Antisocial Disorder Nice Guidence

Issue date: January 2009
Antisocial personality
disorder
Treatment, management and prevention
NICE clinical guideline 77

Developed by the National Collaborating Centre for Mental health
Antisocial personality disorder: treatment, management and prevention
Ordering information
You can download the following documents from www.nice.org.uk/CG77
• The NICE guideline (this document) – all the recommendations.
• A quick reference guide – a summary of the recommendations for
healthcare professionals.
• ‘Understanding NICE guidance’ – a summary for patients and carers.
• The full guideline – all the recommendations, details of how they were
developed, and reviews of the evidence they were based on.
For printed copies of the quick reference guide or ‘Understanding NICE

guidance’, phone NICE publications on 0845 003 7783 or email
publications@nice.org.uk and quote:
• N1763 (quick reference guide)
• N1764 (‘Understanding NICE guidance’).
NICE clinical guidelines are recommendations about the treatment and care of
people with specific diseases and conditions in the NHS in England and
Wales.
This guidance represents the view of NICE, which was arrived at after careful
consideration of the evidence available. Healthcare professionals are
expected to take it fully into account when exercising their clinical judgement.
However, the guidance does not override the individual responsibility of
healthcare professionals to make decisions appropriate to the circumstances
of the individual patient, in consultation with the patient and/or guardian or
carer, and informed by the summary of product characteristics of any drugs
they are considering.
Implementation of this guidance is the responsibility of local commissioners

and/or providers. Commissioners and providers are reminded that it is their
responsibility to implement the guidance, in their local context, in light of their
duties to avoid unlawful discrimination and to have regard to promoting
equality of opportunity. Nothing in this guidance should be interpreted in a way
that would be inconsistent with compliance with those duties.
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Developed by the National Collaborating Centre for Mental Health
Contents
Introduction ...................................................................................................... 4
Person-centred care ........................................................................................ 7
Key priorities for implementation ...................................................................... 8
1 Guidance ................................................................................................. 11
1.1 General principles for working with people with antisocial
personality disorder .................................................................................... 11
1.2 Prevention of antisocial personality disorder – working with
children and young people and their families ............................................. 15
1.3 Assessment and risk management of antisocial
personality disorder ................................................................................... 22
1.4 Treatment and management of antisocial personality disorder and
related and comorbid disorders .................................................................. 26
1.5 Psychopathy and dangerous and severe personality disorder.......... 29
1.6 Organisation and planning of services .............................................. 30
2 Notes on the scope of the guidance ........................................................ 34
3 Implementation ........................................................................................ 34
4 Research recommendations.................................................................... 35
5 Other versions of this guideline ............................................................... 40
5.1 Full guideline ..................................................................................... 40
5.2 Quick reference guide ....................................................................... 40
5.3 ‘Understanding NICE guidance’ ........................................................ 41
6 Related NICE guidance ........................................................................... 41
7 Updating the guideline ............................................................................. 42
8 Definitions of psychological interventions ................................................ 43
Appendix A: The Guideline Development Group ........................................... 45
Appendix B: The Guideline Review Panel ..................................................... 48
Introduction
This guideline makes recommendations for the treatment, management and
prevention of antisocial personality disorder in primary, secondary and
forensic healthcare. This guideline is concerned with the treatment of people
with antisocial personality disorder across a wide range of services including
those provided within mental health (including substance misuse) services,
social care and the criminal justice system.
People with antisocial personality disorder exhibit traits of impulsivity, high

negative emotionality, low conscientiousness and associated behaviours
including irresponsible and exploitative behaviour, recklessness and
deceitfulness. This is manifest in unstable interpersonal relationships,
disregard for the consequences of one’s behaviour, a failure to learn from
experience, egocentricity and a disregard for the feelings of others. The
condition is associated with a wide range of interpersonal and social
disturbance.
People with antisocial personality disorder have often grown up in fractured

families in which parental conflict is typical and parenting is harsh and
inconsistent. As a result of parental inadequacies and/or the child’s difficult
behaviour, the child's care is often interrupted and transferred to agencies
outside the family. This in turn often leads to truancy, having delinquent
associates and substance misuse, which frequently result in increased rates
of unemployment, poor and unstable housing situations, and inconsistency in
relationships in adulthood. Many people with antisocial personality disorder
have a criminal conviction and are imprisoned or die prematurely as a result of
reckless behaviour.
Criminal behaviour is central to the definition of antisocial personality disorder,

although it is often the culmination of previous and long-standing difficulties,
such as socioeconomic, educational and family problems. Antisocial
personality disorder therefore amounts to more than criminal behaviour alone,
otherwise everyone convicted of a criminal offence would meet the criteria for
antisocial personality disorder and a diagnosis of antisocial personality
disorder would be rare in people with no criminal history. This is not the case.
The prevalence of antisocial personality disorder among prisoners is slightly
NICE clinical guideline 77 – Antisocial personality disorder 4

less than 50%. It is estimated in epidemiological studies in the community that
only 47% of people who meet the criteria for antisocial personality disorder
have significant arrest records. A history of aggression, unemployment and
promiscuity were more common than serious crimes among people with
antisocial personality disorder. The prevalence of antisocial personality
disorder in the general population is 3% in men and 1% in women.
Under current diagnostic systems, antisocial personality disorder is not

formally diagnosed before the age of 18 but the features of the disorder can
manifest earlier as conduct disorder. People with conduct disorder typically
show antisocial, aggressive or defiant behaviour, which is persistent and
repetitive, including aggression to people or animals, destruction of property,
deceitfulness, theft and serious rule-breaking. A history of conduct disorder
before the age of 15 is a requirement for a diagnosis of antisocial personality
disorder in the Diagnostic and Statistical Manual of Mental Disorders, fourth
edition (DSM-IV).
The course of antisocial personality disorder is variable and although recovery

is attainable over time, some people may continue to experience social and
interpersonal difficulties. Antisocial personality disorder is often comorbid with
depression, anxiety, and alcohol and drug misuse.
Families or carers are important in prevention and treatment of antisocial

personality disorder. This guideline uses the term ‘families or carers’ to apply
to all family members and other people, such as friends and advocates, who
have regular close contact with the person with antisocial personality disorder.
This guideline draws on the best available evidence. However, there are
significant limitations to the evidence base, notably a relatively small number
of randomised controlled trials (RCTs) of interventions with few outcomes in
common. Some of the limitations are addressed in the recommendations for
further research (see section 4).
At the time of publication (January 2009), no drug has UK marketing

authorisation for the treatment of antisocial personality disorder. The guideline
assumes that prescribers will use a drug’s summary of product characteristics
to inform their decisions for each person.

NICE has developed a separate guideline on borderline personality disorder
(see section 6).

Person-centred care
This guideline offers best practice advice on the care of people with antisocial
personality disorder.
Treatment and care should take into account people’s needs and preferences.
People with antisocial personality disorder should have the opportunity to
make informed decisions about their care and treatment, in partnership with
their healthcare professionals. If someone does not have the capacity to make
decisions, healthcare professionals should follow the Department of Health
guidelines – ‘Reference guide to consent for examination or treatment’ (2001;
available from www.dh.gov.uk). Healthcare professionals should also follow
the code of practice that accompanies the Mental Capacity Act (summary
available from www.publicguardian.gov.uk).
If the person is under 16, healthcare professionals should follow the

guidelines in ‘Seeking consent: working with children’ (available from
www.dh.gov.uk).
Good communication between healthcare professionals and people with

antisocial personality disorder is essential. It should be supported by
evidence-based written information tailored to the person's needs. Treatment
and care, and the information people are given about it, should be culturally
appropriate. It should also be accessible to people with additional needs such
as physical, sensory or learning disabilities, and to people who do not speak
or read English.
If the person agrees, carers (who may include family and friends) should have
the opportunity to be involved in decisions about treatment and care. Families
and carers should also be given the information and support they need.
Care of young people in transition between paediatric and adult services

should be planned and managed according to the best practice guidance
described in ‘Transition: getting it right for young people’ (available from
www.dh.gov.uk).

