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Epidemiological studies show 30% to 50% of all patients in community mental health teams have personality disorders. These are normally comorbid with other psychiatric disorders, often as Galenic syndromes, and are seldom identified. In the Boston (UK) Personality Project all patients under a community health service in Boston in Lincolnshire will be asked to agree to have their personality status assessed using scales recording the new ICD-11 classification, together with clinical ratings, social function and satisfaction. A control group of 100 patients from an adjacent service of similar demographics (Spalding) will also have similar ratings but no personality assessments. Changes in clinical status, social function and service satisfaction will be made after 6 and 12 months in both groups. The patients in the Boston group will be offered matched interventions using a stepped care approach for both the severity of disorder and its domain structure. These interventions will include shorter versions of existing psychological treatments, environmental therapies including nidotherapy, adaptive and acceptance models, drug reduction and social prescribing. Full costs of psychiatric care will be measured in both groups. The main hypothesis is that greater awareness of personality function will lead to better clinical outcomes and satisfaction.

Purpose To examine the nature of positive and negative environmental change on clinical outcome in 210 patients presenting with anxiety and depression and followed up over 30 years. Methods In addition to clinical assessments, major environmental changes, particularly after 12 and 30 years, were recorded in all patients by a combination of self-report and taped interviews. Environmental changes were separated into two major groups, positive or negative, determined by patient opinion. Results Using a combined measure of clinical and social outcomes positive and negative environmental changes were compared. Positive changes were more likely than negative ones to be associated with a good outcome at 12 and 30 years (39% v 3.6% and 30.2% v 9.1% respectively). Similar greater improvement in accommodation (P = 0.009), relationships (P = 0.007), and substance use (p = 0.003) were found with positive changes at 12 years, and psychiatric admissions P = 0.011 (12 years) and social work contacts (P = 0.043)(30 years) were also similarly reduced. Those with personality disorder at baseline had fewer positive changes (P = 0.018) than others at 12 years and fewer positive occupational changes at 30 years (P = 0.041). Service use was greatly reduced in those with positive events with 50–80% more time free of all psychotropic drug treatment (P

It remains something of a mystery why some individuals behave in persistently malevolent and destructive ways towards their fellows, causing untold harm both to themselves and their victims. This book argues that to understand the roots of antisocial behaviour, one first has to understand what motivates the majority of people to behave prosocially - to think, feel and act in non-malevolent ways. All people are motivated to seek emotion goals - to feel thrilled and excited, to feel safe from the threats of others, to feel a sense of justice, and to feel gratified. However some individuals seek these emotion goals in antisocial ways due to an excess of emotions such as distrust, boredom, greed, vengeance and insecurity. The authors outline interpersonal and neurobiological correlates of antisocial personality, its developmental antecedents, its frequency and pattern across different societies and cultures, and different approaches to its treatment and rehabilitation.

SummaryMany mental disorders are linked to personality, but this is rarely recognised in clinical practice. It is suggested here that when the links are very close, the two can be joined. Galenic syndromes are so named because Galen was the first physician to recognise the links between personality and disease.

Background In England, forensic psychiatric hospital services are provided at three security levels: high, medium and low. All are publicly funded and similarly regulated, but medium and low secure services are provided in the private and charitable (PCS) sector as well as the National Health Service (NHS). Originally, medium secure hospital services were conceived as for up to 2 years' inpatient stay, but numbers of longer stay patients have been rising. Little is known about their characteristics or whether they differ between NHS and PCS settings. Aims To describe and compare characteristics of long-stay patients in NHS and in PCS medium security hospital units. Methods Data were extracted from clinical records in 14 NHS and 9 PCS hospital units for all patients fulfilling criteria for long stay: having been in high security for more than 10 years or medium security for more than 5 years or in a mix of both for more than 15 years in total. Results 178 NHS and 107 PCS patients were eligible for inclusion, respectively, 16 and 22% of the total patient populations in these settings. The mean length of stay in a medium or high secure setting was similar: 163 and 164 months. Characteristics of the patients, however, differed between unit type. NHS services admitted more patients from prison and PCS services more from other hospitals. NHS services included a lower proportion of patients with personality disorder or intellectual disability. 'Challenging behaviour' was more prevalent in PCS; a history of absconding was found more often among NHS patients. Conclusions The two systems of service appear to be used differently. More research is needed to explain why patients apparently without behavioural disturbances remain in specialist secure facilities for such a long time and whether their needs are truly being met in the least restrictive environment possible.

