Mark Freestone

Adult antisocial syndrome co-morbid with borderline personality disorder is associated with severe conduct disorder, substance dependence and violent antisociality.

This study tested the hypothesis that syndromal adult antisocial behaviour (AABS) co-morbid with borderline personality disorder (BPD) is a syndrome that emerges from severe conduct disorder (CD) in childhood and adolescence and is strongly associated, in adulthood, with both violence and substance dependence. In a sample of 8 580 community-resident adults screened for the presence of personality disorders, the following predictions arising from this hypothesis were tested: first, that those with AABS co-morbid with BPD would, in comparison with those showing AABS or BPD only, show a high level of antisocial outcomes, including violence; second, that adjusting for co-morbid alcohol dependence would attenuate group differences in many of the antisocial outcomes, and violence in particular; and third, that the AABS/BPD group would show both a high prevalence and a high severity of CD, and that adjusting for co-morbid CD would attenuate any association found between AABS/BPD co-morbidity and violence. Results confirmed these predictions, suggesting that AABS/BPD co-morbidity mediates the relationship between childhood CD and a predisposition to adult violence. The triad of AABS/BPD co-morbidity, alcohol dependence and severe CD is likely associated with the risk of criminal recidivism in offenders with personality disorder following release into the community.

A descriptive evaluation of patients and prisoners assessed for dangerous and severe personality disorder

The Dangerous and Severe Personality Disorder (DSPD) programme was introduced to assess, manage and treat severely personality disordered individuals who present a high risk of serious offending. We describe the clinical and risk characteristics of the first 241 patients admitted to the high-security DSPD service for assessment. Eighty-four percent of patients were regarded as meeting the DSPD criteria. Clinically, the DSPD patients demonstrated high levels of psychopathy, with 78% scoring 25 or more on the Psychopathy Checklist. The most commonly diagnosed personality disorders were antisocial, borderline and paranoid. The risk assessments indicated the DSPD patients exhibited a broad range of risk factors for future offending, suggesting that these patients had extensive treatment needs. The DSPD service had been relatively successful in retaining patients, with 82% of those admitted to treatment remaining within the high-security DSPD service. The clinical mix of the patients may have implications for treatment outcome, and future challenges for the service are highlighted.

Psychiatric diagnosis and differential risks of offending following discharge

Psychiatric diagnosis is not considered a risk factor for offending following discharge. However, treatment interventions and aftercare are strongly influenced by clinical primary diagnosis. We compared differential risks of reoffending of patients falling into six primary diagnostic categories following discharge from Medium Secure Units in the UK: schizophrenia/schizoaffective disorder; delusional disorder; mania/hypomania; depressive disorder; organic brain syndrome; personality disorder. We followed up 1344 patients, on average 6.2 years (SD=2.1) at risk, discharged from 7 of 14 Regional Medium Secure services in England and Wales. Outcomes were period prevalence, incidence, and cumulative probability of criminal conviction. Established demographic and criminal history predictors of reoffending were observed across different diagnostic categories. Risks of all offending were increased for personality disorder, violence/acquisitive offending for delusional disorder, sexual offending for mania/hypomania and violence/acquisitive offending for organic brain syndrome. Patterns of risk over time differed markedly between categories of mental disorder. Most patients with personality disorder who offended violently did so within 4 years of discharge. A subgroup with delusional disorder demonstrated increased risk of violent offending 5 years after discharge. Differential risks of reoffending are observed between different diagnostic groups. Clinical diagnosis should be included together with established risk measures in risk management following discharge. Close supervision of patients with personality disorder should begin immediately after discharge when risks of reoffending are greatest. For delusional disorder further investigation is needed into the marked increase in risk of violence after 5 years.

Commentary on the article by Peter Tyrer and others about the assessment phase of the Dangerous and Severe Personality Disorder Programme

The DSPD (Dangerous and Severe Personality Disorder) Pilot Programme seeks to treat an offender population that has previously not been treated. It also needs to build an evidence base where one scarcely exists, particularly for England and Wales, and relevant research publications are welcomed. In these circumstances, we think that we can offer some further insights into the article by Peter Tyrer and colleagues (Tyrer et al., 2009). Anyone interested in this article would learn more by reading the full report by mainly the same authors, which is published on our website (www.dspdprogramme.gov.uk). It appears there as one of ten research reports or summaries (Tyrer et al., 2007). In some ways, mentioned later, the full IMPALOX report (Tyrer et al., 2007) gives a more rounded picture than the article (Tyrer et al., 2009). We commission research because we want to learn from it, and the IMPALOX research has certainly helped the DSPD Programme to do that. The research highlighted the need for referral and assessment processes to improve – to be quicker and more professional. Much has indeed been done since 2001–2005 (when the research was being conducted in the field). The duration of assessment at Whitemoor Prison, the main location of the research, has dropped from 26 weeks to 16, and now lasts only six weeks in Frankland Prison. As services learn from their practice, training needs have been identified and met, and the assessment process streamlined. More is now done by way of treatment, even during the period of on-site assessment. Thinking about the complete referral and assessment process has moved on considerably. We are actively developing a more seamless approach

