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