Looking in from the outside, what would the ordinary person expect of forensic mental health services? I suggest that there are three questions he or she would ask: (a) Are there public health measures that can be introduced to prevent those with mental disorder going on to commit crimes? (b) Can we identify in advance the individual who is likely to go on and commit a violent act because of his or her mental health difficulties, and prevent that or limit damage? (c) If a seriously harmful act has already been committed, what interventions might prevent a repetition? All of these questions are about prevention of an untoward event in the future and anticipate knowledge. How secure can we be that current forensic mental health practitioners can make adequately evidenced responses? I fear that examination of current literature would indicate that they and their academic colleagues would fall short of these expectations. Reasons for this are undoubtedly numerous. The issues are complex, with the interplay of many variables from the vagaries of human nature through varying presentations of disorders, still often classified rather than diagnosed, to widely differing environments which, further, may suddenly change in a critical way. The impact of a serious offence can be so catastrophic that officialdom often decides that "something must be done." Yet, without a good evidence base, such decision-making is often ineffective and wasteful of resources. The limited evidence base has not been helped by the virtual extinction of an academic forensic psychiatry infrastructure and funding within British universities and the National Health Service. This does not bode well for the future.

Antisocial personality disorder (ASPD) and psychopathy attempt to represent individuals demonstrating callousness and disregard for others. ASPD has been criticized for capturing a heterogeneous population whilst missing the essence of the diagnosis by neglecting interpersonal/affective deficits which measures of psychopathy include. This heterogeneity in operationalizations has led to diverse findings without clear understanding of what characterizes this broader population. This study sought to clarify the neuropsychological profiles of ASPD and psychopathy. The Cambridge Neuropsychological Test Assessment Battery was administered to 85 adult male offenders in a personality disorder secure service and to 20 healthy controls. Of patients with ASPD, 46% met criteria for psychopathy. Of those with psychopathy, 89% met criteria for ASPD. There were two sets of comparisons: ASPD versus other personality disorders versus controls and psychopathy versus other personality disorders versus controls. ASPD showed deficits across executive functions, visual short-term and working memory, and attention (compared with controls). Psychopathy showed deficits limited to attention, complex planning, inhibitory control, and response reversal. Response reversal and visual search deficits appeared specific to ASPD and psychopathy versus other personality disorders and may underpin antisocial traits. Additional deficits in inhibitory control and working memory appeared to distinguish ASPD from other personality disorders.

We compared psychoeducation and problem solving (PEPS) therapy against usual treatment in a multisite randomized-controlled trial. The primary outcome was social functioning. We aimed to recruit 444 community-dwelling adults with personality disorder; however, safety concerns led to an early cessation of recruitment. A total of 154 people were randomized to PEPS and 152 to usual treatment. Follow-up at 72 weeks was completed for 68%. PEPS therapy was no more effective than usual treatment for improving social functioning (adjusted difference in mean Social Functioning Questionnaire scores = -0.73; 95% CI [-1.83, 0.38]; p = 0.19). PEPS therapy is not an effective treatment for improving social functioning of adults with personality disorder living in the community.

Predicting the likelihood of harm posed by mentally disordered offenders remains controversial. It is proposed that a Bayesian approach may help quantify the uncertainty surrounding such prediction. An example of this approach quantifying the risk of breast cancer in the event of a positive mammogram is provided. Copyright © 2017 John Wiley & Sons, Ltd.

