PERSONALITY PERSONALITY DISORDER IN DISORDER IN PERPETRATORS OF PERPETRATORS OF HOMICIDEHOMICIDE
Dr Nicola Swinson
Consultant Forensic Psychiatrist
The State Hospital
DEFINITION PERSONALITY DISORDERDEFINITION PERSONALITY DISORDER
Markedly disharmonious attitudes and behaviour Enduring, long standing and not limited to episodes
mental illness Pervasive and clearly maladaptive Appear in childhood/adolescence and continues
into adulthood Considerable personal distress and usually
occupational and social problems
CLASSIFICATION OF PERSONALITY CLASSIFICATION OF PERSONALITY DISORDERDISORDER
ICD10 and DSM V (as IV) remain disparate Categorical : initial generic criteria and specific
criteria for subtypes Clinical utility as medical model Considerable criticism: “atheoretical” and construed
by expert consensus DSM as “Diagnosis for Simple minds” or “Diagnosis
as a Source of Money”
PROBLEMS WITH CATEGORICAL PROBLEMS WITH CATEGORICAL CLASSIFICATIONCLASSIFICATION
Absence of gold standard Poor interrater reliability of subtypes (kappa 0.25-
0.9) Poor agreement assessment instruments Polythetic criteria and substantial ‘comorbidity’
between subtypes Certain subtypes on spectrum with Axis 1 disorders
eg avoidant PD and social phobia Increasing use of PD-NOS
PERSONALITY DISORDER CLUSTERSPERSONALITY DISORDER CLUSTERS
Cluster A : odd/eccentric Cluster B: dramatic/emotional/erratic Cluster C: anxious/fearful Cluster D: inhibited/obsessional
Less overlap, greater adherence basic personality structure and improved reliability
PERSONALITY DISORDER IN PERSONALITY DISORDER IN HOMICIDEHOMICIDE
Prevalence personality disorder in homicideGudjonsson & Petursson (1982): 21.3%Eronen et al (1996): 33% all PDWallace et al (1998): 11% m PDPutkonen et al (2001): 70% f PDFazel et al (2004): 54% subgroup PD
Methodological limitationsPD as homogenous entityVarying assessment proceduresSmall sample sizesNon UK samples
NATIONAL CONFIDENTIAL INQUIRY NATIONAL CONFIDENTIAL INQUIRY UNIVERSITY OF MANCHESTERUNIVERSITY OF MANCHESTER
Collects national data on suicides & homicides by people under psychiatric services since 1996
Recommends changes to practice & policy to reduce the risk of suicide or homicide
BACKGROUND TO STUDYBACKGROUND TO STUDY Detailed clinical data on homicide includes court reports on national
sample of homicide perpetrators
5808 homicides in England and Wales from 1996 - 2006
Diagnosis PD in 16% (n = 406) court reports
Likely underestimate
Clear evidence (history, current presentation) within reports that would fulfil criteria for a diagnosis of personality disorder, but not diagnosed.
AIMSAIMS
Estimate prevalence of personality disorder using a standardised tool.
Examine characteristics of cases in which there is disagreement between report diagnosis and that made using the standardised tool.
Explore potential reasons for the lack of attribution of a personality disorder diagnosis in reports.
QUANTITATIVE STUDY: QUANTITATIVE STUDY: METHODOLOGYMETHODOLOGY
Sample: court reports - 1996 to 2006
Random sample of 600 (3males: 1 female) from 5808 reports
Systematic retrospective analysis using the Personality Assessment Schedule – Document-Derived Version (PAS-DOC, Tyrer et al 2005)
PERSONALITY ASSESSMENT PERSONALITY ASSESSMENT SCHEDULE SCHEDULE (Tyrer and Alexander 1979)(Tyrer and Alexander 1979)
‘Personality-created maladjustment’ as central component
24 personality variables and 9 point scale Scored wrt effect on social function Results presented as 4 domains,13 categories
and dimensional severity scale Good reliability and validity (Tyrer 83,84; Tyrer
& Seivewright 88)
QUANTITATIVE STUDY : RESULTS (1)QUANTITATIVE STUDY : RESULTS (1)PREVALENCE PD IN PERPETRATORS WITH PREVALENCE PD IN PERPETRATORS WITH REPORTSREPORTS
56% (n = 338) diagnosed PD using PAS-DOC
1/4 (n = 83) diagnosed in reports
QUANTITATIVE STUDY : RESULTS (2)QUANTITATIVE STUDY : RESULTS (2)FACTORS ASSOCIATED WITH PD DIAGNOSIS IN FACTORS ASSOCIATED WITH PD DIAGNOSIS IN REPORTSREPORTS
More likely: alcohol misuse (p = 0.02)drug misuse (p = 0.01)previous convictions violence (p < 0.01); threats of violence (P < 0.01); possession of weapon
(p = 0.03)
No associationDemographics: age; gender; ethnicityOther diagnoses, including symptoms at offencePrevious convictions other offences, including sexual
QUANTITATIVE STUDY : RESULTS (3)QUANTITATIVE STUDY : RESULTS (3)FREQUENCIES INDIVIDUAL DOMAINSFREQUENCIES INDIVIDUAL DOMAINS
DIMENSIONAL ANALYSISDIMENSIONAL ANALYSIS
Severe PD: very high externalising + other/aggression/callousness
n = 209 (35% sample; 62% PDs)
Stranger (p= 0.039); Previous violence (p = 0.000);
Previous possession weapon(p= 0.009)
Complex PD: two remaining domains
n = 52 (9% sample; 15%PDs)
Univariate analysis: spouse (p=0.012),family (p=0.015), stranger (p=0.033).