Key priorities for implementation
Developing an optimistic and trusting relationship
• Staff working with people with antisocial personality disorder should
recognise that a positive and rewarding approach is more likely to be
successful than a punitive approach in engaging and retaining people in
treatment. Staff should:
− explore treatment options in an atmosphere of hope and optimism,
explaining that recovery is possible and attainable
− build a trusting relationship, work in an open, engaging and non-
judgemental manner, and be consistent and reliable.
Cognitive behavioural interventions for children aged 8 years and older

with conduct problems
• Cognitive problem-solving skills training should be considered for children
aged 8 years and older with conduct problems if:
− the child’s family is unwilling or unable to engage with a parent-training
programme (see sections 1.2.6 and 1.2.7).
− additional factors, such as callous and unemotional traits in the child,
may reduce the likelihood of the child benefiting from parent-training
programmes alone.
Assessment in forensic/specialist personality disorder services

• Healthcare professionals in forensic or specialist personality disorder
services should consider, as part of a structured clinical assessment,
routinely using:
− a standardised measure of the severity of antisocial personality
disorder such as Psychopathy Checklist–Revised (PCL-R) or
Psychopathy Checklist–Screening Version (PCL-SV)
− a formal assessment tool such as Historical, Clinical, Risk
Management-20 (HCR-20) to develop a risk management strategy.
Treatment of comorbid disorders

• People with antisocial personality disorder should be offered treatment for
any comorbid disorders in line with recommendations in the relevant NICE
clinical guideline, where available (see section 6). This should happen

regardless of whether the person is receiving treatment for antisocial
personality disorder.
The role of psychological interventions

• For people with antisocial personality disorder with a history of offending
behaviour who are in community and institutional care, consider offering
group-based cognitive and behavioural interventions (for example,
programmes such as ‘reasoning and rehabilitation’) focused on reducing
offending and other antisocial behaviour.
Multi-agency care
• Provision of services for people with antisocial personality disorder often
involves significant inter-agency working. Therefore, services should
ensure that there are clear pathways for people with antisocial personality
disorder so that the most effective multi-agency care is provided. These
pathways should:
− specify the various interventions that are available at each point
− enable effective communication among clinicians and organisations at all
points and provide the means to resolve differences and disagreements.
Clearly agreed local criteria should also be established to facilitate the

transfer of people with antisocial personality disorder between services. As
far as is possible, shared objective criteria should be developed relating to
comprehensive assessment of need and risk.
• Services should consider establishing antisocial personality disorder

networks, where possible linked to other personality disorder networks.
(They may be organised at the level of primary care trusts, local authorities,
strategic health authorities or government offices.) These networks should
be multi-agency, should actively involve people with antisocial personality
disorder and should:
− take a significant role in training staff, including those in primary care,
general, secondary and forensic mental health services, and in the
criminal justice system
− have resources to provide specialist support and supervision for staff

− take a central role in the development of standards for and the
coordination of clinical pathways
− monitor the effective operation of clinical pathways.

1 Guidance
The following guidance is based on the best available evidence. The full
guideline (www.nice.org.uk/CG77fullguideline) gives details of the methods
and the evidence used to develop the guidance.
1.1 General principles for working with people with

antisocial personality disorder
People with antisocial personality disorder have tended to be excluded from
services, and policy implementation guidance from the Department of Health,
‘Personality disorder: no longer a diagnosis of exclusion’ (2003) 1, aims to
address this. To change the current position, staff need to work actively to
engage people with antisocial personality disorder in treatment. Evidence from
both clinical trials and scientific studies of antisocial personality disorder
shows that positive and reinforcing approaches to the treatment of antisocial
personality disorder are more likely to be successful than those that are
negative or punitive.
1.1.1 Access and assessment

1.1.1.1 People with antisocial personality disorder should not be excluded
from any health or social care service because of their diagnosis or
history of antisocial or offending behaviour.
1.1.1.2 Seek to minimise any disruption to therapeutic interventions for

people with antisocial personality disorder by:
• ensuring that in the initial planning and delivery of treatment,

transfers from institutional to community settings take into
account the need to continue treatment
• avoiding unnecessary transfer of care between institutions
whenever possible during an intervention, to prevent disruption
to the agreed treatment plan. This should be considered at initial
planning of treatment.
1
Available at:
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidanc
e/DH_4009546www

1.1.1.3 Ensure that people with antisocial personality disorder from black
and minority ethnic groups have equal access to culturally
appropriate services based on clinical need.
1.1.1.4 When language or literacy is a barrier to accessing or engaging

with services for people with antisocial personality disorder,
provide:
• information in their preferred language and in an accessible

format
• psychological or other interventions in their preferred language
• independent interpreters.
1.1.1.5 When a diagnosis of antisocial personality disorder is made,

discuss the implications of it with the person, the family or carers
where appropriate, and relevant staff, and:
• acknowledge the issues around stigma and exclusion that have

characterised care for people with antisocial personality disorder
• emphasise that the diagnosis does not limit access to a range of
appropriate treatments for comorbid mental health disorders
• provide information on and clarify the respective roles of the
healthcare, social care and criminal justice services.

1.1.1.6 When working with women with antisocial personality disorder take
into account the higher incidences of common comorbid mental
health problems and other personality disorders in such women,
and:
• adapt interventions in light of this (for example, extend their

duration)
• ensure that in inpatient and residential settings the increased
vulnerability of these women is taken into account.
1.1.1.7 Staff, in particular key workers, working with people with antisocial
personality disorder should establish regular one-to-one meetings
to review progress, even when the primary mode of treatment is
group based.
1.1.2 People with disabilities and acquired cognitive

impairments
1.1.2.1 When a person with learning or physical disabilities or acquired
cognitive impairments presents with symptoms and behaviour that
suggest antisocial personality disorder, staff involved in
assessment and diagnosis should consider consulting with a
relevant specialist.
1.1.2.2 Staff providing interventions for people with antisocial personality

disorder with learning or physical disabilities or acquired cognitive
impairments should, where possible, provide the same
interventions as for other people with antisocial personality
disorder. Staff might need to adjust the method of delivery or
duration of the intervention to take account of the disability or
impairment.

1.1.3 Autonomy and choice
1.1.3.1 Work in partnership with people with antisocial personality disorder
to develop their autonomy and promote choice by:
• ensuring that they remain actively involved in finding solutions to

their problems, including during crises
• encouraging them to consider the different treatment options and
life choices available to them, and the consequences of the
choices they make.
1.1.4 Developing an optimistic and trusting relationship

1.1.4.1 Staff working with people with antisocial personality disorder should
recognise that a positive and rewarding approach is more likely to
be successful than a punitive approach in engaging and retaining
people in treatment. Staff should:
• explore treatment options in an atmosphere of hope and

optimism, explaining that recovery is possible and attainable
• build a trusting relationship, work in an open, engaging and non-
judgemental manner, and be consistent and reliable.
1.1.5 Engagement and motivation

1.1.5.1 When providing interventions for people with antisocial personality
disorder, particularly in residential and institutional settings, pay
attention to motivating them to attend and engage with treatment.
This should happen at initial assessment and be an integral and
continuing part of any intervention, as people with antisocial
personality disorder are vulnerable to premature withdrawal from
treatment and supportive interventions.

1.1.6 Involving families and carers
1.1.6.1 Ask directly whether the person with antisocial personality disorder
wants their family or carers to be involved in their care, and, subject
to the person's consent and rights to confidentiality:
• encourage families or carers to be involved

• ensure that the involvement of families or carers does not lead to
a withdrawal of, or lack of access to, services
• inform families or carers about local support groups for families
or carers.
1.1.6.2 Consider the needs of families and carers of people with antisocial
personality disorder and pay particular attention to the:
• impact of antisocial and offending behaviours on the family

• consequences of significant drug or alcohol misuse
• needs of and risks to any children in the family and the
safeguarding of their interests.
1.2 Prevention of antisocial personality disorder –

working with children and young people and their
families
The evidence for the treatment of antisocial personality disorder in adult life is
limited and the outcomes of interventions are modest. The evidence for
working with children and young people who are at risk, and their families,
points to the potential value of preventative measures. There are definitions of
the psychological interventions referred to in the recommendations in
section 8.

