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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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