Personality disorder and risk to others Dr Rajan Darjee BSc(Hons) MB ChB MRCPsych MPhil MD Consultant Forensic Psychiatrist, Royal Edinburgh Hospital Honorary Senior Clinical Lecturer in Forensic Psychiatry, University of Edinburgh
Overview Personality disorder Personality disorder and violence Risk assessment Management
Personality
Personality
Personality traits The Big Five Openness Appreciation for art, emotion, adventure, unusual ideas, curiosity, and variety of experience. Conscientiousness A tendency to show self-discipline, act dutifully, and aim for achievement; planned rather than spontaneous behaviour. Extraversion Energy, positive emotions, urgency, and the tendency to seek stimulation in the company of others. Agreeableness A tendency to be compassionate and cooperative rather than suspicious and antagonistic towards others Neuroticisim A tendency to experience unpleasant emotions easily, such as anger, anxiety, depression, or vulnerability; sometimes called emotional instability.
Personality Situation Behaviour
Determinants of personality
Personality is multi-layered Interpersonal functioning Thoughts, feelings, behaviour, identity Schema Innate temperament
Personality disorder: DSM 5 Definition Evidence that the individuals characteristic and enduring patterns of inner experience and behavior as a whole deviate markedly from the culture expected and accepted range (or norm). Deviation in more than one of : 1. Cognition 2. Affectivity 3. Control over impulses and gratification of needs 4. Manner of relating and handling interpersonal situations Behavior is inflexible, maladaptive or otherwise dysfunctional across a range of personal and social situations. There is personal distress and/or adverse impact on a social environment. There is evidence that deviation is stable and of long duration, having its onset in late childhood or adolescence. Deviation not explained by other mental disorders or organic brain disease.
Psychopathy Personality disorder Personality
Mental illness Psychopathy Personality disorder Personality
DSM 5 Classification Cluster A Paranoid Schizoid Schizotypal Cluster B Antisocial Borderline Histrionic Narcissistic Cluster C Avoidant Dependent Obsessivecompulsive
ICD 10 Classification Paranoid Schizoid Dissocial Emotionally unstable Borderline Impulsive Histrionic Anxious Dependent Anankastic
Categories or dimensions? Criteria for categories overlap Individuals meet criteria for more than one category Categorical classification is not valid Personality disorder, like personality, best viewed dimensionally
Dimensions of personality pathology
Severity of personality dysfunction Severe personality disorder Complex personality disorder Simple personality disorder Dysfunctional personality Normal personality
Psychopathy Interpersonally exploitative and controlling Grandiose Glib / superficial Lying Manipulative Failure to accept responsibility Promiscuous Parasitic Emotionally detached, cold and superficial Lack of remorse Shallow affect Callous /lacks empathy Behaviourally impulsive and socially deviant Proneness to boredom Poor behavioural controls Early behavioural problems Lack realistic future plans Impulsivity Irresponsibility Criminal versatility Recall from conditional release
Psychopathy High risk Untreatable Assumptions Treatment increases risk Disruptive & uncooperative
Prison Studies Male prisoners 65% (47% antisocial) Antisocial > paranoid >borderline > obsessive = avoidant = narcissistic Psychopathy 10 30% Female prisoners 42% (25% borderline, 21% antisocial) Fazel S, and Danesh J. Serious mental disorder in 23000 prisoners: a systematic review of 62 surveys. Lancet 2002: 359: p. 545-50. Andersen HS. Mental health in prison populations. A review--with special emphasis on a study of Danish prisoners on remand. Acta Psychiatr Scand Suppl. 2004: 424: p. 5-59.
Homicide UK 10% Shaw J, Hunt I, Flynn S, Meehan J, Robinson J, Bickley H Parsons R, et al. Rates of mental disorder in people convicted of homicide: National clinical survey. British Journal of Psychiatry, 2006: 188:2: p. 143-7. Sweden 50% Fazel S, and Grann M. Psychiatric morbidity among homicide offenders: a Swedish population study. American Journal of Psychiatry 2004: 161: p. 2129-31.
