The successes and failures of the DSPD experiment: the assessment and management of severe personality disorder

Economic evaluations of mental health interventions in criminal justice

BACKGROUND

Mental health interventions targeting crime perpetrators are available. An overview of the current scenario of their economic benefits will help policy decisions.

AIM

To provide an update on economic evidence for mental health interventions in criminal justice, and to identify challenges and responses in using economic evidence to inform policy.

METHOD

Narrative review with an analysis frame that organises evidence around four points on the criminal justice system pathway: (a) point of contact; (b) post-arrest; (c) incarceration/punishment and (d) post-incarceration.

RESULTS

There is a paucity of high-quality economic evidence, especially from cost-benefit analyses. However, there is some evidence of cost-effectiveness in support of interventions at the point of incarceration, such as cognitive behavioural therapy, multisystemic therapy for juvenile delinquents, therapeutic communities, electronic monitoring and telepsychiatry in forensic psychiatry settings. There is also evidence that post-incarceration interventions such as assertive community treatment can be cost-effective.

CONCLUSION

There remain large evidence gaps. There are also challenges in turning economic evidence on mental health interventions in criminal justice into policy changes and improved practice, such as hidden costs, silo budgeting and delayed pay-off. Research incorporating multi-sectoral costs and benefits recommended by health economics and health technology assessment groups should be prioritised to support difficult resource allocation decisions faced by policy makers.

The dangers of using diagnoses outside of established psychiatric nosology in the courtroom: Analysis and discussion of current Swiss legal precedent from a medical perspective

Akin to many jurisdictions, Switzerland has a dual system of sanctions comprising sentences and measures. To order a therapeutic measure per Article 59 or 63 of the Swiss Criminal Code, the presence of a "severe mental disorder" must be determined. Before the new legal precedent, this required a medical diagnosis according to recognised classification systems like the ICD or DSM. The court then decided if a disorder was "severe" in the legal sense, thereby requiring such a therapeutic measure. However, in two 2019 rulings, the Swiss Federal Supreme Court concluded that a severe mental disorder could legally exist without a diagnosis according to the ICD or DSM, if it is based on offence- and risk-relevant personality-related factors amenable to risk-reducing therapy. We examine the details and context of the rulings, alongside their wider dangers. Specifically, we outline how undue influence could be exerted by non-ICD/DSM diagnostic systems, which were developed within individual theoretical schools of thought and lack empirical validation, like in these two court cases. Such non-manual diagnoses could make the presence of a severe mental disorder dependent upon whether an expert witness employs a particular diagnostic system, which would undermine principles of legality. Moreover, the Court's requirement that the disorder is based on personality-related risk factors amenable to risk-reducing therapy is problematic because research has highlighted the low effectiveness of treatment provided independently of a psychiatric disorder. Finally, broadening entry criteria may increase the number of offenders who require psychiatric treatment, thus endangering the quality of care for those with ICD/DSM-based diagnoses that are known to respond well to treatment (e.g. schizophrenia). In short, fulfilling the Court's request that any non-manual diagnoses are based on personality-related risk factors that are amenable to risk-reducing therapy is not possible for such non-manual diagnoses. Using unvalidated diagnoses could also render the system susceptible to ethical issues and hypothetical misuse, which may adversely affect society's most vulnerable people. To counter these dangers, we suggest that in order to be admissible in court, any diagnostic system must mandatorily fulfil sufficient scientific standards.

The early identification of people with personality disorder in the criminal justice system

The prevalence of personality disorder is very high among criminal justice (correctional) populations, yet our understanding of this condition as it arises in police custody is presently limited. Although healthcare screening has a well-described role within criminal justice settings, including police custody, specific screening for personality disorders has hardly been considered. Yet such screening is broadly in keeping with the aims of liaison and diversion services and the general healthcare principle of early identification, has the potential to inform future care pathways and ameliorate risk and could in some cases inform future sentencing arrangements including community alternatives. Therefore, there is a need for research to consider the design and implementation of a suitable screening tool for application as early as possible in the criminal justice pathway, either as a stand-alone instrument, or as part of a wider package of healthcare screens. It will be important to consider the feasibility of any such design, given environmental and time limitations within police custody and the high levels of substance misuse, with issues relating to intoxication and withdrawal.

The Violence Reduction Programme: An exploration of posttreatment risk reduction in a specialist medium-secure unit

BACKGROUND

There is limited evidence for treatment programmes for offenders with a diagnosis of personality disorder deemed to be of high risk of violence towards others.