1.2.1 General principles
1.2.1.1 Child and adolescent mental health service (CAMHS) professionals
working with young people should:
• balance the developing autonomy and capacity of the young

person with the responsibilities of parents and carers
• be familiar with the legal framework that applies to young
people, including the Mental Capacity Act, the Children Acts and
the Mental Health Act.
1.2.2 Identifying children at risk of developing conduct

problems
1.2.2.1 Services should establish robust methods to identify children at risk
of developing conduct problems, integrated when possible with the
established local assessment system. These should focus on
identifying vulnerable parents, where appropriate antenatally,
including:
• parents with other mental health problems, or with significant

drug or alcohol problems.
• mothers younger than 18 years, particularly those with a history
of maltreatment in childhood
• parents with a history of residential care
• parents with significant previous or current contact with the
criminal justice system.
1.2.2.2 When identifying vulnerable parents, take care not to intensify any
stigma associated with the intervention or increase the child's
problems by labelling them as antisocial or problematic.
1.2.3 Early interventions for preschool children at risk of

developing conduct problems and potentially subsequent
antisocial personality disorder
1.2.3.1 Early interventions aimed at reducing the risk of the development of
conduct problems, and antisocial personality disorder at a later
age, may be considered for children identified to be of high risk of

developing conduct problems. These should be targeted at the
parents of children with identified high-risk factors and include:
• non-maternal care (such as well-staffed nursery care) for

children younger than 1 year
• interventions to improve poor parenting skills for the parents of
children younger than 3 years.
1.2.3.2 Early interventions should usually be provided by health and social

care professionals over a period of 6–12 months, and should:
• consist of well-structured, manualised programmes that are

closely adhered to
• target multiple risk factors (such as parenting, school behaviour,
and parental health and employment).
1.2.4 Interventions for children with conduct problems younger

than 12 years and their families
1.2.4.1 Group-based parent-training/education programmes are
recommended in the management of children with conduct
disorders. 2
1.2.4.2 Individual-based parent-training/education programmes are

recommended in the management of children with conduct
disorders only in situations where there are particular difficulties in
engaging with the parents or a family’s needs are too complex to be
met by group-based parent-training/education programmes. 3
1.2.4.3 Additional interventions targeted specifically at the parents of

children with conduct problems (such as interventions for parental,
marital or interpersonal problems) should not be provided routinely
alongside parent-training programmes, as they are unlikely to have
an impact on the child’s conduct problems.
2
This recommendation is from ‘Parent-training/education programmes in the management of
children with conduct disorders’ (NICE technology appraisal 102).

1.2.4.4 Programme providers should also ensure that support is available
to enable the participation of parents who might otherwise find it
difficult to access these programmes. 4
1.2.4.5 Support to enable the participation of parents who might otherwise

find it difficult to access these programmes might include:
• individual parent-training programmes

• regular reminders about meetings (for example, telephone calls)
• effective treatment of comorbid disorders (in particular, attention
deficit hyperactivity disorder in line with ‘Attention deficit
hyperactivity disorder’ NICE clinical guideline 72).
1.2.5 How to deliver interventions for children with conduct

problems aged younger than 12 years and their families
1.2.5.1 It is recommended that all parent-training/education programmes,
whether group- or individual-based, should: 5
• be structured and have a curriculum informed by principles of

social-learning theory
• include relationship-enhancing strategies
• offer a sufficient number of sessions, with an optimum of 8–12,
to maximise the possible benefits for participants
• enable parents to identify their own parenting objectives
• incorporate role-play during sessions, as well as homework to be
undertaken between sessions, to achieve generalisation of
newly rehearsed behaviours to the home situation
• be delivered by appropriately trained and skilled facilitators who
are supervised, have access to necessary ongoing professional
development, and are able to engage in a productive therapeutic
alliance with parents
• adhere to the programme developer’s manual and employ all of
the necessary materials to ensure consistent implementation of
the programme.
3–5
These recommendations are from ‘Parent-training/education programmes in the
management of children with conduct disorders’ (NICE technology appraisal 102).

1.2.5.2 Programmes should include problem solving (both for the parent
and in helping to train their child to solve problems) and the
promotion of positive behaviour (for example, through support, use
of praise and reward).
1.2.5.3 Programmes should demonstrate proven effectiveness. This should

be based on evidence from randomised controlled trials or other
suitable rigorous evaluation methods undertaken independently. 6
1.2.6 Cognitive behavioural interventions for children aged

8 years and older with conduct problems
1.2.6.1 Cognitive problem-solving skills training should be considered for
children aged 8 years and older with conduct problems if:
• the child’s family is unwilling or unable to engage with a parent-

training programme (see sections 1.2.4 and 1.2.5)
• additional factors, such as callous and unemotional traits in the
child, may reduce the likelihood of the child benefiting from
parent-training programmes alone.
1.2.6.2 For children who have residual problems following cognitive

problem-solving skills training, consider anger control or social
problem-solving skills training, depending on the nature of the
residual problems.
1.2.7 How to deliver interventions for children aged 8 years and

older with conduct problems
1.2.7.1 Cognitive problem-solving skills training should be delivered
individually over a period of 10–16 weeks. Training should focus
typically on cognitive strategies to enable the child to:
• generate a range of alternative solutions to interpersonal

problems
• analyse the intentions of others
• understand the consequences of their actions
6
This recommendation is from ‘Parent-training/education programmes in the management of
children with conduct disorders’ (NICE technology appraisal 102).

• set targets for desirable behaviour.
1.2.7.2 Anger control should usually take place in groups over a period of
10–16 weeks and focus typically on strategies to enable the child
to:
• build capacity to improve the perception and interpretation of

social cues
• manage anger through coping and self-talk
• generate alternative ‘non-aggressive’ responses to interpersonal
problems.
1.2.7.3 Social problem-solving skills training should usually be conducted

in groups over a period of 10–16 weeks. Training should focus
typically on strategies to enable the child to:
• modify and expand their interpersonal appraisal processes

• develop a more sophisticated understanding of beliefs and
desires in others
• improve their capacity to regulate their emotional responses.
Interventions for young people with conduct problems aged

between 12 and 17 years and their families
1.2.7.4 For parents of young people aged between 12 and 17 years with
conduct problems, consider parent-training programmes (see
sections 1.2.4 and 1.2.5).
1.2.7.5 If the parents are unable to or choose not to engage with parent-
training programmes, or the young person’s conduct problems are
so severe that they will be less likely to benefit from parent-training
programmes, consider:
• brief strategic family therapy for those with predominantly drug-

related problems
• functional family therapy for those with predominantly a history
of offending.

1.2.7.6 For young people aged between 12 and 17 years with severe
conduct problems and a history of offending and who are at risk of
being placed in care or excluded from the family, consider
multisystemic therapy.
1.2.7.7 For young people aged between 12 and 17 years with conduct
problems at risk of being placed in long-term out-of-home care,
consider multidimensional treatment foster care.
1.2.8 How to deliver interventions for young people with

conduct problems aged between 12 and 17 years and
their families
1.2.8.1 Brief strategic family therapy should consist of at least fortnightly
meetings over a period of 3 months and focus on:
• engaging and supporting the family

• engaging and using the support of the wider social and
educational system
• identifying maladaptive family interactions (including areas of
power distribution and conflict resolution)
• promoting new and more adaptive family interactions (including
open and effective communication).
1.2.8.2 Functional family therapy should be conducted over a period of

3 months by health or social care professionals and focus on
improving the interactions within the family, including:
• engaging and motivating the family in treatment (enhancing

perception that change is possible, positive reframing and
establishing a positive alliance)
• problem-solving and behaviour change through parent-training
and communication training
• promoting generalisation of change in specific behaviours to
broader contexts, both within the family and the community
(such as schools).

