schizophrenia, people with schizoid personality disorder:

Are in touch with reality, so they're unlikely to experience paranoia or hallucinations

Make sense when they speak (although the tone may not be lively), so they don't have conversational patterns that are strange and hard to follow

When to see a doctor

People with schizoid personality disorder usually only seek treatment for a related problem, such as depression.

If someone close to you has urged you to seek help for symptoms common to schizoid personality disorder, make an appointment with a health care or mental health professional.

If you suspect a loved one may have schizoid personality disorder, gently suggest that the person seek medical attention. It might help to offer to go along to the first appointment.

Causes

Personality is the combination of thoughts, emotions and behaviors that makes you unique. It's the way you view, understand and relate to the outside world, as well as how you see yourself. Personality forms during childhood, shaped through an interaction of inherited tendencies and environmental factors.

In normal development, children learn over time to accurately interpret social cues and respond appropriately. What causes the development of schizoid personality disorder is unknown, although a combination of genetic and environmental factors, particularly in early childhood, may play a role in developing the disorder.

Risk factors

Factors that increase your risk of developing schizoid personality disorder include:

Having a parent or other relative who has schizoid personality disorder, schizotypal personality disorder or schizophrenia

Having a parent who was cold, neglectful or unresponsive to emotional needs

Complications

People with schizoid personality disorder are at an increased risk of:

Developing schizotypal personality disorder, schizophrenia or another delusional disorder

Other personality disorders

Major depression

Anxiety disorders

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Schizoid personality disorder - Symptoms and causes

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Schizoid personality disorder is an uncommon condition in which people avoid social activities and consistently shy away from interaction with others. They also have a limited range of emotional expression. If you have schizoid personality disorder, you may be seen as a loner or dismissive of others, and you may lack the desire or skill to form close personal relationships.

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Schizoid Personality Disorder Symptoms and Treatments, scroll to coping

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Some resilience factors for Schizoid Personality Disorder are practicing being in a social group, getting support from others and practicing identifying emotions.

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Schizoid personality disorder (SPD) is a chronic and pervasive condition characterized by social isolation and feelings of indifference toward other people. Those who live with this disorder are often described as distant or withdrawn and tend to avoid social situations that involve interaction with other people.

They find it difficult to express emotions and lack the desire to form close personal relationships. This type of personality disorder is believed to be relatively rare and tends to affect more men than women. People with schizoid personality disorder are also at risk of experiencing depression.

Schizoid Personality Disorder Symptoms

People with schizoid personality disorder typically experience:

A preoccupation with introspection and fantasy﻿﻿

A sense of indifference to praise and affirmation, as well as to criticism or rejection

Detachment from other people

Little or no desire to form close relationships with others

Indifference to social norms and expectations

Infrequent participation in activities for fun or pleasure

Not enjoying social or family relationships

Often described as cold, uninterested, withdrawn, and aloof

Typical Onset

The disorder is often first noticeable during childhood and is usually apparent by early adulthood. The symptoms of the disorder can have an impact on multiple life domains including family relationships, school, and work.

The DSM-5 defines schizoid personality disorder as a "pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity to form close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior, beginning by early adulthood and present in a variety of contexts."﻿﻿

Work-Life Impact

Those with this disorder also tend to have few friendships, date rarely, and often do not marry. The symptoms of the disorder may also make it difficult to work in positions that require a lot of social interaction or people skills. People with a schizoid personality disorder may do better in jobs that involve working in solitude.

Schizoid Personality Disorder vs. Schizophrenia

While schizoid personality disorder is considered one of the schizophrenia spectrum disorders and shares some common symptoms with schizophrenia and schizotypal personality disorder, there are important distinctions that separate SPD from those two disorders.

Those with SPD rarely experience paranoia or hallucinations.﻿﻿ Also, while they may seem aloof and distant during conversations, they do make sense when they speak, which differs from the difficult to follow speech patterns that often demonstrated by people with schizophrenia.

The causes of schizoid personality disorder are not known,﻿﻿ although it is believed that a combination of genetic and environmental factors play a role. Personality is shaped by a wide variety of factors including inherited traits and tendencies, childhood experiences, parenting, education, and social interactions. All of these factors may play some part in contributing to the development of SPD.﻿﻿

If you are concerned about your symptoms, you may start by consulting your doctor. Your doctor will evaluate your symptoms and check for any underlying medical conditions that might be contributing to your symptoms. In most cases, you will likely then be referred to a mental health professional.

