Useful Information

Admission to the DSPD Programme is based on three factors; risk of serious harm, personality disorder and there being a functional link between the two. A candidate for the DSPD high secure units can be admitted for treatment if assessment confirms that:

• S/he is more likely than not to commit an offence that might be expected to lead to serious physical or psychological harm from which the victim would find it difficult or impossible to recover; and
• S/he has an identifiable severe disorder of personality (defined later) and
• There is an evidential link between the disorder and the risk of offending.

In practice, this means that a person is likely to be suitable if they are very high risk of harm to others on OASys (Offender Assessment System) and have previously been assessed by a psychologist or psychiatrist as having a severe personality disorder or meet several criteria indicated later. The ‘severe’ component will be reflected in a high score on the psychopathy checklist (PCL-R) and /or a diagnosis of two or more personality disorders. The units themselves will determine this.

Treatment is complex and requires a demanding programme of therapy to enable a reduction in potential risks the person poses to other people. It is likely to take a minimum of three years so early identification and referral is essential.

Personality Disorder

Personality disorders are classified using one of two internationally recognised systems: ICD-10 or DSM IV. Diagnosis is based on information held in existing records, clinical interviews and self-report questionnaires. These are not usually applied to young people, as it is believed that personality continues to develop through late teens. Personality disorder is defined as:

“An enduring pattern of inner experience and behaviour that deviates markedly from the individual’s culture.”

DSM-IV identifies three cluster classifications:

Cluster ‘A’ – ‘odd’ or ‘eccentric’

• Paranoid – interpretation of people’s actions as deliberately demeaning or threatening
• Schizoid – indifference to social relationships and restricted range of emotional experience and expression
• Schizotypal – deficit in interpersonal relatedness with peculiarities of ideation, odd beliefs and thinking, unusual appearance and behaviour
  

Cluster ‘B’ – ‘dramatic’

• Histrionic – excessive emotion and attention-seeking, suggestibility, and superficiality
• Narcissistic – pervasive grandiosity, lack of empathy, arrogance, and requirement for excessive admiration
• Anti-social – pervasive pattern of disregard for and violation of the rights of others
• Borderline – pervasive instability of mood, interpersonal relationships and self-image associated with marked impulsivity, fear of abandonment, identity disturbance and recurrent suicidal behaviour and/or other self-harm

Cluster ‘C’ – ‘anxious’ or ‘inhibited’

• Obsessive-compulsive – preoccupation with orderliness, perfectionism and inflexibility that leads to inefficiency
• Avoidant – pervasive social discomfort, fear of negative evaluation and timidity, with feelings of inadequacy in social situations
• Dependant – persistent dependent and submissive behaviour

For a personality disorder to be present, symptoms must be chronic or persistent (continuing for a long time or frequently recurring) and pervasive (affecting numerous areas of their life, for example, social, employment, personal life, etc). They must also cause the individual or those around him or her clinically significant distress or impairment.

The Royal College of Psychiatrists (1999) suggested that ‘severe’ should be defined as “gross societal disturbance” plus “gross severity of personality disorder within the flamboyant group and a personality disorder in at least one other cluster”.

Psychopathy is not, in itself, one of the DSM-IV or ICD-10 classifications. However, high scoring psychopaths present a particularly high risk of serious offending. Hare (1991) describes psychopaths as “grandiose, egocentric, manipulative, dominant, forceful and cold-hearted… they display shallow and labile emotions, are unable to form long-lasting bonds …and are lacking in empathy, anxiety, and genuine guilt and remorse. Behaviourally, psychopaths are impulsive and sensation seeking, and they readily violate social norms. The most obvious expressions of these predispositions involve criminality, substance misuse and a failure to fulfil social obligations and responsibilities.”

Psychopathy should not be confused with “Psychopathic disorder” as defined within the Mental Health Act 1983 as “…a persistent disorder or disability of mind (whether or not including significant impairment of intelligence) which results in abnormally aggressive or seriously irresponsible conduct.” This is a legal rather than a medical definition, which encompasses a range of personality disorders, including psychopathy. The Mental Health Act 2007 amends the 1983 Act to remove the categorisation of mental disorder. The legal category of psychopathic disorder will have no significance after implementation of the 2007 Act, planned for October 2008. Liability for compulsion under the amended Act will depend on clinical evidence of “mental disorder”, defined as “any disorder or disability of the mind”.