All removed from model in multivariate.
RATIONALE QUALITATIVE STUDYRATIONALE QUALITATIVE STUDY
Substantial discrepancy in proportion diagnosed in reports suggests wider factors influential.
Qualitative methods to explore attitudes and beliefs regarding diagnosing personality disorder.
QUALITATIVE STUDY: METHODOLOGYQUALITATIVE STUDY: METHODOLOGY
Focus groups (3): trainees, clinicians and academics
Semi-structured interviews (16): 8 experienced and 8 new consultants, in person or telephone interviews
Themes generated in focus groups and developed further in semi-structured interviews.
QUALITATIVE STUDY : KEY THEMESQUALITATIVE STUDY : KEY THEMESDIAGNOSTIC PROCESSDIAGNOSTIC PROCESS
Higher threshold for diagnosis; comorbid mental illness; adequacy available information
“Once we have said paranoid schizophrenia often we don’t bother too much about nailing additional PDs…loads of them have significant personality disorders but hidden a bit under the mental illness” (E6)
COURT PROCESSCOURT PROCESS Anxiety giving evidence; interpretation of
diagnosis by court; responsibility to court; role within court“the best interests of the patient has nothing to do with the criminal trial because they are not a patient, they are a defendant” (N4)
“I don’t think it is possible for you to have, in the assessment, a relationship with the defendant which somehow is outside of any form of medical communication because, even if you tell the individual, look I am a doctor but you are not my patient, nothing is confidential, this is all for court purposes and so on, within five minutes they have forgotten all that because your whole being screams doctor, and all the techniques you use, empathy, the communication, it’s all medical”(E4)
RECOMMENDATIONSRECOMMENDATIONS Diagnosis; verdict; disposal
“the PD individual wins on the verdict swings but loses on the disposal roundabout, so he gets diminished responsibility manslaughter but he doesn’t get a hospital order.. they go into prison and at the end of the tariff their risk is unaltered because their disorder has essentially not been treated.”(E1)
“I am not saying that all, you know if somebody has a personality disorder all people need to be in a hospital because they don’t, and I think this is where the severity is relevant - if someone is severe enough to not be able to function well in society, they are probably not going to function well in prison and maybe we should be caring for them”(E7)
TRAININGTRAINING
Inadequate; not standardised; deskilled consultants. Mandatory; standardised instruments; cultural shift.
“we change it by actually making it a mandatory part of continuing professional development that consultants should be able to demonstrate, you know, I have to go on this, a whole list of crap, you know so I know all about fires, do I know how to wash my hands, as a psychiatrist I don’t touch patients, but actually can I make a diagnosis of borderline personality disorder using any reliable criteria, no I don’t have to do that at all. “ (E2)
CLASSIFICATIONCLASSIFICATION
validity and reliability categorical system; support dimensional approach to diagnosis
“I mean all our personalities are different and everybody has one, so that, you know, my logic is that therefore the difference between my personality and someone who is disordered is actually a question of degree not a question of there or not there” (E7)
TREATMENTTREATMENT
lack availability effective treatment; diagnosis to exclude from services; provision of services to increase detection
“I can well see where actually there might be a cognitive bit of slippage in my diagnostic approach in that, confronted with somebody, in an open ward staffed by female nurses and I have got this large violent individual who may have schizophrenia really, but somehow I can’t quite see it today, all I can see is his personality disorder” (E2)
“the thing that really gets people detecting mental disorder in prisoners and stuff like that is not the insistence that you have to screen for it but a feeling that by picking it up you are doing something useful and making a difference really so… . I do think yes if you build the services you will get people making the diagnosis more often” (E4)
METHODOLOGICAL LIMITATIONSMETHODOLOGICAL LIMITATIONS
Retrospective analysis of documents, not interviews
Selection bias within qualitative study Generalisability of themes
CONCLUSIONCONCLUSION
Personality disorder underdiagnosed within court reports
Multifactorial –
individual perpetrator characteristics
attitudes, beliefs and experience of clinician
IMPLICATIONS FOR INDIVIDUALIMPLICATIONS FOR INDIVIDUAL
Increased duration sentence and decrease likelihood parole
Exclusion mental health services Wider issues: custody of children, future
employment and housing
BUT Patients want to be told Increased stigma from not identifying Precluded from further treatment
IMPLICATIONS FOR CLINICIANSIMPLICATIONS FOR CLINICIANS
Highly prevalent and challenging for services Failure to identify doesn’t solve the problem Duty to court in forensic cases Training issues
SYSTEMIC IMPLICATIONS: SYSTEMIC IMPLICATIONS: CLASSIFICATIONCLASSIFICATION
ICD11
1. General monothetic definition PD
2. Severity rating
3. Trait qualifiers: monothetic
detached; dissocial; emotional; anankastic
Diagnosis at any age
SYSTEMIC IMPLICATIONS: SERVICE SYSTEMIC IMPLICATIONS: SERVICE DEVELOPMENTDEVELOPMENT
Controversy over responsibility Some developments within SPS – not standardised
or systematic Other services eg SOLS
Lack available effective treatment and services significant factor in dissuading clinicians from diagnosing PD
Need increased engagement in service planning and delivery, leading to more appropriate and effective service model
THANK YOU