1.2.8.3 Multisystemic therapy should be provided over a period of
3–6 months by a dedicated professional with a low caseload, and
should:
• focus specifically on problem-solving approaches with the family

• involve and use the resources of peer groups, schools and the
wider community.
1.2.8.4 Multidimensional treatment foster care should be provided over a

period of 6 months by a team of health and social care
professionals able to provide case management, individual therapy
and family therapy. This intervention should include:
• training foster care families in behaviour management and

providing a supportive family environment
• the opportunity for the young person to earn privileges (such as
time on the computer and extra telephone time with friends)
when engaging in positive living and social skills (for example,
making their bed and being polite) and good behaviour at school
• individual problem-solving skills training for the young person
• family therapy for the birth parents to provide a supportive
environment for the young person to return to after treatment.
1.2.9 Transition from child and adolescent services to adult

services
1.2.9.1 Health and social care services should consider referring
vulnerable young people with a history of conduct disorder or
contact with youth offending schemes, or those who have been
receiving interventions for conduct and related disorders, to
appropriate adult services for continuing assessment and/or
treatment.
1.3 Assessment and risk management of antisocial

personality disorder
In primary and secondary care services, antisocial personality disorder is
under-recognised. When it is identified, significant comorbid disorders such as

treatable depression or anxiety are often not detected. In secondary and
forensic services there are important concerns about assessing risk of
violence and risk of harm to self and others.
1.3.1 Assessment
1.3.1.1 When assessing a person with possible antisocial personality
disorder, healthcare professionals in secondary and forensic
mental health services should conduct a full assessment of:
• antisocial behaviours
• personality functioning, coping strategies, strengths and
vulnerabilities
• comorbid mental disorders (including depression and anxiety,
drug or alcohol misuse, post-traumatic stress disorder and other
personality disorders)
• the need for psychological treatment, social care and support,
and occupational rehabilitation or development
• domestic violence and abuse.
1.3.1.2 Staff involved in the assessment of antisocial personality disorder

in secondary and specialist services should use structured
assessment methods whenever possible to increase the validity of
the assessment. For forensic services, the use of measures such
as PCL-R or PCL-SV to assess the severity of antisocial
personality disorder should be part of the routine assessment
process.
1.3.1.3 Staff working in primary and secondary care services (for example,
drug and alcohol services) and community services (for example,
the probation service) that include a high proportion of people with
antisocial personality disorder should be alert to the possibility of
antisocial personality disorder in service users. Where antisocial
personality disorder is suspected and the person is seeking help,
consider offering a referral to an appropriate forensic mental health
service depending on the nature of the presenting complaint. For
example, for depression and anxiety this may be to general mental
health services; for problems directly relating to the personality

disorder it may be to a specialist personality disorder or forensic
service.
1.3.2 Risk assessment and management

Risk assessment is part of the overall approach to assessment and care
planning as defined in the framework of the Care Programme Approach, and
the following recommendations should be regarded in that context.
Primary care services

1.3.2.1 Assessing risk of violence is not routine in primary care, but if such
assessment is required consider:
• current or previous violence, including severity, circumstances,

precipitants and victims
• the presence of comorbid mental disorders and/or substance
misuse
• current life stressors, relationships and life events
• additional information from written records or families and carers
(subject to the person's consent and right to confidentiality),
because the person with antisocial personality disorder might not
always be a reliable source of information.
1.3.2.2 Healthcare professionals in primary care should consider contact

with and/or referral to secondary or forensic services where there is
current violence or threats that suggest significant risk and/or a
history of serious violence, including predatory offending or
targeting of children or other vulnerable people.
Secondary care services

1.3.2.3 When assessing the risk of violence in secondary care mental
health services, take a detailed history of violence and consider
and record:
• current or previous violence, including severity, circumstances,

• contact with the criminal justice system, including convictions
and periods of imprisonment

• the presence of comorbid mental disorder and/or substance
misuse
(subject to the person's consent and right to confidentiality), as
the person with antisocial personality disorder might not always
be a reliable source of information.
1.3.2.4 The initial risk management should be directed at crisis resolution

and ameliorating any acute aggravating factors. The history of
previous violence should be an important guide in the development
of any future violence risk management plan.
1.3.2.5 Staff in secondary care mental health services should consider a

referral to forensic services where there is:
• current violence or threat that suggests immediate risk or

disruption to the operation of the service
• a history of serious violence, including predatory offending or
targeting of children or other vulnerable people.
Specialist personality disorder or forensic services

1.3.2.6 When assessing the risk of violence in forensic, specialist
personality disorder or tertiary mental health services, take a
detailed history of violence, and consider and record:
• current and previous violence, including severity, circumstances,

• contact with the criminal justice system, including convictions
and periods of imprisonment
• the presence of comorbid mental disorder and/or substance
misuse
(subject to the person’s consent and right to confidentiality), as
the person with antisocial personality disorder might not always
be a reliable source of information.

1.3.2.7 Healthcare professionals in forensic or specialist personality
disorder services should consider, as part of a structured clinical
assessment, routinely using:
• a standardised measure of the severity of antisocial personality

disorder (for example, PCL-R or PCL-SV)
• a formal assessment tool such as HCR-20 to develop a risk
management strategy.
1.3.3 Risk management

1.3.3.1 Services should develop a comprehensive risk management plan
for people with antisocial personality disorder who are considered
to be of high risk. The plan should involve other agencies in health
and social care services and the criminal justice system. Probation
services should take the lead role when the person is on a
community sentence or is on licence from prison with mental health
and social care services providing support and liaison. Such cases
should routinely be referred to the local Multi-Agency Public
Protection Panel.
1.4 Treatment and management of antisocial personality

disorder and related and comorbid disorders
The evidence base for the treatment of antisocial personality disorder is
limited. In the development of the recommendations set out below these
limitations were addressed by drawing on four related sources of evidence,
namely, evidence for: (1) interventions targeted specifically at antisocial
personality disorder; (2) the treatment and management of the symptoms and
behaviours associated with antisocial personality disorder, such as impulsivity
and aggression; (3) the treatment of comorbid disorders such as depression
and drug misuse; and (4) the management of offending behaviour. Although
the focus of several interventions is offending behaviour, the interventions
have the potential to help people with antisocial personality disorder address a
wider range of antisocial behaviours with consequent benefits for themselves
and others.

1.4.1 General principles
1.4.1.1 People with antisocial personality disorder should be offered
treatment for any comorbid disorders in line with recommendations
in the relevant NICE clinical guideline, where available (see section
6). This should happen regardless of whether the person is
receiving treatment for antisocial personality disorder.
1.4.1.2 When providing psychological or pharmacological interventions for

antisocial personality disorder, offending behaviour or comorbid
disorders to people with antisocial personality disorder, be aware of
the potential for and possible impact of:
• poor concordance
• high attrition
• misuse of prescribed medication
• drug interactions (including with alcohol and illicit drugs).
1.4.1.3 When providing psychological interventions for comorbid disorders

to people with antisocial personality disorder, consider lengthening
their duration or increasing their intensity.
1.4.2 The role of psychological interventions

1.4.2.1 For people with antisocial personality disorder, including those with
substance misuse problems, in community and mental health
services, consider offering group-based cognitive and behavioural
interventions, in order to address problems such as impulsivity,
interpersonal difficulties and antisocial behaviour.
1.4.2.2 For people with antisocial personality disorder with a history of

offending behaviour who are in community and institutional care,
consider offering group-based cognitive and behavioural
interventions (for example, programmes such as ‘reasoning and
rehabilitation’) focused on reducing offending and other antisocial
behaviour.
1.4.2.3 For young offenders aged 17 years or younger with a history of

offending behaviour who are in institutional care, offer group-based

cognitive and behavioural interventions aimed at young offenders
and that are focused on reducing offending and other antisocial
behaviour.
1.4.2.4 When providing cognitive and behavioural interventions:
• assess the level of risk and adjust the duration and intensity of
the programme accordingly (participants at all levels of risk may
benefit from these interventions)
• provide support and encouragement to help participants to
attend and complete programmes, including people who are
legally mandated to do so.
1.4.3 The role of pharmacological interventions

