1. Introduction

1.1. Definition of Antisocial Personality Disorder (ASPD)

Recent fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) describes antisocial personality disorder (ASPD) as having “a pattern of disregard for, and violation of, the rights of others” [1]. Specifically, for diagnosing ASPD, the diagnostic guidelines contain four criteria, of which the first criterion encompasses seven sub-criteria generally describing characteristics that are often perceived as socially unacceptable.

1.2. Definition of Stigma and the Labeling Issue

According to Ahmedani, stigma is a discrediting attribute that devalues an individual. It can be viewed as a stereotype, or a negative perception pinned on a person usually when there are deviate characteristics being recognized [2]. Applying to the content of this paper, stigma refers to others’ negative responses toward the ASPD diagnosis as well as the diagnosed individuals.

Modern labeling issues often take place when a person labels an individual with a feature (e.g. a mental disorder, physical characteristic, disability, etc.) that usually implies a pejorative connotation including negative stereotypes and prejudice, or even social withdrawal by the stigmatized individual [3].

1.3. The Present Study

Although there were many research studies conducted on stigmatization of having ASPD labels, contexts of discussions varied and there lacked a review bringing them together to provide a comprehensive overview. Hence, the present study synthesized relevant research findings mainly published over the past five years and discussed them in three main settings: social settings, forensic settings, and medical settings. By doing so, this paper aimed to introduce common conclusions as well as current controversies within the field to discuss possible directions forward, hopefully paving a way for future research studies. 

2. Literature Review

2.1. In Social Settings

As individuals diagnosed with ASPD become popular subjects in modern fiction and mass media, antisocial behaviors and associated characteristics gradually receive more attention in society yet are generally perceived as deviant from the social norms [4]. Considering the raising awareness of stigma and labeling issues in the social context, more research has been conducted on the associated effects and consequences surrounding ASPD [5].

Starting from the beginning, many studies emphasized mental health stigma from a holistic approach [5]. Through examining how individuals who suffered from mental illnesses were stigmatized by society (by others without experiencing a mental health problem), research came to the conclusion that a serious mental illness (SMI) diagnosis – such as personality disorders and psychotic disorders – was accompanied by greater stigma than a common mental health problem (CMHP) such as depression and anxiety. SMI diagnoses, in comparison to CMHP diagnoses, were viewed by the general public as more dangerous and therefore received little sympathy and greater stigma. Nevertheless, Hazell et al. found that earlier research predominantly focused on the stigmatization of SMI diagnoses and symptoms altogether, which could be relatively easy to discover prejudice (stigmatizing responses) being as how SMI symptoms per se were usually incomprehensive and undesirable to others [5]. Hazell et al. then filled in the gap to study diagnosis-specific stigma, isolating and comparing SMI with CMHP diagnoses in order to find out which mental health diagnoses would come with the most stigmatizing effects. Nine case vignettes were implemented in which nine different psychiatric diagnoses were reflected accordingly: ASPD, borderline personality disorder (BPD), dissociative identity disorder (DID), post-traumatic stress disorder (PTSD), generalized anxiety disorder (GAD), obsessive-compulsive disorder (OCD), schizophrenia, bipolar disorder type 1, and depression. Findings showed consistency with previous studies of a varied degree of stigma towards some specific psychiatric diagnoses. Namely, ASPD and schizophrenia (SMI) were the most stigmatized disorders; depression, GAD and OCD (CMHP) were the least. Analysis also suggested that fear was the major component of predicting stigma for most psychiatric diagnoses, and ASPD with its deviating manifestations seemed to be evidently alarmed and rejected by social convention.

On the flip side, another vignette study by O’Connor and Murphy suggested that having a disclosed ASPD label alleviated others’ negative reactions to the accompanying symptoms (that were usually disturbing and undesirable), whereas withholding diagnoses could evoke a greater degree of anger and social distance, as well as a lower degree of positive affect and compassion [6]. O’Connor and Murphy used vignettes that described an individual’s performance of undesirable behaviors in a social context either with or without the ASPD label being disclosed. Through manipulating participants’ acknowledgement of ASPD diagnosis, they were able to examine how having an ASPD label would influence other people’s reactions towards the individual and their associated behaviors. The finding seemingly was in contrast with Hazell et al., yet such results might imply a specific stigma in which a situational factor could potentially play a role in destigmatizing the label. Further explanations were presented in the following Discussion. And to look at it another way, it might also show that ASPD was gradually becoming comprehensible by the masses, at least under some social conditions.