Prevalence

Estimates of the prevalence of personality disorder in community samples vary between 4 and 13%. Almost half of people with a personality disorder will have at least one other. However, it is significantly higher in the Prison population – 73% of male remand, 64% of male sentenced and 50% of female Prisoners. The most common is anti-social personality disorder, 63%, 49% & 31% respectively. For men paranoid is the second most prevalent and for women borderline. A small study which included high tariff offenders attending a probation centre found that, where personality disorder was diagnosable, the average was four .

Personality disorder is also more prevalent in substance-misusing populations. Estimates vary, however, in drug services approximately a third of clients have a personality disorder, the most common being cluster B. In alcohol services this increases to just over half of clients with cluster C more prevalent. Assessments need to be undertaken with particular care in these settings as the presentation may be masked or affected by the substance misuse.

Given the high prevalence rates it is clear that the Probation and Prison Services have worked with personality disordered offenders for many years. A significant proportion will not require specific interventions beyond Offending Behaviour Programmes. However, for some, referral to more specialist provision should be considered. These include the DSPD programme, therapeutic communities in Prison and the NHS.

Whilst research indicating what might be effective interventions regarding personality disorder and offending is limited, it is unlikely that the focus will be on ‘curing’ the disorder, rather, finding effective means of managing the effects of the disorder, through targeting offending behaviour, mental health problems and social functioning.

DSPD Assessment Process

The process is intended to assess whether an individual meets the entry criteria and to plan treatment interventions. The criteria for ‘severe’ Personality Disorder are one of the following. This is assessed using the Psychopathy Checklist – Revised (PCL- R) and a DSM-IV diagnosis through the International Personality Disorder Examination (IPDE):

Entry Criteria	Men	Women
PCL-R score	30 or more	25 or more
PCL-R score	25-29 – and one or more personality disorders (PDs), other than antisocial (ASPD)	18-24 – and two or more PDs other than ASPD
Multiple PDs (DSM-IV)	Two or more	At least three

The criteria for risk are based on information gained from the tools outlined below, with the exception of the last two. These are used to form a structured clinical judgement. The table below is intended only to give a brief overview of the tools used in the DSPD assessment process.

Tool	Description	Comments
VRS (Violence-Risk Scale)	Risk assessment in violent offenders	Strong dynamic element supports measurement of change and formulation of treatment plans
STATIC 99	Actuarial tool for measuring risk in sex offenders
HCR-20 (Historic – Clinical – Risk)	Risk assessment in violent offenders	20 fields combine static and dynamic factors – supports the development of risk management plans
VRS-SO (Violence-Risk Scale – sex offender version)	Sex offender version of the VRS	Strong dynamic element supports measurement of change and formulation of treatment plans
Risk Matrix 2000	Risk assessment tool that categories sex offenders from low to very high risk
PCL-R (Psychopathy Checklist)	Used to measure the presence and level of psychopathy in an individual	Tool also proven effective predictor of violence risk
IPDE	Measures personality disorder using DSM-IV (Diagnostic & Statistical Manual of Mental Disorders) or ICD- 10 (International Statistical Classification of Diseases and Related Health Problems) criteria	Use of this tool is a component part of the structured clinical diagnosis of personality disorder
SCID-1 (Structured Clinical Interview for DSM-IV-TR)	Semi-structured interview used to assist clinicians in the diagnosis of axis 1 clinical disorders	Axis 1 includes all mental health conditions except mental retardation and PD

DSPD referrals for men – Probation Area by Region

HMP Frankland	HMP Whitemoor
NORTH-EAST County Durham Northumbria Teesside	EAST OF ENGLAND Bedfordshire Cambridgeshire Essex Hertfordshire Norfolk Suffolk
NORTH-WEST Cheshire Cumbria Greater Manchester Lancashire Merseyside	SOUTH-WEST Avon & Somerset Devon & Cornwall Dorset Gloucestershire Wiltshire
YORKSHIRE & HUMBERSIDE Humberside North Yorkshire South Yorkshire West Yorkshire	SOUTH-EAST Hampshire Kent Surrey Sussex Thames Valley
EAST MIDLANDS Derbyshire Leicestershire & Rutland Lincolnshire Northamptonshire Nottinghamshire	LONDON All areas
WEST MIDLANDS Staffordshire West Midlands Warwickshire West Mercia
WALES Dyfed-Powys Gwent North Wales South Wales

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