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Dangerous and severe personality disorder – Questions and Answers

The condition known as dangerous and severe personality disorder has, in fact, no legal or medical basis. Yet the government is pouring £126m over three years to develop a variety of DSPD services. David Batty explains

* David Batty
* guardian.co.uk, Wednesday 17 April 2002 09.44 BST
* Article history

What is dangerous and severe personality disorder?

Personality disorder refers to patterns of behaviour or experience resulting from a person’s particular personality that differ markedly from those expected by society and lead to distress or suffering to that person or to others. The government first introduced the term DSPD in a consultation paper Managing Dangerous People with Severe Personality Disorder in 1999, which proposed how to detain and treat a small minority of mentally disordered offenders who pose a significant risk of harm to others and themselves. Specialist services to deal with these people, most of whom are thought to be serious violent and sex offenders, were proposed in the white paper Reforming the Mental Health Act in December 2000.

What are the traits associated with DSPD?

The condition’s characteristics have yet to be clearly defined. But it is thought to be an extreme form of antisocial personality disorder (ASPD) – the diagnosis most commonly associated with psychopathy. The key traits of ASPD include failure to make intimate relationships, impulsiveness, lack of guilt, and not learning from adverse experience. ‘Psychopathic disorder’ is a legal term used in the current mental health legislation to refer to people who have “a persistent disorder or disability of mind… which results in abnormally aggressive or seriously irresponsible conduct.”

How many people have DSPD?

The white paper to reform the mental health act states that 2,00-2,400 people in England and Wales are estimated to have DSPD, although some government officials say there are up to 2,500. According to the Home Office, about 1,400 are estimated to already be in prison. A further 400 are estimated to be patients in high security psychiatric hospitals, with between 300 and 600 at large in the community. About 98% of those with DSPD are believed to be men. However, with the new disorder’s definition still unclear, many psychiatrists contend these figures are just speculation.

Where will people with DSPD be treated?

By 2004 there will be 300-320 high security places to detain, assess and treat DSPD. The 92-bed unit on D-wing at Whitemoor prison, Cambridgeshire, began assessing prisoners last September, offering treatment from March. Another 80 places will be provided at a newly built unit at Frankland prison, Durham, from early 2004. There will be 140 additional places for those with DSPD in special hospitals by April 2004. A new 70-bed unit at Rampton hospital, Nottinghamshire, is due to open in October 2003. Another unit will be built at Broadmoor hospital, Berkshire. DSPD services will also be set up at medium secure prisons and hospitals and in the community to treat and support those assessed as safe to be released or discharged. Community programmes are expected to be piloted in south London and the north-east.

How is DSPD diagnosed?

Assessment on the DSPD unit at Whitemoor high security prison lasts 14 weeks. Inmates undergo psychometric tests to assess their dangerousness and to measure the severity of their personality disorder. They also have a series of interviews with a psychiatrist, while care staff record how disturbed and challenging their behaviour is from day to day. The clinical team then evaluates whether a connection can be made between dangerousness and severe personality disorder by examining the inmate’s past and current offending behaviour and how they interact with other prisoners and staff. Jamie Bennett, head of the Whitemoor DSPD unit, said prisoners would need a long history of sex or violent offences to meet the criteria.

What treatment is there for DSPD?

Inmates at Whitemoor and Rampton receive a psychological therapy called dialectical behavioural therapy (DBT), which aims to help them respond to everyday situations in a problem solving manner rather than emotionally and aggressively. This more positive mindset should enable them to take part in rehabilitation programmes, such as reoffending reduction courses. However, DBT has predominantly been used to treat women with borderline personality disorder who deliberately harm themselves and there is little evidence it will prove effective in helping those with DSPD.

What prompted the DSPD programme?