In addition to the public’s general perception of having an ASPD label, media as one of the reflections of a society is worth taking into account as well. Leading research by Lopera-Mármol et al. investigated the media representation of mental disorders, including ASPD [7, 8]. In the studies, mainstream television series such as The Wire, El Camino: A Breaking Bad Movie, and The End of the F***ing World were analyzed. A misconception between ASPD population and psychopaths was found, as two psychiatric conditions became mistakenly represented on screen. Although there were other measurements, including the Psychopathy Checklist-Revised which adopted “psychopath” as a label of some ASPD features particularly in judicial practices (more in 2.2 In Forensic Settings), the depictions of ASPD population were still considered to be underrepresented in media by failing to realistically portrait based upon clinical or forensic definitions [8, 9]. For instance, modern edutainment falsely associated ASPD with psychopathy labels through accentuating serial killers, sadists, fetishists, or other cold-blooded behaviors involving torture and murders, while few people with ASPD in the real world actually engaged in such behaviors and/or violent activities to this extreme. Such misleading information on the portrayal of the ASPD population could inflict more stigmatizing views among the general public and exacerbate associated labeling effects of having an ASPD diagnosis henceforth.

2.2. In Forensic Settings

It is necessary to note that, over the past few years, “psychopathy” as an extensively abused and misused term has become interchangeable with ASPD because of its manifestation of antisocial traits and behaviors [9]. Notably, psychopathy itself was not an accredited psychiatric diagnosis explicitly included in DSM-5. But psychopathic traits were listed as specifiers under the diagnosis of ASPD in DSM-5, which in a way suggested its sub-relationship with ASPD [10]. It was most likely because of such a close relationship between psychopathy and ASPD, a majority of modern research efforts were moving away from the focus on ASPD towards the psychopathy diagnosis. Particularly in forensic environments, the definitions of being psychopathic or having an ASPD were often blurred and thus applied indistinguishably within related literature. Given the ambiguous situation of two terms being introduced in the criminal justice system, this section reviewed contemporary research on the impacts of ASPD diagnosis including studies surrounding psychopathy. 

Despite a growing body of research, conclusions varied in terms of whether psychopathy (or ASPD) diagnosis leads to disproportionate legal outcomes for an offender due to its associated labeling effects or stigmatization. The role in which psychopathy labels play in judicial proceedings were in sharp contrast. Some scholars suggested that the use of psychopathy evidence had the potential to become a mitigating factor in criminal cases [11]. Others showed the opposite, claiming that offenders labeled with psychopathy were more likely to leave negative impressions on jurors and thus receive harsher punishment compared to their counterparts who did not have a diagnosis despite committing the same crime [12]. But considering being a “psychopath” and its associated problematic traits viewed by society, it was generally believed by most of the legal scholars that having a psychopathy label would produce stigmatizing effects and contribute to unfair verdicts [11]. Having said that, recent debate was more so argued in the direction of whether a psychopathic label would carry more negative connotations than other mental illness diagnoses (e.g., schizophrenia, depression) in provoking prejudicial calls in legal processes.

Usually, case vignette simulations were conducted to mock jury deliberations in order to understand labeling effects and their relationship with legal outcomes. Earlier studies suggested a tendency in which jurors imposed longer sentences on a defendant whom they viewed as highly psychopathic as opposed to a defendant without a psychopathic impression [13]. More recently, Kelley et al. in their quantitative synthesis examined 10 such juror simulation research to analyze the psychopathic diagnosis in relation to jury’s imposition of penalties [12]. The results showed a consistency which indicated that having a psychopathic perception towards hypothetical criminal defendants in vignettes was associated with the representation of being more evil and dangerous, following greater punitive outcomes in terms of capital punishment (more death penalties) or sentence length (longer sentencing).

On the other hand, Berryessa and Wohlstetter as another recent meta-analysis presented conflicting results, suggesting that there were modest or no significant impacts on legal consequences with a specified label of being psychopathic [14]. Likewise, they looked at jury simulation studies and the influence of a psychopathy label on jury-perceived dangerousness and proposed sanctions. Though evidence was shown to be consistent with previous studies in which labeling effects and associated bias were displayed between a psychopathy label and no label, there was evidence demonstrating non-significance when comparing a psychopathy label with other diagnostic labels. In other words, they concluded that there was evidence supporting an association between general labeling effects and adverse legal outcomes, but no specific labeling effects for psychopathy was evident based on its comparison with other psychiatric diagnoses. Moreover, similar topics were discussed by Prasad and Kimonis concerning such specific labeling effects [15]. They pointed out that mixed evidence in regard to psychopathy label and impacts were also reported among youth research. Some studies found a significant labeling effect among juvenile offenders with psychopathy, whereas other scholars found no significance for specific psychopathic labeling effects.