AIM

This study sought to evaluate change in clinician-rated risk of violence in males among offenders accepted to a specialist medium-secure hospital providing treatment based on the Violence Reduction Programme (VRP).

METHOD

A retrospective, records-based cohort study design was used to explore change in risk of violence in a sample including five VRP cohorts composed of 33 offenders. Violence risk scale (VRS) score was the primary outcome measure. Correlates of treatment dropout were also explored.

RESULTS

Twenty-seven men completed treatment. Paired pretreatment and posttreatment VRS scores were available for 19 men. Six men disengaged with treatment. There was a significant mean reduction in risk of violence score (d = 1.08). At the individual level, eleven (57%) participants in the VRP showed reliable reduction in risk of violence. No treatment completers with a complete rating pair demonstrated an increased risk of violence. Younger age and referral from prison were significantly associated with treatment dropout.

CONCLUSION

VRP-based treatment appears to be a promising intervention for specialist services for offenders with a personality disorder diagnosis in the United Kingdom. Longer term follow-up to ascertain whether these apparent treatment gains are accompanied by actual reduction in violent recidivism is now required, and a full scale trial warranted.

Identifying Violent Behavior Using the Oxford Mental Illness and Violence Tool in a Psychiatric Ward of a German Prison Hospital

Background: Although there is evidence that individuals who suffer from severe mental disorders are at higher risk for aggressive behavior, only a minority eventually become violent. In 2017, Fazel et al. developed a risk calculator (Oxford Mental Illness and Violence tool, OxMIV) to identify the risk of violent crime in patients with mental disorders. For the first time, we tested the predictive validity of the OxMIV in the department of psychiatry at the prison hospital in Berlin, Germany, and presented findings from our internal validation. Materials and Methods: We designed a cohort study with 474 patients aged 16-65 years old who met the inclusion criteria of schizophrenia-spectrum or bipolar disorder and classified the patients into two groups: a violent group with 191 patients and a nonviolent group with 283 patients. Violence was defined as the aggressive behavior of a patient with the necessity of special observation. We obtained all the required information retrospectively through patient files, applied the OxMIV tool on each subject, and compared the results of both groups. Sensitivity, specificity, and positive/negative predictive values were determined. We used logistic regression including variable selection and internal validation to identify relevant predictors of aggressive behavior in our cohort. Results: The OxMIV score was significantly higher in the violent group [median 4.21%; Interquartile range (IQR) 8.51%] compared to the nonviolent group (median 1.77%; IQR 2.01%; p < 0.0001). For the risk of violent behavior, using the 5% cutoff for "increased risk," the sensitivity was 44%, and the specificity was 89%, with a positive predictive value of 72% and a negative predictive value of 70%. Applying logistic regression, four items were statistically significant in predicting violent behavior: previous violent crime (adjusted odds ratio 5.29 [95% CI 3.10-9.05], p < 0.0001), previous drug abuse (1.80 [1.08-3.02], p = 0.025), and previous alcohol abuse (1.89 [1.21-2.95], p = 0.005). The item recent antidepressant treatment (0.28 [0.17-0.47]. p < 0.0001) had a statistically significant risk reduction effect. Conclusions: In our opinion, the risk assessment tool OxMIV succeeded in predicting violent behavior in imprisoned psychiatric patients. As a result, it may be applicable for identification of patients with special needs in a prison environment and, thus, improving prison safety.

Antisocial personality disorder: new directions

Antisocial personality disorder is a complex condition carrying high rates of comorbidity and mortality for individuals as well as harmful consequences for their families and society. Despite the publication of National Institute for Health and Care Excellence (NICE) guidelines for the disorder, the evidence base and provision of effective treatments remain inadequate, and the belief that the condition is untreatable remains widespread among psychiatrists and other professionals. This article highlights current diagnostic controversies and summarises the evidence for conceptualising antisocial personality disorder as a disorder of attachment. Informed by this developmental perspective, we provide a framework for the management and treatment of adults with antisocial personality disorder, highlighting the importance of creating a safe setting and recommending adaptations of therapeutic technique to facilitate the engagement of this ‘treatment-rejecting’ patient population. We conclude with an outline of the current government policy on the treatment of high-risk offenders with personality disorder.

LEARNING OBJECTIVES

Factors associated with progression in the London pathway project

BACKGROUND

The London Pathways Partnership (LPP) Community Service is an approach to mainstreaming the identification of offenders with severe personality disorder to address their needs and reduce their risk.