Much of the impetus for the DSPD programme has come from high-profile cases such as that of Michael Stone, who in 1996 attacked Josie Russell and killed her mother and sister several years after his personality disorder was deemed untreatable. The Home Office regards those with DSPD as “a group hitherto poorly served by criminal justice or mental health services” and believes “the serious nature of the crimes they typically commit has a disproportionate impact on the public’s fear of crime.” The Mental Health Act 1983 only allows people to be committed to hospital where psychiatrists believe the person is treatable and many do not believe personality disorder is. But proposed reform of the mental health act would allow detention of people with PD – even, in some cases, if they had committed no crime.

How much will the programme cost?

The government has set aside £126m over three years to develop high security, medium security and community DSPD services. The prison service has been allocated £70m and the NHS £56m. Although Home Office officials were unable to estimate treatment costs in high security settings, Dr Ian Keitch, head of DSPD at Rampton, said treatment at the hospital was projected to cost £180,000 per bed per year. Although this is £30,000 more than current treatment costs for patients believed to have DSPD, Dr Keitch said this was less than treatment costs for female self-harmers – £200,000. However, he admitted the cost could not be justified on current evidence. Peter Tyrer, professor of community psychiatry at Imperial College, said a £2m three-year research programme to assess the effectiveness of the treatment programmes, should lead to improved cost efficiency.

Why is the term so controversial?

DSPD currently has no legal or medical basis and many doctors regard it as a political invention. A survey of nearly 1,200 psychiatrists published in the British Journal of Psychiatry in 2000 found almost two-thirds disagreed with the plan for detaining people with personality disorders, and almost a third said they might boycott it. There is no firm evidence base for the disorder or the new assessment and treatment programmes. The Royal College of Psychiatrists says there is no “entirely satisfactory” diagnosis of antisocial traits that threaten public safety. A recent study in the Lancet warned DSPD is so vaguely defined that six people would have to be detained to prevent one from acting violently, raising major concerns about civil liberties.

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Dangerous people with severe personality disorder British proposals for managing them are glaringly wrong—and unethical

BMJ. 1999 October 30; 319(7218): 1146–1147.

PMCID: PMC1116939
Copyright © 1999, British Medical Journal

Paul E Mullen, professor of forensic psychiatry
Monash University and Institute of Forensic Mental Health, Victoria, 3084 Australia

This summer the British Department of Health and the Home Office jointly issued a paper on Managing Dangerous People with Severe Personality Disorder.1 The paper was apparently “based on the results of extensive informal discussions” and sets out the government’s policy objectives in dealing with what the paper calls the “dangerous severely personality disordered.” The paper avoids descending into the apparently unending debate over what is, or is not, a personality disorder and to what extent personality disorders are treatable and attempts to cut through the gordian knot with what presumably are intended as straightforward and practical proposals for action. If only it were that simple.

This government “framework for the future” proposes legal powers for detaining indefinitely people with dangerous severe personality disorder. Specialists, including psychiatrists, are to be employed both to better identify people with dangerous severe personality disorder and to develop “approaches to detention and management.” Finally a comprehensive programme of research is to be established to support development of policy and practice. The proposals make a point of insisting that “indeterminate detention will be authorised only on the basis of evidence from an intensive specialist assessment” (my italics).

There are people whose antisocial and self damaging behaviours are at least in part a product of abiding character traits such as impulsivity and suspiciousness combined with abnormalities of mental state, including instability of mood and dissociative symptoms. Such distressed and disturbed individuals currently attract little interest from mental health professionals and even less from those who fund services. Clinical experience suggests, however, that such disorders can be improved, if not cured, even if research has failed to pinpoint the best therapeutic approaches. Severely personality disordered individuals are over-represented among recidivist offenders, though such disorders do not inevitably lead to serious offending; nor are serious offenders drawn exclusively from their ranks.

Crime and violence are major political issues. Surveys indicate growing public support for more punitive approaches to offenders,2 and populist governments around the world, be they left, right, or third way leaning, fall over themselves to respond to law and order agendas. In England and Wales section 2 of the Crimes (Sentencing) Act already provides for discretionary life sentences for those convicted a second time for serious violence or a sexual offence. The courts have, however, shown a signal lack of enthusiasm for imposing such sentences, frustrating the government’s carceral enthusiasms. The proposals set out in this document openly acknowledge the hope that the judicial reluctance to sentence on the basis of predicted future behaviour will be reduced if courts are provided with medical evidence that offenders have dangerous severe personality disorder.