The State Hospital, Carstairs, ScotlandIntroductionIn 1999, the UK government introduced theconcept of dangerous and severe personalitydisorder (DSPD) and established four pilot DSPDservices in high security prisons (Frankland andWhitemoor) and hospitals (Broadmoor andRampton) to develop a process to assess and treatmen meeting certain criteria for dangerousness,personality disorder and risk. The aims of thesehigh security DSPD services were (1) to improvepublic protection; (2) to provide new treatmentservices that improve mental health outcomesand reduce risk and (c) to better understand whatworks in the treatment and management of thosewho meet the DSPD criteria (Department ofHealth, 2005).The DSPD programme was highly controver-sial at inception. It was set up in the immediate af-termath of a horrific murder of a mother and herchild walking home from school. The perpetratorwas an individual identified with antisocial per-sonality disorder who was not properly engagedin any form of treatment programme because hewas regarded as too difficult to help. Although thiswas the immediate precipitant to the introductionof the DSPD programme, it also chimed morebroadly with the Government dissatisfaction withpsychiatry’s failure to provide interventions forthose with personality disorder (believing themto be untreatable) together with a need to protectthe public (Rutherford, 2010). Pressure then grewup to remove what was commonly called the‘treatability clause’ from the Mental Health Act.This clause allowed dangerous people with signifi-cant personality disorder to be spared from com-pulsory admission on the grounds that noeffective treatment was available, and so the newlegislation changed this. As a consequence, dan-gerous people with personality disorder could bedetained in hospital for treatment. This had thedual purpose of providing for a group hitherto de-nied treatment together with protecting thepublicfrom those with this mental disorder.There was also a political motive. Tony Blair,the Prime Minister, had repeatedly said in opposi-tion that any new Labour government would be‘tough on crime, and tough on the causes ofcrime’, and the envisaged programme was an ex-cellent way of demonstrating this. In its 2001Manifesto, the Labour Party declared that it wouldprotect citizens from ‘…the most dangerous of-fenders of all…i.e. those with severe personalitydisorder.’ It was not a policy envisaged by the

The aim of this article was to compare the characteristics and outcome of homicide and non-homicide mentally disordered patients all of whom had been hospitalised. Seventy-four patients with a homicide conviction were compared with 521 convicted of a non-homicide offense. The former group were older, were more likely to be diagnosed with schizophrenia but less likely to have suffered from childhood adversity, and had less criminality. They also had fewer convictions during the follow-up. Little distinguished these two groups with both suffering from multiple disadvantages suggesting the need for ongoing care and support.

Background There is a need for a measure to evaluate change in treatment for offenders with a personality disorder, and the Progress Rating Scale (PRS) was developed to meet this need taking account of multiprofessional input. Method The PRS comprises six process and five non-process items developed via thematic analysis of routine CPA patient treatment reports at a forensic Personality Disorder Service. Rating for items was fully standardized and operationalized with revisions aiming to maximize inter-rater agreement reflecting good face and content validity. Psychometric properties were examined using PRS ratings for 147 patients at three different time points in conjunction with relevant psychometrics. Results Following refinement, the instrument demonstrated good content validity. Intra-class correlations suggested moderate to substantial inter-rater agreement (intraclass correlations: 0.63–0.92). Item analyses indicated good internal consistency for process items (Cronbach's alpha: 0.82–0.88). Correlations with relevant psychometrics revealed meaningful relationships between PRS scores, defence styles and social problem solving. PRS score trajectories were in line with previously known treatment outcomes supporting predictive validity. Conclusion The PRS shows promise as process measure in clinical settings but requires further testing on other samples to confirm initial findings and demonstrate its utility. Copyright © 2015 John Wiley & Sons, Ltd.

Background: Evidence suggests the relationship between personality disorder (PD) and violence in offenders might be clarified by considering sub-groups of PD offenders defined by patterns of PD comorbidity. Aim: to identify patterns of PD comorbidity associated with severe violence, defined by its severity, quantity and age of onset (Violence Index: VI) in a forensic sample of 100 PD offenders. Methods: Correlations were first computed between VI and a range of personality and criminological variables; next, patients with antisocial/borderline comorbidity were compared with other PD patients; finally, regression analysis was conducted to identify unique predictors of VI. Results: The antisocial deviance factor of psychopathy and antisocial/borderline comorbidity were each significantly and independently associated with severe violence. Patients showing both a high psychopathy score and antisocial/borderline comorbidity had a significantly greater VI than those without these characteristics. Conclusion: PD...