1.4.3.1 Pharmacological interventions should not be routinely used for the
treatment of antisocial personality disorder or associated
behaviours of aggression, anger and impulsivity.
1.4.3.2 Pharmacological interventions for comorbid mental disorders, in

particular depression and anxiety, should be in line with
recommendations in the relevant NICE clinical guideline (see
section 6). When starting and reviewing medication for comorbid
mental disorders, pay particular attention to issues of adherence
and the risks of misuse or overdose.
1.4.4 Drug and alcohol misuse

Drug and alcohol misuse occurs commonly alongside antisocial personality
disorder, and is likely to aggravate risk of harm to self and others and
behavioural disturbances in people with antisocial personality disorder.
1.4.4.1 For people with antisocial personality disorder who misuse drugs,
in particular opioids or stimulants, offer psychological interventions
(in particular, contingency management programmes) in line with
recommendations in the relevant NICE clinical guideline (see
section 6).
1.4.4.2 For people with antisocial personality disorder who misuse or are
dependent on alcohol, offer psychological and pharmacological

interventions in line with existing national guidance for the
treatment and management of alcohol disorders.
1.4.4.3 For people with antisocial personality disorder who are in

institutional care and who misuse or are dependent on drugs or
alcohol, consider referral to a specialist therapeutic community
focused on the treatment of drug and alcohol problems.
1.5 Psychopathy and dangerous and severe personality

disorder
People with psychopathy and people who meet criteria for dangerous and
severe personality disorder (DSPD) represent a small proportion of people
with antisocial personality disorder. However, they present a very high risk of
harm to others and consume a significant proportion of the services for people
with antisocial personality disorder. In the absence of any high-quality
evidence for the treatment of DSPD, the Guideline Development Group drew
on the evidence for the treatment of antisocial personality disorder to arrive at
their recommendations. Interventions will often need to be adapted for DSPD
(for example, a significant extension of the duration of the intervention).
People with DSPD can be seen as having a lifelong disability that requires
continued input and support over many years.
1.5.1 Adapting interventions for people who meet criteria for

psychopathy or DSPD
1.5.1.1 For people in community and institutional settings who meet criteria
for psychopathy or DSPD, consider cognitive and behavioural
interventions (for example, programmes such as ‘reasoning and
rehabilitation’) focused on reducing offending and other antisocial
behaviour. These interventions should be adapted for this group by
extending the nature (for example, concurrent individual and group
sessions) and duration of the intervention, and by providing booster
sessions, continued follow-up and close monitoring.
1.5.1.2 For people who meet criteria for psychopathy or DSPD, offer
treatment for any comorbid disorders in line with existing NICE
guidance. This should happen regardless of whether the person is

receiving treatment for psychopathy or DSPD because effective
treatment of comorbid disorders may reduce the risk associated
with psychopathy or DSPD.
1.5.2 Intensive staff support

1.5.2.1 Staff providing interventions for people who meet criteria for
psychopathy or DSPD should receive high levels of support and
close supervision, due to increased risk of harm. This may be
provided by staff outside the unit.
1.6 Organisation and planning of services

There has been a considerable expansion of services for people with
antisocial personality disorder in recent years involving a wider range of
agencies in the health and social care sector, the non-statutory sector and the
criminal justice system. If the full benefit of these additional services is to be
realised, effective care pathways and specialist networks need to be
developed.
1.6.1 Multi-agency care

1.6.1.1 Provision of services for people with antisocial personality disorder
often involves significant inter-agency working. Therefore, services
should ensure that there are clear pathways for people with
antisocial personality disorder so that the most effective multi-
agency care is provided. These pathways should:
• specify the various interventions that are available at each point

• enable effective communication among clinicians and
organisations at all points and provide the means to resolve
differences and disagreements.
Clearly agreed local criteria should also be established to facilitate

the transfer of people with antisocial personality disorder between
services. As far as is possible, shared objective criteria should be
developed relating to comprehensive assessment of need and risk.
1.6.1.2 Services should consider establishing antisocial personality

disorder networks, where possible linked to other personality

disorder networks. (They may be organised at the level of primary
care trusts, local authorities, strategic health authorities or
government offices.) These networks should be multi-agency,
should actively involve people with antisocial personality disorder
and should:
• take a significant role in training staff, including those in primary

care, general, secondary and forensic mental health services,
and in the criminal justice system
• have resources to provide specialist support and supervision for
staff
• take a central role in the development of standards for and the
coordination of clinical pathways
• monitor the effective operation of clinical pathways.
1.6.2 Inpatient services

1.6.2.1 Healthcare professionals should normally only consider admitting
people with antisocial personality disorder to inpatient services for
crisis management or for the treatment of comorbid disorders.
Admission should be brief, where possible set out in a previously
agreed crisis plan and have a defined purpose and end point.
1.6.2.2 Admission to inpatient services solely for the treatment of antisocial

personality disorder or its associated risks is likely to be a lengthy
process and should:
• be under the care of forensic/specialist personality disorder

services
• not usually be under a hospital order under a section of the
Mental Health Act (in the rare instance that this is done, seek
advice from a forensic/specialist personality service).
1.6.3 Staff training, supervision, support

Working in services for people with antisocial personality disorder presents a
considerable challenge for staff. Effective training and support is crucial so
that staff can adhere to the specified treatment programme and manage any
emotional pressures arising from their work.

Staff competencies
1.6.3.1 All staff working with people with antisocial personality disorder
should be familiar with the ‘Ten essential shared capabilities: a
framework for the whole of the mental health practice’ 7 and have a
knowledge and awareness of antisocial personality disorder that
facilitates effective working with service users, families or carers,
and colleagues.
1.6.3.2 All staff working with people with antisocial personality disorder
should have skills appropriate to the nature and level of contact
with service users. These skills include:
• for all frontline staff, knowledge about antisocial personality

disorder and understanding behaviours in context, including
awareness of the potential for therapeutic boundary violations
(for example, inappropriate relations with service users)
• for staff with regular and sustained contact with people with
antisocial personality disorder, the ability to respond effectively
to the needs of service users
• for staff with direct therapeutic or management roles,
competence in the specific treatment interventions and
management strategies used in the service.
1.6.3.3 Services should ensure that all staff providing psychosocial or

pharmacological interventions for the treatment or prevention of
antisocial personality disorder are competent and properly qualified
and supervised, and that they adhere closely to the structure and
duration of the interventions as set out in the relevant treatment
manuals. This should be achieved through:
• use of competence frameworks based on relevant treatment

manuals
• routine use of sessional outcome measures
• routine direct monitoring and evaluation of staff adherence, for
example through the use of video and audio tapes and external
audit and scrutiny where appropriate.
7
Available from www.eftacim.org/doc_pdf/10ESC.pdf

Supervision and support
1.6.3.4 Services should ensure that staff supervision is built into the routine
working of the service, is properly resourced within local systems
and is monitored. Supervision, which may be provided by staff
external to the service, should:
• make use of direct observation (for example, recordings of

sessions) and routine outcome measures
• support adherence to the specific intervention
• promote general therapeutic consistency and reliability
• counter negative attitudes among staff.
1.6.3.5 Forensic services should ensure that systems for all staff working
with people with antisocial personality disorder are in place that
provide:
• comprehensive induction programmes in which the purpose of

the service is made clear
• a supportive and open environment that encourages reflective
practice and honesty about individual difficulties such as the
potential for therapeutic boundary violations (such as
inappropriate relations with service users)
• continuing staff support to review and explore the ethical and
clinical challenges involved in working in high-intensity
environments, thereby building staff capacity and resilience.