The DSM-5 diagnostic criteria state that people must display at least four of the following symptoms in order to be diagnosed with SPD:

Always chooses solitary activities

Emotional detachment and lack of emotional expression﻿﻿

Experiences little pleasure from activities

Indifference to criticism or praise

Lack of desire or enjoyment for close personal relationships

Little or no interest in sex with other people

No close friends other than immediate family

Schizoid personality disorder is most often diagnosed by a psychiatrist or another mental health professional who is trained to diagnose and treat personality disorders. General practitioners often lack the training to make this type of diagnosis, especially since the condition is so uncommon and is often confused with other mental disorders.

People who have schizoid personality disorder rarely seek out treatment on their own. It is often only after the condition has severely interrupted multiple areas of a person's life that treatment is sought.

Schizoid personality disorder can be challenging to treat. Those with the disorder rarely seek treatment and may struggle with psychotherapy because they find it difficult to develop working relationships with a therapist.﻿﻿ The social isolation that characterizes schizoid personality disorder also makes it difficult to find support and assistance.

Medications may be used to treat some of the symptoms of schizoid personality disorder such as anxiety and depression. Such medications are usually used in conjunction with other treatment options such as cognitive behavioral therapy (CBT) or group therapy.

CBT can help people with SPD identify problematic thoughts and behaviors and develop new coping skills. Group therapy may help people practice interpersonal skills.

One-on-one therapy can seem intimidating for people with this condition because it requires a great deal of social interaction. Such treatments may be most effective when mental health professionals are careful to avoid pushing too hard and clients are not faced with excessive pressure and emotional demands.﻿﻿

Because of the nature of the condition, you might feel that it is simply easier to keep to yourself rather than seek out professional help. Even if you generally prefer solitude, people with schizoid personality disorder do experience loneliness and isolation. There are things that you can do to seek out support.

Consider joining a work or hobby-related social group. Because emotional intimacy can be challenging for people with schizoid personality disorder, you might find it easier to socialize with others in the context of an occupational or recreational pursuit. This can be a great way to develop social connections without overwhelming yourself.

If you have a loved one with this condition, you can help by avoiding judgment, being patient, and encouraging the individual to seek treatment. Avoid trying to push the individual into activities or relationships that make them feel uncomfortable or pressured. Instead, look for activities that you can do together that don't require a great deal of emotional investment.

A Word From Verywell

The condition is usually enduring, chronic, and lifelong, but with support and effective treatment, people who live with it can continue to live functional lives.

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Schizoid Personality Disorder Symptoms and Treatments

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Schizoid personality disorder (SPD) is a chronic and pervasive condition characterized by social isolation and feelings of indifference toward other people. Those who live with this disorder are often described as distant or withdrawn and tend to avoid social situations that involve interaction with other people.

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This website explains the different treatments that are available for a person with Schizoid personality disorder.

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Diagnosis

After a physical exam to help rule out other medical conditions, your primary care provider may refer you to a mental health professional for further evaluation.

Diagnosis of schizoid personality disorder is typically based on:

Thorough discussion of your symptoms

Symptoms listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association

Your medical and personal history

Treatment

If you have schizoid personality disorder, you may prefer to go your own way and avoid interacting with others, including doctors. You may be so used to a life without emotional closeness that you're not sure you want to change - or that you can.

You might agree to start treatment only at the urging of a family member who is concerned about you. But help from a mental health professional who's experienced in treating schizoid personality disorder can have a major positive impact. Treatment options include:

Talk therapy (psychotherapy). Psychotherapy can be helpful. If you'd like to develop closer relationships, a modified form of cognitive behavioral therapy may help you change the beliefs and behaviors that are problems. A therapist understands your need for personal space and how difficult it is for you to open up about your inner life. He or she can listen to and help guide you without pushing too hard.

Group therapy. A goal of individual treatment may be a group setting in which you can interact with others who are also practicing new interpersonal skills. In time, group therapy may also provide a support structure and improve your social skills.

Medications. Although there's no specific drug to treat schizoid personality disorder, certain drugs can help with issues such as anxiety or depression.

With appropriate treatment and a skilled therapist, you can make significant progress and improve your quality of life.

Preparing for your appointment

You're likely to start by seeing your primary care doctor. However, in some cases when you call to set up an appointment, you may be referred directly to a mental health professional.

Take a family member or friend along, if possible. With your permission, someone who has known you for a long time may be able to answer questions or share information with the doctor that you don't think to bring up.

Here's some information to help you prepare for your appointment.

What you can do

Before your appointment, make a list of:

Any symptoms you or your family noticed and for how long. Ask friends or relatives if they've felt concerned about your behavior and what they've noticed.