AIMS

To evaluate the result of the full-scale implementation of the LPP and evaluate factors associated with an offender's progression on the pathway.

METHOD

The data collected as part of the LPP project and Offender Assessment System data were used to evaluate who was screened into the pathway and their progression on the pathway.

RESULTS

Over 3,400 offenders were screened into the pathway in the first 48 months of implementation but fewer were recorded as having progressed. It was not possible to determine whether this attrition reflected appropriate pathway action, inefficient service provision or weak recording procedures. Certain types of offenders were represented at progressive stages of the pathway. Those who had violent or sexual offences, had received custodial sentences, had more personality disorder indicators and were of higher risk were more likely to be found at progressive stages of the pathway. When probation areas began implementing the service was also found to be related to pathway movement. Also, those of Non-White ethnicity were no less likely than those of White ethnicity to be recommended or referred for services but were significantly less likely to start services.

CONCLUSIONS

The LPP attempts to balance breadth (covering all offenders being convicted in London) with depth (developing a feasible pathway for all offenders identified with severe personality disorder) and has done so with some success.

IMPLICATIONS

Future research should examine the continued rollout of the LPP service, and importantly the relationship between salient individual, risk and personality features, pathway inputs and measures of later reoffending. Copyright © 2017 John Wiley & Sons, Ltd.

Inpatient forensic-psychiatric care: Legal frameworks and service provision in three European countries

Laws governing the detention and treatment of mentally disordered offenders (MDOs) vary widely across Europe, yet little information is available about the features of these laws and their comparative advantages and disadvantages. The purpose of this article is to compare the legal framework governing detention in forensic psychiatric care in three European countries with long-established services for MDOs, England, Germany and the Netherlands. A literature review was conducted alongside consultation with experts from each country. We found that the three countries differ in several areas, including criteria for admission, review of detention, discharge process, the concept of criminal responsibility, service provision and treatment philosophy. Our findings suggest a profound difference in how each country relates to MDOs, with each approach contributing to different pathways and potentially different outcomes for the individual. Hopefully making these comparisons will stimulate debate and knowledge exchange on an international level to aid future research and the development of best practice in managing this population.

The Impact on Staff of Working with Personality Disordered Offenders: A Systematic Review

BACKGROUND

Personality disordered offenders (PDOs) are generally considered difficult to manage and to have a negative impact on staff working with them.

AIMS

This study aimed to provide an overview of studies examining the impact on staff of working with PDOs, identify impact areas associated with working with PDOs, identify gaps in existing research,and direct future research efforts.

METHODS

The authors conducted a systematic review of the English-language literature from 1964-2014 across 20 databases in the medical and social sciences.

RESULTS

27 papers were included in the review. Studies identified negative impacts upon staff including: negative attitudes, burnout, stress, negative counter-transferential experiences; two studies found positive impacts of job excitement and satisfaction, and the evidence related to perceived risk of violence from PDOs was equivocal. Studies demonstrated considerable heterogeneity and meta-analysis was not possible. The overall level of identified evidence was low: 23 studies (85%) were descriptive only, and only one adequately powered cohort study was found.

CONCLUSIONS

The review identified a significant amount of descriptive literature, but only one cohort study and no trials or previous systematic reviews of literatures. Clinicians and managers working with PDOs should be aware of the potential impacts identified, but there is an urgent need for further research focusing on the robust evaluation of interventions to minimise harm to staff working with offenders who suffer from personality disorder.

Preliminary studies of the ICD-11 classification of personality disorder in practice

OBJECTIVE

This study aims to compare ICD-10 and putative ICD-11 classifications of personality disorder in different clinical populations.

DESIGN

Prospective recording of ICD-10 and ICD-11 personality disorder classifications was carried out in (1) an anxious medical population, (2) an acute psychiatric in-patient population and (3) a retrospective recording of a mixed anxiety depression cohort in which all baseline data were scored from baseline information using the ICD-11 classification and compared with the original ICD-10 assessments.

METHOD

Comparison of ICD-10 and ICD-11 prevalence of personality disorder in each population was carried out.

RESULTS

Data from 722 patients were recorded. Using the ICD-10 criteria, the prevalence of generic personality disorder was 33.8% compared with 40.4% using the ICD-11 ones (χ2  = 6.7; P < 0.01), with 103 (14.3%) discordant assessments. Using the severity definitions in ICD-11, 34.3% of patients had personality difficulty. Severity level varied greatly by population; severe personality disorder was five times more common in the inpatient group. The four domain traits originally denoted as qualifying severity in ICD-11, negative affective, dissocial, anankastic and detached, were linked to anxious, borderline, dissocial, anankastic and schizoid personality disorders in ICD-10. Many patients had pathology in two or more domains.