2.3. In Medical Settings

Although there has been no specific treatment for ASPD, and most of the population with a diagnosis of ASPD do not tend to seek professional and medical treatment [8], current literature has indicated stigmatization of ASPD diagnosis within the medical context itself. Unlike other medicalized diagnostic labels, patients who were labeled as having ASPD usually were determined as clinically untreatable [4]. Many research studies also concluded that there was a negative perception of treatment amenability among people with ASPD as well as a lower expectation for its success, leading to fewer treatment referrals [15]. Such a phenomenon within the medical environment was criticized by lots of scholars, rebuking that diagnostic labels became the means to exclude certain groups of people from receiving adequate professional support [4].

In Sorg, the study analyzed internet posts and comments written by individuals who have ASPD diagnoses and investigated the ASPD labeling effects in their access to medicalization [4]. Results from the sample suggested that, besides a few individuals who were pleasant with the professional support they received from mental health services and providers, many others expressed being mistreated by psychiatric professionals, including rejection of therapy because an ASPD diagnosis was unfolded. Other than professional resources, a shortage of ASPD self-help resources was found as well that exaggerated ASPD construct by demonizing them.

Fortunately, many clinicians who interact therapeutically with ASPD cases were more aware of the stigmatizing challenges faced by patients with an ASPD label. They left note to the potential pejorative implications of specific psychiatric terms, and actively recommended alternative choices of terminology in order to avoid labeling and offending patients that might discourage adherence [16]. For example, the most recent version of International Classification of Diseases adopted new modifications of ASPD: instead of using the term “antisocial”, naming it as “dissocial” [17]. Other debates also concerned replacing “personality disorder” to “personality difficulty”, following with other alternative suggestions, to be less stigmatizing and unappealing for the patients in the therapeutic process. To name a few, the most commonly recommended terms for “antisocial” were conduct/behavior problems, rule-breaking, problems with empathy or seeing another point of view, or borrowing the terms that individuals use to describe their own symptoms [16].

3. Discussion

3.1. Symptom-Specific Stigma and Situational Effects

In society’s common perception towards the ASPD population, it is generally believed that behaviors and symptoms associated with an ASPD diagnosis are problematic and socially unacceptable. Research studying diagnosis-specific stigma further indicated that an ASPD diagnosis alone was able to generate stigma, in which more danger and less sense of pity were perceived by others [5]. However, other researchers suggested that a disclosure of an ASPD diagnosis could reduce other people’s negative perceptions when symptoms were displayed in a public context [6]. People were more likely to express sympathy and other positive responses under such an acknowledgment, otherwise showing more anger and withdrawnness towards those who were misbehaving. Though two findings may appear to be at odds, the underlying variance offers valuable possibilities in guiding future research. All nine case vignettes in Hazell et al. identified patients’ diagnosis in the first place (ASPD, BPD, PTSD, DID, OCD, GAD, depression, bipolar disorder type 1, or schizophrenia), followed by descriptions of the associated core symptoms. O’Connor and Murphy, instead, had six vignettes describing an individual’s display of socially undesirable behaviors with or without a disclosed diagnosis (Mild, Moderate, or Severe ASPD or BPD). Such a difference in vignettes design as well as the contradiction of findings may insinuate a symptom-specific stigma given in a particular situation. Specifically, symptoms laid out in Hazell et al. were more medically defined, compared to symptoms in O’Connor and Murphy that were illustrated in a more descriptive way within socially interactive settings. It may suggest stigmatization of the use of terminology (when describing symptoms) and/or situational effects in terms of symptoms display. Either way, the performance of ASPD symptoms as well as the social context of the symptom exhibition may be key factors to determining social attitudes towards the population, and thus future research can examine specific symptoms (e.g. ASPD behaviors) and their relationship with stigma under different social conditions.

3.2. The Power of Media and Future Development of Media Production

Media, as one of the social facets, has also shown a large amount of misrepresentation of the ASPD population that may lead to heavy stigmatization [7, 8]. Particularly speaking, misconceptions surrounding ASPD and psychopathy were found in many popular TV series in which they falsely depicted individuals who have ASPD diagnosis to an extreme where psychopaths were usually defined. Further improvement of media production should therefore be much more cautious in delivering messages as they tend to be influential. However, there is a lack of research in the current research body that investigates how, or to what extent, such misleading portrayal on screen shapes ASPD stigmatization among audiences. Among many existing literature that navigated the power of mass media and the influence on its intended audience, it is recommended that scholars can study from an ASPD-specific approach to provide more insights. One suggestion is to conduct in-depth research on how the media plays a role in generating fear towards the ASPD population. Hazell et al. not only discovered a higher degree of stigma towards ASPD diagnosis, but also found that fear was a crucial determinant of stigmatization [5]. Future research may want to look at how such fear is generated and specifically through what means. Together, studying whether media portrayals of ASPD population contributes to the production of public fear can add more to the current understanding of media effects. But more importantly, it may also help assess if mass media is able to in turn serve as an educational tool that ameliorates modern stigmatization.

