A postal survey of the assessment procedure for personality disorder in forensic settings

Value of standard personality assessments in informing clinical decision-making in a medium secure unit

Background

Assessing those with personality disorder for treatment in secure settings is known to be unsatisfactory.

Aim

To examine the utility of a standardised assessment of offenders with personality disorder referred for treatment in secure care in a naturalistic study.

Method

A consecutive series of 89 men were assessed with a battery of four recommended instruments measuring personality and risk. Decisions on whether or not to admit were based on a multidisciplinary discussion informed by these assessments.

Results

Of the 89 comprehensively assessed referrals, 60 (67%) were offered admission. High scores on the Psychopathy Checklist–Revised (especially on Factor 1) was the only measure that was associated with rejection. Of 44 patients discharged, 29 (66%) failed to complete treatment; none of the pre-admission assessments distinguished ‘completers' from ‘non-completers'. Although skills were acquired on the unit, follow-up of 24 men in the community showed that this had only a marginal effect on re-offending rate (58%).

Conclusions

Current recommended assessment methods appear unsatisfactory in identifying those who either (a) complete treatment or (b) benefit from treatment. Our results throw doubt on their value.

Assessment of personality disorder

In 2003 the Department of Health, in conjunction with the National Institute for Mental Health in England, outlined the government's plan for the provision of mental health services for people with a diagnosis of personality disorder. This emphasised the need for practitioners to have skills in identifying, assessing and treating these disorders. It is important that personality disorders are properly assessed as they are common conditions that have a significant impact on an individual's functioning in all areas of life. Individuals with personality disorder are more vulnerable to other psychiatric disorders, and personality disorders can complicate recovery from severe mental illness. This article reviews the classification of personality disorder and some common assessment instruments. It also offers a structure for the assessment of personality disorder.

The validity and clinical utility of structured diagnoses of antisocial personality disorder with forensic patients

Current DSM-based instruments for personality disorders (PDs) limit the investigation of the course and outcome of treatment of these disorders. This study examined the validity of the Shedler-Westen Assessment Procedure-200 (SWAP-200) and the Structured Clinical Interview for DSM-IV Axis II PD (SCID-II) in a sample of forensic PD patients. Results based on 66 participants indicated that the SWAP-200 Q-factors reduced the frequency of diagnostic comorbidity of PD categories by half compared with the SCID-II. Only the SWAP-200's Antisocial PD category showed good convergent and discriminant validity with respect to other instruments describing aspects of PD. The validity of the cutoff score for severe antisocial PD was confirmed, and this category predicted severe incidents in the hospital at 1 year of follow-up. A violence risk scale was constructed, which differentiated violent and nonviolent offenders. The results support the validity of the SWAP-200 and its potential clinical utility with forensic PD patients.

Reclaiming the humanity in personality disorder

This paper provides a commentary upon the nursing care of individuals diagnosed with personality disorder and associated education courses. The discussion focuses upon recent policy trends in the UK as a point of departure. This policy discourse is critical of mainstream mental health services in previously operating to exclude such individuals. One of the consequences has been a recent growth in interest in relevant training courses, many of which devote significant attention to staff attitudes regarding this client group. Various previous researchers and commentators have remarked upon the implications for practice of a perceived negative attitude among care staff. We reflect upon our own anecdotal experience of developing and delivering new university-based courses for practitioners working in the field of personality disorder to offer a particular critique of the UK context, in which this policy, training, and practice is framed. Social constructionist theories are drawn on to offer insights into public and practitioner discourse and the possible effects on therapeutic relationships. The available discourse constructs individuals with a diagnosis of personality disorder as essentially different from other people. We argue that staff training and practice development initiatives are likely to be more successful if such discourse is challenged, and attempts are made in therapeutic encounters to recognize shared characteristics and positive attributes as much as perceived difference and negative attributes. We refer to this as a re-engagement with common humanity. Despite the singular national context, the discursive themes explored are not necessarily restricted to the UK.

Characteristics of offenders referred to a medium secure NHS personality disorder service: the first five years

BACKGROUND

As new services for offenders with personality disorder emerge in the UK, there is interest in the methods of assessments and characteristics of patients admitted.

AIM

To evaluate use of selection criteria for admission to a dedicated personality disorder service within medium secure hospital provision in the UK, and to test for features that discriminate between those admitted and those rejected.

METHOD

A structured multidisciplinary assessment was administered to offenders referred to a new personality disorder service in a medium secure psychiatric unit. The evaluation included self-report and observer ratings across a range of domains including categorical axis I disorders and axis II disorders, dimensional assessment of personality and ratings of intellect and risk.

RESULTS

Sixty-eight male offenders were assessed, of whom 47 were offered admission. No differences were found between those accepted or rejected on demographic, offence and most clinical characteristics. Axis I comorbidity was high in both groups (over 90%). There was no indication of staff overriding exclusion criteria but men who were accepted had greater extraversion and conscientiousness on the NEO-FFI.

CONCLUSION

Staff screening men for suitability for admission to this new specialist medium security hospital unit stayed true to given exclusion criteria in their decision not to offer a bed. Characteristics with face value as qualities necessary for engagement in treatments appeared to influence positive choices. Next steps will be to test the validity of choice with outcome studies.

Using the SWAP-200 in a personality-disordered forensic population: is it valid, reliable and useful?

BACKGROUND

Treatment and risk management of forensic patients relies heavily on diagnosing psychopathology, yet the reliability of clinical diagnoses of personality disorder has been found to be only fair to low. Structured instruments for the global assessment of personality disorder are infrequently used in clinical assessments possibly due to their limited validity and clinical utility.

AIMS/METHODS

The Shedler-Westen Assessment Procedure-200 (SWAP-200) was developed in an effort to address these limitations. Although good reliability and validity in relation to clinicians' diagnosis of personality disorder has been reported, to date the validity of this instrument has not been assessed in relation to other standardized instruments or in a personality-disordered, forensic population. This study aims to establish the reliability and validity of the SWAP-200 against other diagnostic instruments and measures of interpersonal functioning in a personality disordered forensic population.

RESULTS

This paper reports the results of 30 subjects from a high secure hospital in the UK who were assessed with the SWAP-200, the Structured Clinical Interview for DSM-IV Personality Disorders (SCID-II), the Adult Attachment Interview (AAI) and the Chart of Interpersonal Reactions in Closed Living Environments (CIRCLE). Preliminary results suggest that the SWAP-200 is a reliable instrument for the diagnosis of personality disorder in forensic patients.

CONCLUSIONS

Although the small sample size allows only preliminary conclusions about the validity of this instrument, early results show a reduction of the diagnosis of comorbidity compared with the SCID-II, together with an increased number of expected associations between independent measures of interpersonal functioning and categories of personality disorder.