CONCLUSIONS

The ICD-11 classification of personality disorder yields somewhat higher levels of personality dysfunction than ICD-10, possibly because the age range for the onset of diagnosis is now flexible. The range of severity levels make the classification more useful than ICD-10 in clinical practice as it identifies the greater pathology necessary for intervention.

What do people in forensic secure and community settings think of their personality disorder diagnosis? A qualitative study

PURPOSE

The aim of this study was to explore the experience of having a personality disorder diagnosis within the context of forensic secure and community services.

METHODS

We used an interpretative phenomenological analysis to analyse interviews with 10 service users purposively recruited from services in South London.

RESULTS

Participants described two facets of their lived experience: (1) the way they see themselves now, in light of their offending and social background and (2) the pejorative nature of the personality disorder label, its relationship to mental illness and their need to distance themselves from it.

CONCLUSIONS

Having a forensic identity affects participants' perceptions of their diagnosis and its treatment as well as their views about themselves.

Measuring IPDE-SQ personality disorder prevalence in pre-sentence and early-stage prison populations, with sub-type estimates

Understanding the prevalence and type of personality disorder within prison systems allows for the effective targeting of resources to implement strategies to alleviate symptoms, manage behaviour and attempt to reduce re-offending. This study aimed to determine the prevalence of personality disorder (PD) traits within a local urban high-turnover adult male prison with a remand/recently sentenced population in London, UK. The International Personality Disorder Examination - Screening Questionnaire (IPDE-SQ) self-administered questionnaire (ICD-10 version) was completed by 283 prisoners (42% completion rate). 77% of respondents reached the threshold for one or more PDs. The most common PD types were Paranoid PD (44.5%), Anankastic PD (40.3%), Schizoid PD (35%) and Dissocial PD (25.8%). These results confirm and extend existing knowledge regarding the prevalence of PD in prison populations into a high-turnover, urban, remand population. The stark comparison with community samples indicates that a more equitable standard of service delivery within the criminal justice system, focussing on preventive and early intervention services, is now required.

Measurement of predictive validity in violence risk assessment studies: a second-order systematic review

The objective of the present review was to examine how predictive validity is analyzed and reported in studies of instruments used to assess violence risk. We reviewed 47 predictive validity studies published between 1990 and 2011 of 25 instruments that were included in two recent systematic reviews. Although all studies reported receiver operating characteristic curve analyses and the area under the curve (AUC) performance indicator, this methodology was defined inconsistently and findings often were misinterpreted. In addition, there was between-study variation in benchmarks used to determine whether AUCs were small, moderate, or large in magnitude. Though virtually all of the included instruments were designed to produce categorical estimates of risk - through the use of either actuarial risk bins or structured professional judgments - only a minority of studies calculated performance indicators for these categorical estimates. In addition to AUCs, other performance indicators, such as correlation coefficients, were reported in 60% of studies, but were infrequently defined or interpreted. An investigation of sources of heterogeneity did not reveal significant variation in reporting practices as a function of risk assessment approach (actuarial vs. structured professional judgment), study authorship, geographic location, type of journal (general vs. specialized audience), sample size, or year of publication. Findings suggest a need for standardization of predictive validity reporting to improve comparison across studies and instruments.

Use of risk assessment instruments to predict violence and antisocial behaviour in 73 samples involving 24 827 people: systematic review and meta-analysis

OBJECTIVE

To investigate the predictive validity of tools commonly used to assess the risk of violence, sexual, and criminal behaviour.

DESIGN

Systematic review and tabular meta-analysis of replication studies following PRISMA guidelines.

DATA SOURCES

PsycINFO, Embase, Medline, and United States Criminal Justice Reference Service Abstracts.

REVIEW METHODS

We included replication studies from 1 January 1995 to 1 January 2011 if they provided contingency data for the offending outcome that the tools were designed to predict. We calculated the diagnostic odds ratio, sensitivity, specificity, area under the curve, positive predictive value, negative predictive value, the number needed to detain to prevent one offence, as well as a novel performance indicator-the number safely discharged. We investigated potential sources of heterogeneity using metaregression and subgroup analyses.