What is wrong then with proposals that promise far greater resources for a relatively ignored group of mentally disordered people and at the same time hold out the prospect of increased community safety? If dangerousness was really a characteristic of some personality disordered individuals rather than a characteristic of some acts by some of them; if the proposed special centres, with their multidisciplinary teams armed with “batteries of standardised procedures,” could reliably recognise dangerous severe personality disorder; if these proposals were really about providing care and treatment for the personality disordered; and if health professionals were really judges and jailers charged with maintaining public order, then perhaps these proposals would be worth taking seriously. But none of these assumptions holds true.

Enthusiastic advocates exist for actuarial methods of predicting future criminality, and some place considerable theoretical emphasis on the contribution of personality.3,4 In practice, however, the probability of future offending is predicted most effectively by past offending.5 Variables such as being a substance abuser or having a history of being abused as a child, have significant, if less consistent, associations with increased rates of future violence.4,6 Mental health variables contribute little to such predictive characteristics. A diagnosis of psychopathy, or antisocial personality disorder, often does little more than recycle the history of prior offending behaviours in a different form, producing a potentially spurious association between personality disorder and offending. In practice, therefore, we would be identifying people with dangerous severe personality disorder not on mental health, or even personality, variables but on their past offending, their past history of victimisation, and their current drug and alcohol habits. Except for substance abuse, none of these predictive factors is open to change.

The government’s proposals masquerade as extensions to mental health services. They are in fact proposals for preventive detention, not too far removed from the dangerous offender and sexual predator laws in North America.5They aim to make judges more amenable to imposing discretionary life sentences. They are intended, as Eastman observed in these pages,7 to circumvent the European Convention on Human Rights, which prohibits preventive detention except in those of unsound mind. With their promises of new money and research funding, they hope to bribe doctors into complicity in the indefinite detention of certain selected offenders. Discussion of the ethical dilemmas that these proposals present for health professionals is absent, presumably because they are ethically and professionally indefensible.

There is a crying need for mental health services for severely personality disordered individuals. Such services would decrease the morbidity and staggering mortality associated with these conditions. In the process they would contribute to community safety. The British government’s proposals largely ignore this central issue of developing appropriate treatment services in favour of creating a system for locking up men and women who frighten officials. On first reading this document created both disappointment and foreboding. On more careful consideration it became clear that the contradictions were so glaring, the deceptions so open and palpable, and the agenda so obvious, that these proposals can surely not have any chance of influencing reality.
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>References

References
1.
Department of Health; Home Office. Managing dangerous people with severe personality disorder. London: Home Office; 1999. http://www.homeoffice.gov.uk/cpd/persdis.htm http://www.homeoffice.gov.uk/cpd/persdis.htm.
2.
Kury, H; Ferdinand, T. Public opinion and punitivity. Int J Law Psych. 1999;22:373–392. [PubMed]
3.
Hare, RD. The Hare PCL-R: some issues concerning its use and misuse. Legal Criminol Psychol. 1998;3:99–112.
4.
Quinsey, VL; Harris, GT; Rice, ME; Cormier, CA. Violent offenders: appraising and managing risk. Washington, DC: American Psychological Association; 1998.
5.
Heilbrun, K; Ogloff, JRP; Picarello, K. Dangerous offender statutes in the United States and Canada: implications for risk assessment. Int J Law Psych. 1999;22:393–415. [PubMed]
6.
Steadman, HJ; Mulvey, E; Monahan, J; Robbins, PC; Appelbaum, PS; Grisso, T, et al. Violence by people discharged from acute psychiatric inpatient facilities and by others in the same neighborhoods. Arch Gen Psych. 1998;55:393–401. [PubMed]
7.
Eastman, N. Public health psychiatry or crime prevention? BMJ. 1999;318:549–551. [PubMed]

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