Triage, decision-making and follow-up of patients referred to a UK forensic service: validation of the DUNDRUM toolkit

BackgroundForensic medium secure services in the UK are a scarce but essential resource providing care for those in the criminal justice system with severe mental disorder. Appropriate allocation of beds to those most in need is essential to ensure efficient use of this resource. To improve decision-making processes in a UK forensic service, an admissions panel utilized the DUNDRUM 1&2 (D1 & D2) triage instruments.MethodsDemographic, diagnostic and clinical information on a prospective sample of referrals to a UK adult forensic service was gathered (n = 195). D1 and D2 measures were scored by a panel of clinical managers considering referral information and clinician opinion in reaching their ratings; those not admitted were also followed up.ResultsWithin the sample, D1 ratings were predictive of decisions to admit (AUC = .79) and also differentiated between levels of security (F(4) = 16.54, p < .001). Non-admission was not significantly associated with increased risk of offending at follow-up. Items relating to self-harm and institutional behaviour did not show a predictive relationship with the panel decision to admit.ConclusionsUse of a structured professional judgement tool showing good predictive validity has improved transparency of decisions and appears to be associated with more efficient use of resources, without increased risk to the public.

Effectiveness of modified therapeutic community treatment within a medium-secure service for personality-disordered offenders

There is debate as to whether secure hospital treatment for offenders with personality disorder can be effective relative to criminal justice interventions. This study examines the evidence for long-term treatment of such offenders in hospital within in a modified therapeutic community model including accredited offending behaviour programmes. A panel sample of 47 patients were followed up on measures of violence risk (HCR-20, VRS) and symptom severity (SCL90-R). Intention-to-treat analysis with reliability thresholds showed significant positive change between assessment and discharge in both violence risk (VRS) and symptoms (SCL90-R) indicating a positive treatment effect. Threshold effects for treatment effectiveness seemed to occur at 1 year of treatment for risk and 3 years for symptom reduction.

Assessments and admissions during the first 6 years of a UK medium secure DSPD service

BACKGROUND Offenders with personality disorder represent a considerable burden on mental health and criminal justice services. Millfields Unit was one of the pilot medium secure units (MSUs) established by the UK Department of Health and Ministry of Justice to provide dedicated services for such individuals. AIMS Our study aimed to describe a complete cohort of referrals made to the service and to explore decisions on admissions to the Unit. METHODS File review was used to collect a structured data set of information on the first 158 referrals. These were then analysed descriptively and inferentially. RESULTS Previous psychological treatment in prison and evidence of motivation for further treatment were the strongest predictors of admission to the service. People admitted showed evidence of more extensive criminal histories, prior treatment failure and higher level of risk than those accepted into conventional medium secure units. Despite the stated purpose of the units being for people with personality disorder, a high number of patients with a primary diagnosis of psychotic illness were referred. CONCLUSION The new service accepted a high-risk group of people with personality disorder whose needs would not otherwise have been met.

Anxiety disorders and intimate partner violence: can the association be explained by coexisting conditions or borderline personality traits?

Abstract Intimate partner violence (IPV) is a serious, preventable public health problem. IPV perpetration is strongly associated with Anxiety disorders at the population level. We investigated whether the association could be explained by coexisting psychiatric conditions or Borderline personality traits, using a combined data-set of two National Household Surveys (n = 15,973). Results showed women were more likely to report perpetrating IPV than men. Anxiety disorders were associated with IPV. When coexisting psychiatric conditions together with a categorical diagnosis of Borderline Personality Disorder (BPD) were investigated as explanatory variables, 19.2% of the association between Anxiety disorders and IPV was explained. Using individual Borderline traits in place of a categorical diagnosis of BPD, 58.3% of the association was explained. In conclusion, the association between Anxiety disorders and IPV was partly, but not fully, explained by coexisting psychiatric conditions and individual Borderline traits. Perpetrators of IPV should be screened for Anxiety disorders and among those with Anxiety disorders, Borderline traits are important.

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.

External Trigger Factors for Violent Offending: Findings From the U.K. Prisoner Cohort Study

The role of “triggers” for violence is seldom considered when assessing risk of violence in prisoners and forensic patients. A sample of 494 cases from a two-phase study of violent prisoners in England and Wales were rated for presence of acute risk factors and “triggers” occurring before the index offense. Logistic regression was performed to test prediction of acute factors and triggers by preoffense static and stable dynamic factors. Regression models were then built to investigate associations between triggers and violent reoffending post release. Although stable dynamic risk factors were accurately predicted by static actuarial risk, neither were associated with specific violence triggers. An argument with a stranger resulting in violence was associated with future violent reoffending. Violence triggers are highly context-specific but cannot be predicted using existing risk factors. They have a complex relationship with preexisting dynamic factors resulting in future violence.