Antisocial Personality Disorder: A Care Staff Guide to NICE CG77

Few diagnoses attract as much stigma as antisocial personality disorder. People with the diagnosis are sometimes excluded from services, assumed to be untreatable, or treated with suspicion. NICE guideline CG77 takes a very different position, and its principles are important for every member of a team, from clinicians to support staff.

A non-exclusion principle

CG77 states that people with antisocial personality disorder should not be excluded from any health or social care service because of their diagnosis or offending history. It asks staff to engage people actively in treatment, to use positive and rewarding approaches rather than negative or punitive ones, and to explore options with hope and optimism, explaining that recovery is possible. Services should work in partnership with the person, promote autonomy and choice, and involve them in solving problems, including during crises.

Keeping people engaged

NICE notes that people with the condition are prone to dropping out of treatment early. Motivation to engage should therefore be addressed at the initial assessment and throughout treatment. Key workers should hold regular one-to-one reviews, even when treatment is delivered in groups, and interventions should be offered in the person's preferred language where language or literacy is a barrier. In practice this means reliability, clear boundaries and honesty from staff, so the person knows what to expect.

Assessment and under-recognition

The guideline says antisocial personality disorder is under-recognised in primary and secondary care, and that comorbid conditions such as depression and anxiety are often missed. A full assessment should cover antisocial behaviour, personality functioning, comorbidities, treatment and support needs, and domestic violence or abuse. When diagnosing, professionals should explain that the diagnosis does not restrict access to treatment for comorbid mental health conditions, and clarify the roles of healthcare, social care and criminal justice services. Our guide to dual diagnosis is relevant because substance misuse and personality disorder frequently co-occur.

Risk assessment and multi-agency working

Risk assessment should include a detailed violence history and collateral information from records or family, because the person may not be a reliable source. NICE advises considering referral to forensic or specialist personality disorder services for current serious violence or threats, or a history of serious or predatory violence, including targeting children or vulnerable people. High-risk cases need a comprehensive multi-agency risk management plan, with probation leading when a person is on a community sentence or licence. Our guide to MAPPA explains how these arrangements work.

Treatment

The guideline is realistic about the evidence. It says the evidence for treating adult antisocial personality disorder is limited and outcomes are modest. For people who meet criteria for psychopathy or dangerous and severe personality disorder, it suggests considering cognitive and behavioural programmes aimed at reducing offending, adapted with longer duration, concurrent individual and group sessions, booster sessions and close follow-up. Comorbid disorders should be treated in line with existing NICE guidance regardless of other treatment. Admissions should mainly be for crisis management or to treat comorbid disorders, should be brief with a defined purpose and end point, and ideally follow a prior crisis plan.

Women and people with additional needs

NICE notes that women with the diagnosis often have more comorbidities, so interventions may need to last longer and inpatient and residential settings should consider their greater vulnerability. For people with a learning or physical disability or acquired cognitive impairment, consider specialist advice and adjust the delivery method or duration of interventions.

Families and carers

Ask the person whether they want family or carers involved. Their involvement should not reduce or withdraw the person's access to services. NICE also asks services to consider the impact of antisocial behaviour, substance misuse and risks to children, and to provide information about local support groups.

Children and young people

CG77 advises against labelling children or parents as antisocial, because it can increase stigma and problems. Parent-training programmes are the core intervention for children under 12 with conduct problems, and other approaches include anger control, problem-solving skills training and family-based therapies. Vulnerable young people with a history of conduct disorder or youth offending should be considered for referral to adult services during transition.

What this means for staff

• Be consistent and fair. Reliability and clear boundaries build trust.
• Avoid language that labels or punishes. Describe behaviour factually and focus on what helps.
• Take risk seriously without prejudging. Share concerns through the right channels and record them clearly.
• Look for what is missed. Depression, anxiety, trauma and substance use often sit behind behaviour.
• Look after yourselves. NICE says staff need supervision and support, especially in high-intensity settings.

Our guide to borderline personality disorder covers another personality disorder where consistency and non-judgemental care are essential.

Supporting staff learning

Learnsignal's CPD courses can help teams develop skills in risk, communication and trauma-aware practice.

Frequently asked questions

Can people with antisocial personality disorder be refused a service? No. NICE says they should not be excluded from any health or social care service because of their diagnosis or offending history.

Is there a medicine for it? The guideline focuses on psychosocial approaches and on treating comorbid conditions.

Who leads risk management in high-risk cases? A multi-agency plan is needed, with probation leading when the person is on a community sentence or licence.