Background Ego defences, often considered central to clinical work, have received surprisingly little attention in the forensic literature. Method In this exploratory study, 114 male inpatients completed the Defence Style Questionnaire (DSQ) following their admission to a specialist personality disorder (PD) service. Change in DSQ scores over time was examined using mixed effects models for those (n = 48) remaining in treatment for at least 18 months. Results Defensive functioning at baseline was less mature in comparison with non-clinical norms, with two other non-forensic PD samples, and with a male paedophile sample, but was unrelated to criminal history. Axis II severity was negatively associated with overall defensive functioning (ODF). Antisocial PD was positively associated with a maladaptive defence style. Borderline PD was negatively associated with self-sacrificing defences. Avoidant PD was negatively associated with both self-sacrificing and adaptive styles. Non-completion of treatment was predicted by low ODF scores and high maladaptive defence style scores at baseline. ODF improved significantly over time in treatment and was predicted by strong antisocial and weak schizotypal PD pathologies. Conclusions Defence style, as measured by the DSQ, appears to have the potential to inform assessment and measure change in this group of offenders. Copyright © 2014 John Wiley & Sons, Ltd.

Controversy remains about whether sex offenders can be treated effectively, as shown by recent exchanges in this journal (Hickey, 2012; Ho and Ross, 2012; Mann et al., 2012) and elsewhere (Rice and Harris, 2003; Marshall and Marshall, 2007; Seto et al., 2008; Rice and Harris, 2013). The main areas of disagreement are on quality of evidence and its interpretation. The gold standard for evidence is considered to be the randomised controlled trial (RCT). Having recently completed Cochrane Reviews into psychological and pharmacological interventions for sex offenders (Dennis et al., 2012; Khan et al., 2014), confined to RCTs, we propose to examine the place of such ‘gold standard evidence’ in determining the role of treatment of sex offenders.

Aims and methodWe examined readmission to psychiatric hospital of 550 patients discharged from one medium secure unit over 20 years. Multiple sources were used to obtain readmission data.ResultsReadmission was common, particularly to non-secure psychiatric hospitals. At least 339 patients (61.6%) were readmitted to any psychiatric hospital (mean follow-up 9.5 years), with over a third (37.6%) subsequently being readmitted to medium- or high-security or both. Of those discharged directly to the community, having previous in-patient treatment and a Mental Health Act classification of mental illness were associated with shorter time to first readmission.Clinical implicationsThe long-standing nature of disorders is evident in the high rates of readmission overall and the need for readmission to medium and high secure services, suggesting that these patients require long-term follow-up and support from mental health services.

This case report describes an individual convicted of a violent offence whose complex mental health difficulties appear to be a reason for excluding him from services. During the individual’s admission to a specialised service for personality disorder, a range of structured and semi-structured assessments identified an array of psychological difficulties. Clinical formulation was informed by a contemporary evidence-based typology and suggested that his violence was characterised by anxiety and vengeful/ruminative anger. The fact that the individual’s needs were multiple – including autism, personality disorder, dyslexia and a rare neuropsychological profile – paradoxically appeared to be a reason for mental health services not to intervene, so that he continues to languish in prison. As forensic services in the future are likely to be required to provide for an increasingly difficult clientele, this case highlights not only potential deficiencies in current forensic mental health provision, but the challe...

Background Research suggests that a particular externalising phenotype, manifested in a developmental trajectory from severe childhood conduct disorder through early-onset substance abuse to adult antisocial/borderline personality disorder co-morbidity, may increase risk of antisocial behaviour in general and criminal recidivism in particular. Aim This study aims to test the hypothesis that antisocial/borderline co-morbidity together with the triad of substance dependence, severe conduct disorder and borderline pathology would result in an increased risk of criminal recidivism. Methods Fifty-three men who had been assessed and treated in a secure hospital unit were followed up after they had returned to the community. They were assessed for severity of the following: (i) antisocial personality disorder; (ii) borderline personality disorder; (iii) drug/alcohol dependence; and (iv) high Psychopathy Checklist Revised scores (factors 1 and 2). Results Patients with antisocial/borderline co-morbidity took significantly less time to re-offend compared with those without such co-morbidity. Both Psychopathy Checklist Revised factor 2 and the tripartite risk measure significantly predicted time to re-offence; the former largely accounted for the predictive accuracy of the latter. Conclusion Risk of criminal recidivism can be adequately assessed without recourse to the pejorative term ‘psychopath’. It is sufficient to assess the presence of the three elements of our risk measure: borderline and antisocial personality disorders in the context of drug/alcohol dependence and severe childhood conduct disorder. Practical implications of the study are as follows. (i) Sound assessment of personality, inclusive of a detailed history of childhood conduct disorder as well as adolescent and adult substance misuse, yields good enough information about risk of recidivism without recourse to the pejorative concept of ‘psychopathy’. (ii) Given the high risk of alcohol-related violence in individuals with antisocial/borderline co-morbidity, there is a need for specific alcohol-directed interventions to help such men retain control of their substance use. Copyright © 2013 John Wiley & Sons, Ltd.