2 Notes on the scope of the guidance
NICE guidelines are developed in accordance with a scope that defines what
the guideline will and will not cover. The scope of this guideline is available
from www.nice.org.uk/nicemedia/pdf/ASPDscopeFinalforweb.pdf
How this guideline was developed
NICE commissioned the National Collaborating Centre for Mental Health to

develop this guideline. The Centre established a Guideline Development
Group (see appendix A), which reviewed the evidence and developed the
recommendations. An independent Guideline Review Panel oversaw the
development of the guideline (see appendix B).
There is more information in the booklet: ‘The guideline development process:

an overview for stakeholders, the public and the NHS’ (third edition, published
April 2007), which is available from www.nice.org.uk/guidelinesprocess or
from NICE publications (phone 0845 003 7783 or email
publications@nice.org.uk and quote reference N1233).
3 Implementation
The Healthcare Commission assesses how well NHS organisations meet core
and developmental standards set by the Department of Health in ‘Standards
for better health’ (available from www.dh.gov.uk). Implementation of clinical
guidelines forms part of the developmental standard D2. Core standard C5
says that NHS organisations should take into account national agreed
guidance when planning and delivering care.
NICE has developed tools to help organisations implement this guidance

(listed below). These are available on our website (www.nice.org.uk/CG77).
• Slides highlighting key messages for local discussion.

• Costing tools:
− costing report to estimate the national savings and costs associated with
implementation
− costing template to estimate the local costs and savings involved.
• Audit support for monitoring local practice.

4 Research recommendations
The Guideline Development Group has made the following recommendations
for research, based on its review of evidence, to improve NICE guidance and
patient care in the future. The relatively large number of recommendations
made reflects the paucity of research in this area.
4.1 Severity as a potential moderator of effect in group-

based cognitive and behavioural interventions
Does the pre-treatment level of the severity of disorder/problem have an
impact on the outcome of group-based cognitive and behavioural
interventions for offending behaviour? A meta-analysis of individual participant
data should be conducted to determine whether the level of severity assessed
at the beginning of the intervention moderates the effect of the intervention.
The study (for which there are large data sets that include over 10,000
participants) could inform the design of a large-scale RCT (including potential
modifications of cognitive and behavioural interventions) to test the impact of
severity on the outcome of cognitive and behavioural interventions.
Why this is important

Research has established the efficacy of cognitive and behavioural
interventions in reducing reoffending. However, the effects of these
interventions in a range of offending populations are modest. The impact of
severity on the outcome of these interventions has not been systematically
investigated, and post hoc analyses and meta-regression of risk as a
moderating factor have been inconclusive. Expert opinion suggests that
severe or high-risk individuals may not benefit from cognitive and behavioural
interventions, but if they were to be of benefit then the cost savings could be
considerable.
4.2 Group-based cognitive and behavioural interventions

for populations outside criminal justice settings
Are group-based cognitive and behavioural interventions effective in reducing
the behaviours associated with antisocial personality disorder (such as
impulsivity, rule-breaking, deceitfulness, irritability, aggressiveness and
disregard for the safety of self or others)? This should be tested in an RCT

that examines medium-term outcomes (including cost effectiveness) over a
period of at least 18 months. It should pay particular attention to the
modification and development of the interventions to ensure the focus is not
just on offending behaviour, but on all aspects of the challenging behaviours
associated with antisocial personality disorder.

Not all people with antisocial personality disorder are offenders but they
exhibit a wide range of antisocial behaviours. However, the evidence for the
treatment of these behaviours outside the criminal justice system is extremely
limited. Following publication of the Department of Health’s policy guidance,
‘Personality disorder: no longer a diagnosis of exclusion’ (2003), it is likely that
there will be an increased requirement in the NHS to offer treatments for
antisocial personality disorder.
4.3 Effectiveness of multisystemic therapy versus

functional family therapy
Is multisystemic therapy or functional family therapy more clinically and cost
effective in the treatment of adolescents with conduct disorders? A large-scale
RCT comparing the clinical and cost effectiveness of multisystemic therapy
and functional family therapy for adolescents with conduct disorders should be
conducted. It should examine the medium-term outcomes (for example,
offending behaviour, mental state, educational and vocational outcomes and
family functioning) over a period of at least 18 months. The study should also
be designed to explore the moderators and mediators of treatment effect,
which could help to determine the factors associated with benefits or harms of
either multisystemic therapy or functional family therapy.

Multisystemic therapy and functional family therapy are two interventions with
a relatively strong evidence base in the treatment of adolescents with conduct
disorders, but there have been no studies directly comparing their clinical and
cost effectiveness. Their use in health and social care services in the UK is
increasing. Both interventions target the same population, but although they
share some common elements (that is, work with the family), multisystemic
therapy is focused on both the family and the wider resources of the school,

community and criminal justice systems, and through intensive individual case
work seeks to change the pattern of antisocial behaviour. In contrast,
functional family therapy focuses more on the immediate family environment
and uses the resources of the family to change the pattern of antisocial
behaviour. The study should be designed to facilitate the identification of sub-
groups within the conduct disorder population who may benefit from either
multisystemic therapy or functional family therapy.
4.4 Interventions for infants at high risk of developing

conduct disorders
Do specially designed parent-training programmes focused on sensitivity
enhancement (a set of techniques designed to improve secure attachment
behaviour between parents and children) reduce the risk of behavioural
disorders, including conduct problems and delinquency, in infants at high risk
of developing these problems? An RCT comparing parent-training
programmes focused on sensitivity enhancement with usual care should be
undertaken. It should examine the long-term outcomes over a period of at
least 5 years, but with consideration given to the possibility of a further
10-year follow-up. The study should also be designed to explore the
moderators and mediators of treatment effect that could help determine the
factors associated with benefits or harms of the intervention.

There is limited evidence from non-UK studies that interventions focused on
developing better parent–child attachment can have benefits for infants at risk
of developing conduct disorder. Determining the criteria and then identifying
children at high risk (usually via parental risk factors) is difficult and
challenging. Even when these factors are agreed, engaging parents in
treatment can be difficult. It is important that a range of effective interventions
is developed to increase the treatment choice and opportunities for high-risk
groups. Several interventions, such as Nurse–Family Practitioners, are being
developed and trialled in the UK. It is important for this group of children to
have an alternative, effective intervention.

4.5 Treatment of comorbid anxiety disorders in antisocial
personality disorder
Does the effective treatment of anxiety disorders in antisocial personality
disorder improve the long-term outcome for antisocial personality disorder?
An RCT of people with antisocial personality disorder and comorbid anxiety
disorders that compares a sequenced treatment programme for the anxiety
disorder with usual care should be conducted. It should examine, over a
period of at least 18 months, the medium-term outcomes for key symptoms
and behaviours associated with antisocial personality disorder (including
offending behaviour, deceitfulness, irritability and aggressiveness, and
disregard for the safety of self or others), as well as drug and alcohol misuse,
and anxiety. The study should also be designed to explore the moderators
and mediators of treatment effect which could help determine the role of
anxiety in the course of antisocial personality disorder.

Comorbidity with Axis I disorders is common in antisocial personality disorder,
and chronic anxiety has been identified as a particular disorder that may
exacerbate the problems associated with antisocial personality disorder.
There are effective treatments (psychological and pharmacological) for
anxiety disorders but they are often not offered to people with antisocial
personality disorder. Current treatment guidelines set out clear pathways for
the stepped or sequenced care of people with anxiety disorders. An RCT to
test the benefit of this approach in the treatment of anxiety would potentially
lead to a significant reduction in illness burden but a reduction in antisocial
behaviour would have wider societal benefits. The study should provide
important information on the challenges of delivering these interventions for a
population that has typically both rejected and been refused treatment.
4.6 Using selective serotonin reuptake inhibitors to

increase cooperative behaviour in people with
antisocial personality disorder in a prison setting
Although there is evidence that selective serotonin reuptake inhibitors
(SSRIs), such as paroxetine, increase cooperative behaviour in normal people
and do so independently of the level of sub-syndromal depression, this has

yet to be tested in other settings. Given that people with antisocial personality
disorder are likely to have difficulties cooperating with one another (because
of a host of personality traits that include persistent rule-breaking for personal
advantage, suspiciousness, grandiosity, etc.). An RCT should be conducted to
find out whether these reported changes of behaviour with an SSRI in normal
people generalises to clinical populations in different settings.