Key personal information, including traumatic events in your past and any current, major stressors. Find out about your family's medical history, including any history of mental illness.

Your medical information, including other physical or mental health conditions with which you've been diagnosed.

All medications you take, including the names and doses of any medications, herbs, vitamins or other supplements.

Questions to ask your doctor to make the most of your appointment.

Some basic questions to ask your doctor include:

What is likely causing my symptoms or condition?

What are other possible causes?

Is my condition likely temporary or long term?

What treatments are most likely to be effective for me?

If you're recommending medications, what are the possible side effects?

Is there a generic alternative to the medicine you're prescribing?

How much can I expect my symptoms to improve with treatment?

I have other health conditions. How can I best manage them together?

Are there brochures or other printed materials that I can have? What websites do you recommend?

Don't hesitate to ask any other questions during your appointment.

What to expect from your doctor

Your doctor is likely to ask you a number of questions. Be ready to answer them to reserve time to go over points you want to focus on. Your doctor may ask:

What are the problems or symptoms that concern you?

Have you noticed that your symptoms get worse in certain situations? If yes, what are those situations, and how do you handle them?

Do you have close friends or family? If not, does it bother you?

How would you describe yourself?

Do you frequently choose to do things by yourself?

Do you confide in anyone who is not in your immediate family?

What do you prefer to do in your free time?

Have you ever thought about harming yourself or others? Have you ever done so?

Have your family members or friends expressed concern about your behavior?

Have any of your close relatives been diagnosed with or treated for mental illness?

Do you drink alcohol or use drugs? If so, how often?

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Schizoid personality disorder - Diagnosis and treatment - Mayo Clinic

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Schizoid personality disorder is an uncommon condition in which people consistently shy away from interaction with others and have a limited range of emotional expression.

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This website talk about ways that you can be more present and live in the moment.

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Have you ever felt like you were "in your head," lost in thought, and not really in the present moment?

Maybe you've heard a coach tell an athlete to "get their head in the game" rather than focusing on worries, insecurities, or mental distractions.

These are common examples of what results from a mind-first approach. You may lose touch with the important information coming from your body and emotions. Ultimately, you may even feel less human.

Our culture places high value on reason, efficiency, and the quantifiable. However, intelligence and output alone don't equal well-being or contentment.

While the ability to think, reason, and calculate is essential, there's a lot more to being human than the mind.

According to dancer, massage therapist, yoga instructor, and Buddhist practitioner, Luisa Giraldo, we can reconnect our mind and our body through simple, intentional practices that focus on integration rather than separation.

This is how we become truly embodied.

Want to know more about what conscious embodiment means? Read on to learn how to get "in your body" and get up close and personal with life.

From an early age growing up in Columbia, Giraldo felt drawn to the twin fields of physical movement and mental health and healing.

Giraldo went on to study psychology, concentrating on dance therapy and the ways that dance can lead to expression and release. Giraldo also completed training as a yoga teacher and massage therapist.

You could say that touch, movement, and the body are central to her work. To meet external challenges, Giraldo says she pays attention to what's going on inside of her.

When her body talks, she listens.

You don't have to have a career in mind-body training to benefit from cultivating body awareness. Below, Giraldo offers several tips for embodied living, no matter your walk of life.

Get curious about your body

Giraldo notes that some people know their bodies well, while others need guidance to reconnect. To gently find your way back into your body, the first step is getting curious.

Ask yourself these questions with an attitude of curiosity, without judgment or needing to "fix" anything. You can also try a number of other exercises to help you feel grounded.

Explore the mind-body connection

"When I meet with someone, I like to understand who that person is and what they're going through," Giraldo explains. "A lot of our tension comes from our minds and emotions: things we say, do, and think."

Sometimes it helps to gently assess the stressors on your body - both from without and from within your own mind.

First, Giraldo asks her clients about their self-care habits:

How are you feeling?

How have you been sleeping?

How is your appetite?

What have you been feeding yourself?

How often have you been exercising?

These questions can help you tune in to which basic needs may need more attention.

Then, Giraldo asks about the bigger picture:

What's your life situation?

What are your sources of stress?

What are you telling yourself about your situation?

How do you think you're handling it?

What are you telling others about yourself in this situation?

What parts of your body hurt or feel tense?

These questions, as well as how you answer them, can give clues to your sources of stress. They can also help you become more aware of how you relate to stressors.

Find ways to release tension

There are plenty of ways to release tension, including:

Giraldo notices that people look and move differently when tension is released from the body, including:

breathing more deeply

walking with a looser stride

opening their chest rather than hunching their shoulders

smiling more readily

Once tension is released, these behaviors can help prevent it from coming back.