Rates of personality disorder in sexual offenders Longitudinal national birth cohort (Fazel et al. 2007) OR of 30 in sexual offenders compared with general population Paedophilic sex offenders (Raymond et al. 1999) 60% Elderly sex offenders (Fazel et al. 2002) 33% Referrals for specialist residential treatment (Dunsieth et al. 2004) Sexual murderers (Stone 2001, Firestone et al.1998, Proulx & Sauvetre 2007, Hills et al. 2007) 60% 50-90%
Other specific groups Serial arsonists antisocial/borderline Domestic violence antisocial, borderline, narcissistic subgroups Stalkers majority have various types of personality disorders Spree murderers especially paranoid/narcissistic/obsessional
Rates of offending in community samples High rates of offending and violence in individuals with cluster B personality disorders
Why the association? Various traits, individually and combined, are relevant to offending. interpersonal conflict (suspiciousness, hostility, argumentativeness, rigidity, arrogance, clinginess), behavioural dyscontrol angry emotional reactions not considering consequences for self or others taking pleasure in violating rules and others. Personality pathology may lead to inability to form intimate relationships, maintain work, establish a stable lifestyle or meet basic needs, which may predispose to offending. Impulsivity, need for stimulation, intolerance of dysphoric affect and inability to regulate affect predispose to drug and alcohol misuse leading to offending
Personality disorder as a risk factor Hanson and Brussiere (1998), Hanson and Morton-Borgon (2004) Psychopathy, antisocial personality disorder and personality disorder all related to general, violent and sexual recidivism Psychopathy plus sexual deviance is a really bad combination
What leads to violence? PERPETRATOR CIRCUMSTANCES VIOLENT ACT VICTIM
Risk Model Static factors TREATMENT NEEDS LONG-TERM RISK Stable dynamic factors Acute dynamic factors: triggers/precipita nts MONITORING & SUPERVISION Acute dynamic factors: state/context OFFENCE
HCR-20 v3 (Douglas et al. 2013) HISTORICAL FACTORS History of problems with... 1. Violence 2. Other antisocial behaviour 3. Relationships 4. Employment 5. Substance use 6. Major mental disorder 7. Personality disorder 8. Traumatic experiences 9. Violent attitudes 10. Treatment or supervision CLINICAL FACTORS Recent problems with... 1. Insight 2. Violent ideation/intent 3. Symptoms of major mental disorder 4. Instability 5. Treatment or supervision RISK MANAGEMENT FACTORS Future problems with... 1. Professional services & plans 2. Living situation 3. Personal support 4. Treatment or supervision response 5. Stress or coping
Process Gather case information Rate presence and relevance of each item Construct a risk formulation Set out plausible future risk scenarios Make a risk management plan Rate summary risk judgments (conclusory opinions): Future Violence/Case Prioritization Serious Physical Harm Imminent Violence
Management General aspects Based on proper assessment & formulation Get relationships right; mend rifts and ruptures in relationship with you Engagement Validation Sooth core pain Education Treat other disorders Consistency / Constancy / Flexibility Clear goals Deal with crises
Management Psychological treatment Therapeutic community Cognitive behavioural therapy - schema focused Dialectical behavioural therapy Cognitive analytical therapy Psychodynamic psychotherapy Pharmacological treatment antipsychotics antidepressants mood stabilisers
A pragmatic approach Engagement Get relationships right Don t make things worse Intervention appropriate to motivational stage Focus on one issue crucial to risk and one issue crucial to the individual
Useful theoretical frameworks Attachment Schema Psychodynamic Cognitive analytic
Reflective practice issues Transference and counter-transference Team dynamics: within teams and between teams/disciplines/agencies Supervision
Team dynamics What s going on? What is the underlying dynamic? Can you see how childhood, offence and current supervisory dynamics mirror each other?
Childhood attachments Offence dynamics Current supervisory relationships
Anger management?
PSYCHOLOGICAL THERAPY vs. PSYCHOLOGICALLY INFORMED MANAGEMENT
But what about.. Responsibility Punishment Remorse Mental health legislation Calling the police Blame culture Should mental health services get involved?