Clozapine: an effective treatment for seriously violent and psychopathic men with antisocial personality disorder in a UK high-security hospital

Abstract

ObjectiveA number of studies have demonstrated the anti-aggressive properties of clozapine in schizophrenia and its positive effect in borderline personality disorder. There is no published literature on the treatment of antisocial personality disorder (ASPD) with clozapine. We present a case series of 7 patients with primary ASPD and high psychopathic traits treated with clozapine, having a significant history of serious violence and currently detained in a UK based high-security hospital.MethodsA retrospective review of case notes was carried out to formulate Clinical Global Impression (CGI) scores and record incidents of violence and aggression. Effect on specific symptom domains (cognitive-perceptual, impulsive-behavioural dyscontrol, affective dysregulation) was also noted. Metabolic parameters and serum clozapine levels were also sampled.ResultsAll 7 patients showed significant improvement on clozapine. It was shown to benefit all symptom domains, especially impulsive behavioral dyscontrol and anger. The number of violent incidents committed by 6 of the 7 patients reduced significantly, and all patients’ risk of violence reduced. Clozapine serum levels for 6 of the 7 patients were in the range 150–350 ng/mL.ConclusionClozapine is of benefit in reducing the clinical severity of ASPD. It improved all symptom domains, especially impulsive-behavioral dyscontrol and anger, and reduced levels of aggression and violence, especially at lower doses (serum levels <350 ng/m). To our knowledge, this is the first account of clozapine treatment in patients with ASPD and high psychopathy.

Schizophrenia and violence: realities and recommendations

“…In addition, clozapine, but not other antipsychotic medications (e.g., Beck et al, 1997), has demonstrated effectiveness in reducing aggression in psychotic patients (Volavka, 2013), and so strategies that integrate targeted medication use with evidence-based milieu, and group and individual psychological interventions will typically be most effective. Clozapine has also demonstrated effectiveness in reducing aggression in men with antisocial personality disorder, including in those scoring high in psychopathy (Brown et al, 2014). This suggests that this medication may be effective for both Type I and II patients as categorized by Hodgins (2008).…”

Mesocorticolimbic dopamine functioning in primary psychopathy: A source of within-group heterogeneity

“…Intriguingly, recent findings have indicated that the DA regulating antipsychotic Clozapine, which shows among the highest D1-to-D2 receptor occupancy ratio compared to other antipsychotics (see Tauscher et al, 2004), substantially reduced impulsive violence, aggression, and anger in forensic psychiatric inpatients with high levels of psychopathy (Brown et al, 2014). In fact, Clozapine mainly works by improving the tonic stimulation of D1-receptors in the PFC (Ahlenius, 1999), which may normalize D1-to-D2 receptor activation and thereby improve cognitive stability and control of immediate tendencies in primary psychopathy.…”

Disrupted functional connectome in antisocial personality disorder

“…Our results provide insights for understanding the functional brain networks of ASPD. As of now, some researchers have already started examining ways to reduce the clinical severity of ASPD through medicinal interventions and selective treatment (Brown et al 2014). Our results may provide some useful information for their further consideration.…”