3.3. Psychopaths versus ASPD Individuals

Meanwhile, it is worth giving thought to how ASPD and psychopath are used interchangeably in the judicial context, and whether this is something that should be addressed in the future. According to Widiger and Widiger, studies of definitions suggested that there were significant differences between the two [18]. One being that most of the population with a diagnosis of ASPD did not meet the criteria of being the so-called psychopaths; psychopath, rather than being an equivalent terminology to ASPD, should be more accepted and understood as a severe form of it. Similar misconceptions between ASPD and psychopath population were also discussed in the stretch of media and entertainment previously. Yet for the most part, rigorous practices of law and justice nonetheless consent to such misconceived definitions, allowing unjust labels and associated potential biases to take place. Though past findings exhibited inconsistency on the effects of an ASPD (psychopathy) label and questioned its significance in contrast to other psychiatric labels [14], scholars cannot overlook the issue of a psychopath label swaying jury decision and punishment outcomes. Considering the essence of ASPD and psychopaths are different on scale and extremity, two diagnoses should be treated separately as the labeling effect and its associated stigma may prompt different consequences. Therefore, terminology and definition should be adopted more rigidly as to avert potential prejudice altogether to deliver justice. 

While some indicated that having an ASPD (psychopathy) label elicited more negative feelings among the jury and therefore executed more severe punishment, others suggested that such labeling effects were not significant for ASPD (psychopathy) specifically, but rather, were applicable to all psychiatric labels [12, 14]. Yet despite conflicting results, these impacts – whether being adverse or benign – exist due to the effects of labeling, and therefore worth discussing and giving recognition to. On account of this, further studies and replications are necessary in order to reach more robust conclusions.

3.4. Modification Within Therapeutic Application

Contrastingly, mental health professionals are in better awareness of the labeling issues and the potential harms that can be brought upon their patients. However, instead of handling it for good, mistreatment was uncovered in which the ASPD population was discriminated against by the lack of professional resources and support [4]. ASPD became the label that was viewed by many practitioners as unamendable, and therefore many were unwilling to offer psychiatric assistance in the first place [15]. Other resources such as self-help manuals provided by medical institutions or mental health facilities were either left out or discredited ASPD construct. It is a concerning problem that demands urgent attention to be addressed in a timely manner. In other respects, another portion of practitioners in the field was convinced that ASPD diagnosis particularly was the one with more stigmatizing outcomes, and advocate for using alternative terms and descriptions whenever referring to it as to prevent labeling effects from taking place in the therapeutic setting. This is clearly a way to move forward, though more future suggestions are encouraged in order to find the most effective approach.

4. Conclusion

Previous sections of the paper have discussed the impact of ASPD labeling and stigmatization from social, forensic, and medical perspectives. Together, this paper provides a comprehensive overview of current literature related to the topic at issue. 

Specifically speaking, the manifestation of ASPD symptoms in public environments may play a role with situational effects that influence the way the general population perceives ASPD individuals. Further research can be conducted to review such phenomena. In addition to social stigma, mass media portrayal of ASPD population tends to be misleading and confuses ASPD diagnosis with psychopaths. Future research direction can investigate how such misrepresentation induces ASPD stigma (particularly taking fear into consideration), which not only helps expand current understanding of the power of mass media, but also helps develop resolutions. 

Similar misconception between psychopaths and ASPD also exists in the judicial system, which is a serious matter in question given that contemporary studies are unsure whether there is a varying degree of stigmatization – and therefore prejudice – between an ASPD diagnosis and a psychopath label in the legal proceedings. More research is needed to draw a conclusion so that to decide if an official clarification is necessary to ever distinguish the two in order to prevent unfair imposition of punishment. 

Lastly, it has been found that maltreatment and oppression towards the ASPD population are still present in therapeutic practices. Although more and more practitioners have become aware of ASPD stigmatization and overtly expressed for a change, scholars should undertake more systematic studies to look for optimal ways of reducing stigma and labeling before applying valid regulation or modification to the practical field.

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