RESULTS

Risk assessments were conducted on 73 samples comprising 24,847 participants from 13 countries, of whom 5879 (23.7%) offended over an average of 49.6 months. When used to predict violent offending, risk assessment tools produced low to moderate positive predictive values (median 41%, interquartile range 27-60%) and higher negative predictive values (91%, 81-95%), and a corresponding median number needed to detain of 2 (2-4) and number safely discharged of 10 (4-18). Instruments designed to predict violent offending performed better than those aimed at predicting sexual or general crime.

CONCLUSIONS

Although risk assessment tools are widely used in clinical and criminal justice settings, their predictive accuracy varies depending on how they are used. They seem to identify low risk individuals with high levels of accuracy, but their use as sole determinants of detention, sentencing, and release is not supported by the current evidence. Further research is needed to examine their contribution to treatment and management.

Severe personality disorder in the secure estate: continuity and change

The Response to Offender Personality Disorder Consultation was released in October 2011. For some this is a welcome step in the right direction due to its therapeutic optimism, however for practitioners operating in the secure estate there are significant challenges ahead. This aim of this article is to discuss the increasing convergence of health and criminal justice and their inherent ideological and practical difficulties. It does so with reference to the consultation on offender personality disorder pathways and in particular the implications regarding multi-disciplinary and cross agency approaches to risk, public protection and personality disorder respectfully. It concludes that before embarking on a new wave of determining and responding to those with personality disorder, offender or otherwise, a more in-depth and empirically informed critical reflection is warranted.

The dangerous and severe personality disorder experiment--review of empirical research

BACKGROUND

A pilot programme for the treatment of individuals with dangerous and severe personality disorder (DSPD) was established in the UK in 2001. A substantial investment had been made into research and evaluation of the initiative, but it is not clear what the outcomes of this research have been.

AIM

This study aimed to review empirical research on the DSPD programme.

METHOD

We conducted a systematic literature review by using electronic searches of the databases MEDLINE, PsycINFO and EMBASE, complemented by hand searches of key journals and websites.

RESULTS

We identified a total of 29 empirical research papers and three comprehensive research reports. Most studies were concerned with describing the DSPD population and confirmed that the projects targeted high-risk personality disordered offenders. Qualitative research identified a number of concerns regarding stigma, restrictiveness of the environment and indeterminate detention. Organisational enquiries recognised inefficiencies in assessment and treatment delivery. No high-quality trials were carried out of specific treatments or service environments.

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

The key question--what treatments are effective for high-risk personality disordered offenders--remains unanswered. More time would be needed to fully assess the impact of this programme, and similar future initiatives should allow longer observation periods.

Are patients deemed 'dangerous and severely personality disordered' different from other personality disordered patients detained in forensic settings?

BACKGROUND

In 1999, the UK government initiated a programme for the assessment and treatment of individuals deemed to have 'dangerous and severe personality disorder' (DSPD). After over 10 years of specialist service development, it is not clear whether DSPD patients represent a distinct group.

AIMS

The aim of this study was to establish whether people admitted to DSPD hospital units could be distinguished in presentation or personality traits from people with personality disorder admitted to standard secure hospital services.

METHODS

Thirty-eight men detained in high-security hospital DSPD units were compared with 62 men detained in conventional medium or high security hospital units, using the Psychopathy Checklist-Revised (PCL-R) and other standard personality disorder, clinical and offending measures.

RESULTS

Compared with their counterparts in standard services, the DSPD group had higher scores on PCL-R psychopathy, significantly more convictions before age 18 years, greater severity of institutional violence and more prior crimes of sexual violence. Regression analysis confirmed that only PCL-R Factor 1, reflecting core interpersonal and affective features of psychopathy, predicted group membership.

CONCLUSION

The DSPD group emerged as having higher psychopathy scores, but as there is currently no evidence that the core personality features of psychopathy are amenable to treatment, there is little justification for treating high-psychopathy forensic patients differently from those with other disorders of personality.

The baby, the bathwater and the bath itself: a response to Tyrer et al.'s review of the successes and failures of dangerous and severe personality disorder

A recent paper by Tyrer et al. in this journal has reviewed the dangerous and severe personality disorder (DSPD) initiative in the assessment and management of severe personality disorder associated with high risk. This previous paper summarized the authors' perceptions of the successes and failures of the DSPD pilot. In the present paper we identify some inaccuracies in the previous review and provide a critique of the conclusions reached.

Forensic psychiatry and public protection

The prominence of risk in UK social and criminal justice policy creates opportunities, challenges and dangers for forensic psychiatry. The future standing of the specialty will depend not only on the practical utility of its responses to those opportunities and challenges, but also the ethical integrity of those responses.