Predicting the likelihood of harm posed by mentally disordered offenders remains controversial. It is proposed that a Bayesian approach may help quantify the uncertainty surrounding such prediction. An example of this approach quantifying the risk of breast cancer in the event of a positive mammogram is provided. Copyright © 2017 John WileySons, Ltd.

BackgroundPrevious studies of borderline personality disorder report neuropsychological impairments in several domains, including memory. No studies have compared memory functioning in high-risk prisoners with borderline personality disorder with similar prisoners with other personality disorders.AimsTo explore mnemonic impairments in prisoners undergoing personality assessment as part of the dangerous and severe personality disorder initiative or detained in a medium secure facility.MethodWe investigated memory function in 18 prisoners with borderline personality disorder and 18 prisoners with other personality disorders.ResultsPrisoners with borderline personality disorder exhibited a pattern of multi-modal impairments in the immediate and delayed recall of verbal and visual information, with some association with affective instability. These deficits were not associated with the severity of personality disturbance.ConclusionsThese data suggest that memory deficits have some specificity in relation to the constituent traits of borderline personality disorder and indicate that neuropsychological assessment may be a source of useful adjunctive information for distinguishing between the cognitive and psychological difficulties of individual prisoners.

Background Assessments of personality disorder (PD) by clinicians or researchers are not always congruent with the problems that clients view as most salient. This can result in disagreement over areas for change, leading to dissatisfaction and the risk of treatment attrition. Method The sample comprised 141 treatment-seeking adults with PD. Each described the five things they most wanted to change about themselves. These target problems were compared with PD diagnoses obtained from the International Personality Disorder Examination. Results The congruence between the clients' target problems and PD traits identified by the professionals was generally weak. Disagreement arose where a client's target problem was not a PD trait and, less frequently, where the client and the professional agreed on the presence of a trait but not on its importance. Surprisingly, doubting the trustworthiness of others was the most commonly reported target problem in this treatment-seeking sample even though many such participants did not qualify for that particular paranoid trait. Conclusion Personality disorder diagnoses were generally poor indicators of the problems these clients cited as most important. This lack of correspondence may explain some of the lack of effectiveness of interventions for PD. Copyright © 2012 John Wiley & Sons, Ltd. Key Practitioner Message: The problem that a client with personality disorder (PD) views as most important may only be weakly identified in a formal diagnostic assessment. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, PD traits are insufficient to describe fully the things clients most want to change about themselves. Many clients with PD consider difficulty trusting others to be their most important problem, despite not qualifying for that particular paranoid trait. Risk of disagreement between the clinician and the client might be reduced if both parties can engage in a discussion about the results of any formal diagnostic assessment.

Patients who set fires are a perennial cause of concern with psychiatric services although perhaps rather neglected in the clinical research literature. The current study considered the characteristics on admission of 129 patients, 93 men and 36 women, with a known history of arson who had been admitted to a medium secure psychiatric hospital. The distinguishing characteristics of the sample were high numbers of patients with extensive criminal histories, most probably due to high levels of prison transfer and a higher occurrence of mental illness than psychopathic disorder. Aside from return to prison, most patients were discharged either to another psychiatric hospital or directly to the community. There was a high rate of re-conviction after discharge, mainly for minor offences, with about one in 10 of discharged patients committing arson. It was established, however, that not all incidents of arson led to a prosecution. It is concluded that there are weaknesses in the areas of both risk assessment and evidence-based treatment for arsonists.

