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Personality disorder and risk to others

Dr Rajan DarjeeBSc(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’

• Appreciation for art, emotion, adventure, unusual ideas, curiosity, and variety of experience.

Openness

• A tendency to show self-discipline, act dutifully, and aim for achievement; planned rather than spontaneous behaviour.

Conscientiousness

• Energy, positive emotions, urgency, and the tendency to seek stimulation in the company of others.

Extraversion

• A tendency to be compassionate and cooperative rather than suspicious and antagonistic towards others

Agreeableness

• A tendency to experience unpleasant emotions easily, such as anger, anxiety, depression, or vulnerability; sometimes called emotional instability.

Neuroticisim

Behaviour

Personality Situation

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

Psychopathy

Personality disorder

Personality

Mental illness

DSM 5 Classification

Cluster A

• Paranoid

• Schizoid

• Schizotypal

Cluster B

• Antisocial

• Borderline

• Histrionic

• Narcissistic

Cluster C

• Avoidant

• Dependent

• Obsessive-compulsive

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

•Grandiose

•Glib / superficial

•Lying

•Manipulative

•Failure to accept responsibility

•Promiscuous

•Parasitic

Interpersonally exploitative

and controlling

•Lack of remorse

•Shallow affect

•Callous /lacks empathy

Emotionally detached, cold and superficial

•Proneness to boredom

•Poor behavioural controls

•Early behavioural problems

•Lack realistic future plans

• Impulsivity

• Irresponsibility

•Criminal versatility

•Recall from conditional release

Behaviourally impulsive and

socially deviant

Psychopathy

High risk Untreatable

Treatment increases risk

Disruptive & uncooperative

Assumptions

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• OR of 30 in sexual offenders

compared with general population

Longitudinal national birth cohort

(Fazel et al. 2007)

• 60%‘Paedophilic sex offenders’

(Raymond et al. 1999)

• 33%Elderly sex offenders

(Fazel et al. 2002)

• 60%Referrals for specialist residential treatment

(Dunsieth et al. 2004)

• 50-90%Sexual murderers

(Stone 2001, Firestone et al .1998, Proulx & Sauvetre 2007, Hills et al.

2007)

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

VICTIM

PERPETRATOR CIRCUMSTANCES

VIOLENT ACT

What leads to violence?

Risk Model

OFFENCE

Static factors

Stable dynamic factors Acute dynamic

factors: state/context

Acute dynamic factors:

triggers/precipitants

LONG-TERM

RISK

TREATMENT

NEEDS

MONITORING &

SUPERVISION

HCR-20 v3(Douglas et al. 2013)

HISTORICAL FACTORSHistory 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 FACTORSRecent 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

• 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

General aspects

Management

• Therapeutic community

• Cognitive behavioural therapy - schema focused

• Dialectical behavioural therapy

• Cognitive analytical therapy

• Psychodynamic psychotherapy

Psychological treatment

• antipsychotics

• antidepressants

• mood stabilisers

Pharmacological treatment

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

Current supervisory relationships

Offence dynamics

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?

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