subtype, the childhood-onset subtype, especially if callous and unemotional traits are present, tends to have a worse treatment outcome. diagnosis section ii the main text of fifth edition of the diagnostic and statistical manual of mental disorders (dsm-5) defines antisocial personality disorder as being characterized by at least three of the following traits: failure to conform to social norms and laws, indicated by repeatedly engaging in illegal activities. deceitfulness, indicated by continuously lying, using aliases, or conning others for personal gain and pleasure. exhibiting impulsivity or failing to plan ahead. irritability and aggressiveness, indicated by repeatedly getting into fights or physically assaulting others. reckless behaviors that disregard the safety of others. irresponsibility, indicated by repeatedly failing to consistently work or honor financial obligations. lack of remorse after hurting or mistreating another person. in order to be diagnosed with antisocial personality disorder under the dsm-5, one must be at least 18 years old, show evidence of onset of conduct disorder before age 15, and antisocial behavior cannot be explained by schizophrenia or bipolar disorder. section iii (alternative model of personality disorders) in response to criticisms of the extant (section ii/dsm-iv) criteria for personality disorders, including their discordance with current models in the scientific literature, high comorbidity rate, overuse of some categories and underuse of others, and overwhelming use of the personality disorder-not otherwise specified (pd-nos) diagnosis, the dsm-5 workgroup on personality disorders devised a dimensional model, wherein categoric personality diagnoses reflect extreme variations of normal personality traits. in response to criticisms of the extant section ii/dsm-iv criteria for aspd, namely its failure to capture the interpersonal and affective features of psychopathy, new criteria were proposed. in addition to the new criteria, the individual must be at least 18 years old, the traits must cause dysfunction or distress, and should not be better explained by another mental disorder, the pathophysiological effects of a substance, or a person's cultural or social background. also included as a "with psychopathic traits" specifier modelled after the fearless dominance scale of the psychopathic personality inventory, defined by low anxiousness and withdrawal and high attention-seeking. researchers have also proposed the inclusion of grandiosity and restricted affectivity to better capture psychopathy. psychopathy main article: psychopathy psychopathy is commonly defined as a personality disorder characterized partly by antisocial behavior, a diminished capacity for empathy and remorse, and poor behavioral controls. psychopathic traits are assessed using various measurement tools, including canadian researcher robert d. hare's psychopathy checklist, revised (pcl-r). "psychopathy" is not the official title of any diagnosis in the dsm or icd; nor is it an official title used by other major psychiatric organizations. the dsm and icd, however, state that their antisocial diagnoses are at times referred to (or include what is referred to) as psychopathy or sociopathy. american psychiatrist hervey cleckley's work on psychopathy formed the basis of the diagnostic criteria for aspd, and the dsm states aspd is often referred to as psychopathy. however, critics argue aspd is not synonymous with psychopathy as the diagnostic criteria are not the same, since criteria relating to personality traits are emphasized relatively less in the former. these differences exist in part because it was believed such traits were difficult to measure reliably and it was "easier to agree on the behaviors that typify a disorder than on the reasons why they occur". although the diagnosis of aspd covers two to three times as many prisoners than the diagnosis of psychopathy, robert hare believes the pcl-r is better able to predict future criminality, violence, and recidivism than a diagnosis of aspd. he suggests there are differences between pcl-r-diagnosed psychopaths and non-psychopaths on "processing and use of linguistic and emotional information", while such differences are potentially smaller between those diagnosed with aspd and without. additionally, hare argued confusion regarding how to diagnose aspd, confusion regarding the difference between aspd and psychopathy, as well as the differing future prognoses regarding recidivism and treatability, may have serious consequences in settings such as court cases where psychopathy is often seen as aggravating the crime. nonetheless, psychopathy has been proposed as a specifier under an alternative model for aspd. in the dsm-5, under "alternative dsm-5 model for personality disorders", aspd with psychopathic features is described as characterized by "a lack of anxiety or fear and by a bold interpersonal style that may mask maladaptive behaviors (e.g., fraudulence)". low levels of withdrawal and high levels of attention-seeking combined with low anxiety are associated with "social potency" and "stress immunity" in psychopathy.: 765 under the specifier, affective and interpersonal characteristics are comparatively emphasized over behavioral components. research suggests that, even without the "with psychopathic traits" specifier, these section iii criteria accurately capture the affective-interpersonal features of psychopathy, though the specifier increases coverage of the interpersonal and lifestyle facets of the pcl-r. millon's subtypes theodore millon suggested 5 subtypes of aspd. however, these constructs are not recognized in the dsm and icd. subtype features nomadic antisocial (including schizoid and avoidant features) drifters; roamers, vagrants; adventurers, itinerant vagabonds, tramps, wanderers; typically adapt easily in difficult situations, shrewd and impulsive. mood centers in doom and invincibility. malevolent antisocial (including sadistic and paranoid features) belligerent, mordant, rancorous, vicious, sadistic, malignant, brutal, resentful; anticipates betrayal and punishment; desires revenge; truculent, callous, fearless; guiltless; many dangerous criminals including serial killers. covetous antisocial (including negativistic features) rapacious, begrudging, discontentedly yearning; hostile and domineering; envious, avaricious; pleasures more in taking than in having. risk-taking antisocial (including histrionic features) dauntless, venturesome, intrepid, bold, audacious, daring; reckless, foolhardy, heedless; unfazed by hazard; pursues perilous ventures. reputation-defending antisocial (including narcissistic features) needs to be thought of as infallible, unbreakable, indomitable, formidable, inviolable; intransigent when status is questioned; overreactive to slights. elsewhere, millon differentiates ten subtypes (partially overlapping with the above) – covetous, risk-taking, malevolent, tyrannical, malignant, disingenuous, explosive, and abrasive – but specifically