There is little evidence in the literature on the pharmacotherapy of antisocial
personality disorder to justify the use of any particular medication. However,
multiple drugs in various combinations are used in this group either to control
aberrant behaviour or in the hope that something might work. Current
interventions lack a clear rationale. This recommendation has the potential to
advance the field in that (a) it is linked to a clear hypothesis (that cooperative
behaviour is linked to a dysregulation of the serotonin receptors – for which
there is substantial evidence) and (b) that it is feasible to obtain an answer to
this question, given that there are a large number of individuals detained in
prison settings who would meet ASPD criteria. Constructing an experimental
task that requires cooperative activity would not be difficult in such a setting,
since all of those who might be willing to participate are already detained. The
successful execution of this research would be important in that it (a) would
establish the feasibility of conducting such a trial in a prison setting with this
group, and (b) provide a clear and sensible outcome measure of antisocial
behaviour that might be generalised to other settings.
4.7 A therapeutic community approach for antisocial

personality disorder in a prison setting
Is a therapeutic community approach in a prison setting more clinically and
cost effective in the treatment and management of antisocial personality
disorder than routine prison care? There should be a large-scale RCT
comparing the clinical and cost effectiveness of the therapeutic community
approach for adults with antisocial personality disorder with routine care. It
should examine the medium-term outcomes (for example, offending
behaviour, mental state and vocational outcomes) over a period of at least
18 months following release from prison. The study should also be designed
to explore the moderators and mediators of treatment effect, which could help

to determine the factors associated with benefits or harms of the therapeutic
community approach.

There is evidence from RCTs that the therapeutic community approach is of
value with drug and alcohol misusers in a prison setting at reducing the
incidence of offending behaviour on release. However, there are no equivalent
studies of a programme in the prison system on antisocial personality disorder
populations that do not have significant drug or alcohol problems. Data that do
exist are from non-UK settings. Answering this question is of importance
because outcomes for adults with antisocial personality disorder are poor and
there are already considerable resources devoted to a therapeutic community
approach in the UK prison system (for example, HMP Grendon Underwood).
The study could inform policy and resources decisions about the management
of antisocial personality disorder in the criminal justice system.
5 Other versions of this guideline
5.1 Full guideline

The full guideline, 'Antisocial personality disorder: treatment, management
and prevention' contains details of the methods and evidence used to develop
the guideline. It is published by the National Collaborating Centre for Mental
Health, and is available from www.nccmh.org.uk, our website
(www.nice.org.uk/CG77fullguideline) and the National Library for Health
(www.nlh.nhs.uk).
5.2 Quick reference guide

A quick reference guide for healthcare professionals is available from
www.nice.org.uk/CG77quickrefguide
For printed copies, phone NICE publications on 0845 003 7783 or email
publications@nice.org.uk (quote reference number N1763).

5.3 ‘Understanding NICE guidance’
A summary for patients and carers (‘Understanding NICE guidance’) is
available from www.nice.org.uk/CG77publicinfo
For printed copies, phone NICE publications on 0845 003 7783 or email
publications@nice.org.uk (quote reference number N1764).
We encourage NHS and voluntary sector organisations to use text from this
booklet in their own information about antisocial personality disorder.
6 Related NICE guidance

Published
Borderline personality disorder: treatment and management. NICE clinical
guideline 78 (2009). Available from www.nice.or.uk/CG78
Attention deficit hyperactivity disorder: diagnosis and management of ADHD

in children, young people and adults. NICE clinical guideline 72 (2008).
Available from www.nice.org.uk/CG72
Anxiety (amended): management of anxiety (panic disorder, with or without

agoraphobia, and generalised anxiety disorder) in adults in primary,
secondary and community care. NICE clinical guideline 22 (2007). Available
from www.nice.org.uk/CG22
Depression (amended): management of depression in primary and secondary

care. NICE clinical guideline 23 (2007). Available from www.nice.org.uk/CG23
Drug misuse: psychosocial interventions. NICE clinical guideline 51 (2007).

Drug misuse: opioid detoxification. NICE clinical guideline 52 (2007). Available

from www.nice.org.uk/CG52
Bipolar disorder: the management of bipolar disorder in adults, children and

adolescents in primary and secondary care. NICE clinical guideline 38 (2006).

Parent-training/education programmes in the management of children with
conduct disorders. NICE technology appraisal guidance 102 (2006). Available
from www.nice.org.uk/TA102
Obsessive–compulsive disorder: core interventions in the treatment of

obsessive-compulsive disorder and body dysmorphic disorder. NICE clinical
guideline 31 (2005). Available from www.nice.org.uk/CG31
Post-traumatic stress disorder (PTSD): the management of PTSD in adults

and children in primary and secondary care. NICE clinical guideline 26 (2005).
Violence: the short-term management of disturbed/violent behaviour in in-

patient psychiatric settings and emergency departments. NICE clinical
guideline 25 (2005). Available from www.nice.org.uk/CG25
Self-harm: the short-term physical and psychological management and

secondary prevention of self-harm in primary and secondary care. NICE
clinical guideline 16 (2004). Available from www.nice.org.uk/CG16
Schizophrenia: core interventions in the treatment and management of

schizophrenia in primary and secondary care. NICE clinical guideline 1
(2002). Available from www.nice.org.uk/CG1
7 Updating the guideline

NICE clinical guidelines are updated as needed so that recommendations
take into account important new information. We check for new evidence
2 and 4 years after publication, to decide whether all or part of the guideline
should be updated. If important new evidence is published at other times, we
may decide to do a more rapid update of some recommendations.

8 Definitions of psychological interventions
Anger control: usually offered to children who are aggressive at school,
anger control includes a number of cognitive and behavioural techniques
similar to cognitive problem-solving skills training (see below). It also includes
training of other skills such as relaxation and social skills.
Brief strategic family therapy: an intervention that is systemic in focus and

is influenced by other approaches. The main elements include engaging and
supporting the family, identifying maladaptive family interactions and seeking
to promote new and more adaptive family interactions.
Cognitive problem-solving skills training: an intervention that aims to

reduce children’s conduct problems by teaching them different responses to
interpersonal situations. Using cognitive and behavioural techniques with the
child, the training has a focus on thought processes. The training includes:
• teaching a step-by-step approach to solving interpersonal problems

• structured tasks such as games and stories to aid the development of skills
• combining a variety of approaches including modelling and practice, role-
playing and reinforcement.
Functional family therapy: a family-based intervention that is behavioural in

focus. The main elements include engagement and motivation of the family in
treatment, problem-solving and behaviour change through parent-training and
communication-training, and seeking to generalise change from specific
behaviours to positively influence interactions both within the family and with
community agencies such as schools.
Multidimensional treatment foster care: using strategies from family

therapy and behaviour therapy to intervene directly in systems and processes
related to antisocial behaviour (for example, parental discipline, family
affective relations, peer associations and school performances) for children or
young people in foster care and other out-of-home placements. This includes
group meetings and other support for the foster parents and family therapy
with the child’s biological parents.