Touch and be touched

While professional massage can sometimes be expensive, you don't have to spend money to experience the healing power of touch.

Giraldo says she used to massage her friends' shoulders and her dad's feet long before she was certified.

Simply exchanging touch with a friend or loved one can be a powerful avenue to getting in your body. And if you can find a friend to trade full-body massages with, even better!

You can also practice self-massage to reap the benefits of touch. You can try:

When paired with intention and conscious observation of your sensations, this is a powerful way to reinforce the mind-body connection.

There are even massage products you can use to get to those hard-to-reach places. Short of that, a good hug or cuddle session can do wonders.

Explore mindfulness

Mindfulness is a powerful tool to help you connect to your body and the present moment.

The good news is that you can find a mindfulness activity for virtually any time or place. Meditation is another way to explore the world of mindfulness, and many meditations are free and accessible.

Giraldo attends a weekly in-person meditation at a local Unitarian Universalist church. Otherwise, she uses a meditation app and free meditation resources online.

Many community centers, churches, and social groups offer free or low cost meditations.

Breathe more deeply

Giraldo uses breathing techniques learned from yoga to open and close her massage therapy sessions.

A 2019 review found that yogic or diaphragmatic breathing positively affects physiological and neurocognitive functions in healthy people.

Want to open the lungs, heart, and chest and breathe deeper? Give the exercises below a try:

Reconnect to the earth

"When we live in cement cities, we forget that the earth gives us life, water, and food," Giraldo says. "I need to get my hands in the dirt."

To reconnect with your earthy roots, you can try:

If you don't have a garden plot, try planting a few herbs in your window.

"Food is medicine," says Giraldo. If we plant our own lettuce, tomatoes, even simply our own herbs, we take an active role in nourishing ourselves.

Another way to reconnect to the earth is to go barefoot. A park or an apartment yard will do for this.

Often referred to as grounding or earthing, this practice can be as simple as feeling the dewy grass or crunching leaves under your feet.

Finally, tuning into the seasonal changes can help you connect to the cyclical, predictable stability of nature.

You can look for sunsets, sunrises, the waxing and waning of the moon, and the changing topography from spring to summer, winter to fall.

Accept limitations

Giraldo has been practicing Buddhism since 1994. A core tenet of Buddhism is that by accepting suffering, you become liberated.

Giraldo believes that our bodies illustrate this wisdom.

To be human is to live in a body with natural constraints and limitations, such as:

Even if we meditate, do yoga, eat healthily, and look "young," all of the above is true.

This is known as impermanence in Buddhism and many other spiritual traditions. Accepting this blunt but inevitable truth frees us from fighting against all the things we can't control.

"About 90 percent of my life is outside of my control," Giraldo admits.

The more we have compassion for our basic human limitations, the more we can accept the limitations of others and surrender to whatever life brings.

Manage your relationship with technology

Giraldo acknowledges that it's hard to stay embodied in a technology-based society. For those who live in cities like her, staying connected to nature can be challenging.

Despite the challenges, Giraldo says there are small ways to remember the present even in the concrete jungle.

For instance, you may have had the experience of being on your device and being totally absent from your surroundings. When someone nearby spoke to you, you may have realized you had no idea what they said.

Here are some guidelines Giraldo uses to prevent these missed moments of embodiment:

When in an in-person meeting, check your phone no more than once.

Being honest and straightforward when you do check is less disruptive than sneaking a peek.

See what it feels like to put away your phone one hour before sleep.

Before checking your phone in the morning, explore your own waking feelings by journaling or recording dreams.

Social media connects people, says Giraldo, but when it's your default way of interacting, it can also disconnect you.

When we're disconnected from our bodies, we're disconnected from each other too. We may drift away from ourselves and our loved ones, thinking constantly about the past and future, says Giraldo.

"Go back to the body, to social connection, to the present, and to peace," she urges.

This is what conscious embodiment is all about.
Karen Sosnoski's fiction and nonfiction, most recently in The Temper, explores what happens when people face their limitations through disability, illness, addiction, sports, or other intense encounters, such as art. Her work has appeared in diverse publications including Romper, Culture Trip, The Sunlight Press, Argot Magazine, LA Times, Poets and Writers, Word Riot, Grappling, Bitch, Radioactive Moat, PsychologyToday.com, and on Studio 360 and This American Life. Berkeley Media distributes her documentary film, "Wedding Advice: Speak Now or Forever Hold Your Peace."

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