stresses that "the number 10 is by no means special ... taxonomies may be put forward at levels that are more coarse or more fine-grained.": 223 treatment aspd is considered to be among the most difficult personality disorders to treat. rendering an effective treatment for aspd is further complicated due to the inability to look at comparative studies between psychopathy and aspd due to differing diagnostic criteria, differences in defining and measuring outcomes and a focus on treating incarcerated patients rather than those in the community. because of their very low or absent capacity for remorse, individuals with aspd often lack sufficient motivation and fail to see the costs associated with antisocial acts. they may only simulate remorse rather than truly commit to change: they can be seductively charming and dishonest, and may manipulate staff and fellow patients during treatment. studies have shown that outpatient therapy is not likely to be successful, but the extent to which persons with aspd are entirely unresponsive to treatment may have been exaggerated. most treatment done is for those in the criminal justice system to whom the treatment regimes are given as part of their imprisonment. those with aspd may stay in treatment only as required by an external source, such as parole conditions. residential programs that provide a carefully controlled environment of structure and supervision along with peer confrontation have been recommended. there has been some research on the treatment of aspd that indicated positive results for therapeutic interventions. psychotherapy, also known as "talk" therapy, has been found to help treat patients with aspd. schema therapy is also being investigated as a treatment for aspd. a review by charles m. borduin features the strong influence of multisystemic therapy (mst) that could potentially improve this issue. however, this treatment requires complete cooperation and participation of all family members. some studies have found that the presence of aspd does not significantly interfere with treatment for other disorders, such as substance use, although others have reported contradictory findings. therapists working with individuals with aspd may have considerable negative feelings toward patients with extensive histories of aggressive, exploitative, and abusive behaviors. rather than attempt to develop a sense of conscience in these individuals, which is extremely difficult considering the nature of the disorder, therapeutic techniques are focused on rational and utilitarian arguments against repeating past mistakes. these approaches would focus on the tangible, material value of prosocial behavior and abstaining from antisocial behavior. however, the impulsive and aggressive nature of those with this disorder may limit the effectiveness of this form of therapy. the use of medications in treating antisocial personality disorder is still poorly explored, and no medications have been approved by the fda to specifically treat aspd. a 2020 cochrane review of studies that explored the use of pharmaceuticals in aspd patients, of which eight studies met the selection criteria for review, concluded that the current body of evidence was inconclusive for recommendations concerning the use of pharmaceuticals in treating the various issues of aspd. nonetheless, psychiatric medications such as antipsychotics, antidepressants, and mood stabilizers can be used to control symptoms such as aggression and impulsivity, as well as treat disorders that may co-occur with aspd for which medications are indicated. prognosis according to professor emily simonoff of the institute of psychiatry, psychology and neuroscience, there are many variables that are consistently connected to aspd, such as: childhood hyperactivity and conduct disorder, criminality in adulthood, lower iq scores and reading problems. the strongest relationship between these variables and aspd are childhood hyperactivity and conduct disorder. additionally, children who grow up with a predisposition of aspd and interact with other delinquent children are likely to later be diagnosed with aspd. like many disorders, genetics play a role in this disorder but the environment holds an undeniable role in its development. boys are almost twice as likely to meet all of the diagnostic criteria for aspd than girls (40% versus 25%) and they will often start showing symptoms of the disorder much earlier in life. children that do not show symptoms of the disease through age 15 will almost never develop aspd later in life. if adults exhibit milder symptoms of aspd, it is likely that they never met the criteria for the disorder in their childhood and were consequently never diagnosed. overall, symptoms of aspd tend to peak in late teens and early twenties, but can often reduce or improve through age 40. aspd is ultimately a lifelong disorder that has chronic consequences, though some of these can be moderated over time. there may be a high variability of the long-term outlook of antisocial personality disorder. the treatment of this disorder can be successful, but it entails unique difficulties. it is unlikely to see rapid change especially when the condition is severe. in fact, past studies revealed that remission rates were small, with up to only 31% rates of improvement instead of remittance. as a result of the characteristics of aspd (e.g., displaying charm in effort of personal gain, manipulation), patients seeking treatment (mandated or otherwise) may appear to be "cured" in order to get out of treatment. according to definitions found in the dsm-5, people with aspd can be deceitful and intimidating in their relationships. when they are caught doing something wrong, they often appear to be unaffected and unemotional about the consequences. over time, continual behavior that lacks empathy and concern may lead to someone with aspd taking advantage of the kindness of others, including his or her therapist. without proper treatment, individuals with aspd could lead a life that brings about harm to themselves or others. this can be detrimental to their families and careers. those with aspd lack interpersonal skills (e.g., lack of remorse, lack of empathy, lack of emotional-processing skills). as a result of the inability to create and maintain healthy relationships due to the lack of interpersonal skills, individuals with aspd may find themselves in predicaments such as divorce, unemployment, homelessness and even premature death by suicide. they also see higher rates of committed crime, reaching peaks in their late teens and often committing higher-severity crimes in their younger ages of diagnoses. comorbidity of other mental illnesses such as depression or substance use disorder is prevalent among patients with aspd. people with aspd are also more likely to commit homicides and other crimes. those who are imprisoned longer often see higher rates of improvement with symptoms of aspd than others who have been imprisoned for a shorter amount of time. according to one study,