How can I differentiate between Antisocial Personality Disorder and other personality disorders in a primary care setting?

To differentiate Antisocial Personality Disorder (ASPD) from other personality disorders in a primary care setting, focus on the following key clinical features and assessment steps:

• History of antisocial behaviours: Look for a persistent pattern of disregard for others’ rights, including repeated acts of violence, criminal behaviour, deceitfulness, impulsivity, and failure to conform to social norms, often starting in childhood or adolescence (e.g., conduct disorder history) and continuing into adulthood ¹.
• Contact with the criminal justice system: Note any history of convictions, imprisonment, or involvement with youth offending schemes, which is more characteristic of ASPD than other personality disorders ¹.
• Assessment of comorbidities: Evaluate for coexisting mental health disorders such as depression, anxiety, substance misuse, or other personality disorders, as these are common and may complicate the clinical picture ¹.
• Use of structured assessment tools: While more common in specialist or forensic settings, consider referral for formal assessment tools like the Psychopathy Checklist (PCL-R or PCL-SV) if ASPD is suspected and the clinical picture is complex ¹.
• Consider the reliability of information: Patients with ASPD may be unreliable historians; corroborate history with family, carers, or records when possible, respecting confidentiality ¹.
• Differentiate from other personality disorders: Unlike borderline or narcissistic personality disorders, ASPD is specifically marked by a pervasive pattern of antisocial and criminal behaviour rather than primarily emotional instability or grandiosity ¹.

In summary, in primary care, differentiation relies on identifying a consistent pattern of antisocial and criminal behaviours, history of conduct disorder, and associated risk factors, supported by collateral information and consideration of comorbidities, with referral to specialist services for formal assessment when needed ¹.