Multisystemic therapy: using strategies from family therapy and behaviour
therapy to intervene directly in systems and processes related to antisocial
behaviour (for example, parental discipline, family affective relations, peer
associations and school performances) for children or young people.
Parent-training programmes: an intervention that aims to teach the

principles of child behaviour management, to increase parental competence
and confidence in raising children and to improve the parent/carer–child
relationship by using good communication and positive attention to aid the
child’s development. Examples of well-developed programmes are the Triple
P (Sanders et al. 2000) and Webster-Stratton (Webster-Stratton et al. 1988).
Self-talk: the internal conversation a person has with themselves in response

to a situation. Using or changing self-talk is a part of anger control training
(see above).
Social problem skills training: a specialist form of cognitive problem-solving

training that aims to:
• modify and expand the child’s interpersonal appraisal processes through

developing a more sophisticated understanding of beliefs and desires in
others
• improve the child’s capacity to regulate his or her own emotional
responses.
References
Sanders MR, Markie-Dadds C, Tully LA et al. (2000) The triple positive
parenting program: a comparison of enhanced, standard, and self-directed
behavioral family intervention for parents of children with early onset conduct
problems. Journal of Consulting and Clinical Psychology 68: 624–40.
Webster-Stratton C, Kolpacoff M, Hollinsworth T (1988) Self-administered

videotape therapy for families with conduct-problem children: comparison with
two cost-effective treatments and a control group. Journal of Consulting and
Clinical Psychology 56: 558–66.

Appendix A: The Guideline Development Group
Professor Conor Duggan (Chair, Guideline Development Group)
Professor of Forensic Mental Health, University of Nottingham; Honorary
Consultant Psychiatrist, Nottinghamshire Healthcare Trust
Dr Stephen Pilling (Facilitator, Guideline Development Group)

Joint Director, The National Collaborating Centre for Mental Health; Director,
Centre for Outcomes Research and Effectiveness, University College London
Dr Gwen Adshead
Consultant Forensic Psychotherapist, Broadmoor Hospital, West London
Mental Health NHS Trust
Ms Amy Brown
Research Assistant (2007), The National Collaborating Centre for Mental
Health
Professor Jeremy Coid

Professor of Forensic Psychiatry, Wolfson Institute of Preventive Medicine,
Queen Mary, University of London
Mr Neil Connelly
Representing the interests of service users and carers
Mr Colin Dearden
Deputy Chief Probation Officer, Lancashire Probation Service
Mr Alan Duncan
Systematic Reviewer, The National Collaborating Centre for Mental Health
Mr Matthew Dyer
Health Economist (2008–2009), The National Collaborating Centre for Mental
Health
Dr Brian Ferguson
Consultant Psychiatrist, Lincolnshire Partnership NHS Trust

Ms Esther Flanagan
Guideline Development Manager (2008–2009), The National Collaborating
Centre for Mental Health
Professor Peter Fonagy

Freud Memorial Professor of Psychoanalysis; Head of Research Department
of Clinical, Educational and Health Psychology, University College London;
Chief Executive, Anna Freud Centre, London
Dr Savas Hadjipavlou
Programme Director, The Dangerous People with Severe Personality Disorder
(DSPD) Programme, Ministry of Justice
Professor Eddie Kane

Director, Personality Disorder Institute, University of Nottingham
Mr Ryan Li
Project Manager (2008), The National Collaborating Centre for Mental Health
Professor Anthony Maden

Professor of Forensic Psychiatry, Imperial College; Honorary Consultant,
West London Mental Health NHS Trust
Dr Ifigeneia Mavranezouli
Senior Health Economist, The National Collaborating Centre for Mental Health
Professor James McGuire

Professor of Forensic Clinical Psychology, University of Liverpool; Honorary
Consultant Clinical Psychologist, Mersey Care NHS Trust
Dr Nicholas Meader
Systematic Reviewer, The National Collaborating Centre for Mental Health
Ms Anne Morgan
Health Economist
Dr Catherine Pettinari
Centre Manager, The National Collaborating Centre for Mental Health

Ms Peny Retsa
Health Economist (2007–2008), The National Collaborating Centre for Mental
Health
Ms Maria Rizzo
Research Assistant (2007–2008), The National Collaborating Centre for
Mental Health
Ms Carol Rooney
Deputy Director of Nursing, St Andrew’s Healthcare
Ms Beth Shackleton
Implementation Advisor, The National Collaborating Centre for Mental Health
Ms Sarah Stockton
Senior Information Scientist, The National Collaborating Centre for Mental
Health
Dr Clare Taylor
Editor, The National Collaborating Centre for Mental Health
Dr Nat Wright
Clinical Director for Substance Misuse, HM Prison Service Leeds

Appendix B: The Guideline Review Panel
The Guideline Review Panel is an independent panel that oversees the
development of the guideline and takes responsibility for monitoring
adherence to NICE guideline development processes. In particular, the panel
ensures that stakeholder comments have been adequately considered and
responded to. The panel includes members from the following perspectives:
primary care, secondary care, lay, public health and industry.
Mr Peter Robb - Chair

Consultant ENT Surgeon, Epsom and St Helier University Hospitals and The
Royal Surrey County NHS Trusts
Dr Christine Hine
Consultant in Public Health (Acute Commissioning), Bristol and South
Gloucestershire PCTs
Mr John Seddon
Lay member
Mr Mike Baldwin
Project Development Manager, Cardiff Research Consortium

Antisocial Disorder Nice Guidence

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Issue date: January 2009

NICE clinical guideline 77

For printed copies of the quick reference guide or ‘Understanding NICE

Implementation of this guidance is the responsibility of local commissioners

National Institute for Health and Clinical Excellence

NICE clinical guideline 77

People with antisocial personality disorder exhibit traits of impulsivity, high

People with antisocial personality disorder have often grown up in fractured

Criminal behaviour is central to the definition of antisocial personality disorder,

NICE clinical guideline 77 – Antisocial personality disorder 4

Under current diagnostic systems, antisocial personality disorder is not

The course of antisocial personality disorder is variable and although recovery

Families or carers are important in prevention and treatment of antisocial

At the time of publication (January 2009), no drug has UK marketing

NICE clinical guideline 77 – Antisocial personality disorder 5

NICE clinical guideline 77 – Antisocial personality disorder 6

If the person is under 16, healthcare professionals should follow the

Good communication between healthcare professionals and people with

Care of young people in transition between paediatric and adult services

NICE clinical guideline 77 – Antisocial personality disorder 7

Cognitive behavioural interventions for children aged 8 years and older

Assessment in forensic/specialist personality disorder services

Treatment of comorbid disorders

NICE clinical guideline 77 – Antisocial personality disorder 8

The role of psychological interventions

Clearly agreed local criteria should also be established to facilitate the

• Services should consider establishing antisocial personality disorder

NICE clinical guideline 77 – Antisocial personality disorder 9

NICE clinical guideline 77 – Antisocial personality disorder 10

1.1 General principles for working with people with

1.1.1 Access and assessment

1.1.1.2 Seek to minimise any disruption to therapeutic interventions for

• ensuring that in the initial planning and delivery of treatment,

NICE clinical guideline 77 – Antisocial personality disorder 11

1.1.1.4 When language or literacy is a barrier to accessing or engaging

• information in their preferred language and in an accessible

1.1.1.5 When a diagnosis of antisocial personality disorder is made,

• acknowledge the issues around stigma and exclusion that have

NICE clinical guideline 77 – Antisocial personality disorder 12

• adapt interventions in light of this (for example, extend their

1.1.2 People with disabilities and acquired cognitive

1.1.2.2 Staff providing interventions for people with antisocial personality

NICE clinical guideline 77 – Antisocial personality disorder 13

• ensuring that they remain actively involved in finding solutions to

1.1.4 Developing an optimistic and trusting relationship

• explore treatment options in an atmosphere of hope and

1.1.5 Engagement and motivation

NICE clinical guideline 77 – Antisocial personality disorder 14

• encourage families or carers to be involved

• impact of antisocial and offending behaviours on the family

1.2 Prevention of antisocial personality disorder –

NICE clinical guideline 77 – Antisocial personality disorder 15

• balance the developing autonomy and capacity of the young

1.2.2 Identifying children at risk of developing conduct

• parents with other mental health problems, or with significant

1.2.3 Early interventions for preschool children at risk of

NICE clinical guideline 77 – Antisocial personality disorder 16