Ninety-five patients discharged from a specialist Personality Disorder (PD) service were prospectively assessed for Axis II disorders and Psychopathy. Sequential regression models tested the ability of different conceptual definitions of PD and Psychopathy to predict criminological and psychosocial outcome over a mean follow-up of 4.16 years. Trait definitions of PD modestly predicted criminological outcome. After controlling for age, IQ and PD, time to first reconviction after entering the community was predicted by PCL-R Factors 1, 2, and previous convictions. Psychosocial outcome was predicted by PCL-R with high scores on the affective-interpersonal Factor 1 providing strongest prediction of poor psychosocial outcome.

Objective Outcomes for any mental health service will vary with the characteristics of those admitted as well as with the clinical provision of the service itself. This study aims to explore, for a medium secure forensic service in England, temporal changes in (1) characteristics of those admitted and (2) outcome after discharge and (3) to examine whether such changes are related. Method Baseline characteristics and reconviction outcomes were derived from multiple data sources for 550 first admissions to a medium secure forensic unit for a 20-year period. Time to reconviction was examined using Kaplan–Meier analysis and Cox regression. Results Over time, severity of admissions increased, as did discharges to prison; discharges to non-secure hospitals reduced. Risk of reconviction increased by 3.9%–4.2% for each year of admission from 1983, which was explained by the increased admission of higher-risk patients. Conclusion This medium secure service admitted patients with increasing levels of risk; reoffending rates reflect admission characteristics. Service funding decisions should take account of the characteristics of those admitted. Significant outcomes This study indicates that the profile of patients admitted over a 20-year period increased in severity. Over time, reconviction after discharge occurred earlier after release. This increase in reconviction was explained by the type of patient admitted. Limitations Examination of a cohort from a single medium secure unit limits the generalizability of the findings. The study focuses on a criminological outcome measure (i.e. reconviction); other domains may be equally relevant (e.g. the relief of psychological distress). Examining an entire series of admissions introduces heterogeneity by, for example, considering the outcome of men and women together. Copyright © 2012 John Wiley & Sons, Ltd.

Early-onset alcohol abuse (EOAA) was previously found to both mediate and moderate the effect of childhood conduct disorder (CD) on adult antisocial behavior (ASB) in an American community sample of young adults (Howard, R., Finn, P. R., Gallagher, J., & Jose, P. (2011). Adolescent-onset alcohol abuse exacerbates the influence of childhood conduct disorder on late adolescent and early adult antisocial behavior. Journal of Forensic Psychiatry and Psychology. Advance online publication. doi:10.1080/14789949.2011.641996). This study tested whether this result would generalize to a British forensic sample comprising 100 male forensic patients with confirmed personality disorder. Results confirmed that those in whom EOAA co-occurred with CD showed the highest level of personality pathology, particularly Cluster B traits and antisocial/borderline comorbidity. Those with co-occurring CD with EOAA, compared with those showing only CD, showed more violence in their criminal history and greater recreational drug use. Regression analysis showed that both EOAA and CD predicted adult ASB when covariates were controlled. Further analysis showed that EOAA significantly mediated but did not moderate the effect of CD on ASB. The failure to demonstrate an exacerbating effect of EOAA on the relationship between CD and ASB likely reflects the high prevalence of CD in this forensic sample. Some implications of these findings are discussed.

BACKGROUND: In 1999, the UK government initiated a programme for the assessment and treatment of individuals deemed to have 'dangerous and severe personality disorder' (DSPD). After over 10 years of specialist service development, it is not clear whether DSPD patients represent a distinct group. AIMS: The aim of this study was to establish whether people admitted to DSPD hospital units could be distinguished in presentation or personality traits from people with personality disorder admitted to standard secure hospital services. METHODS: Thirty-eight men detained in high-security hospital DSPD units were compared with 62 men detained in conventional medium or high security hospital units, using the Psychopathy Checklist-Revised (PCL-R) and other standard personality disorder, clinical and offending measures. RESULTS: Compared with their counterparts in standard services, the DSPD group had higher scores on PCL-R psychopathy, significantly more convictions before age 18 years, greater severity of institutional violence and more prior crimes of sexual violence. Regression analysis confirmed that only PCL-R Factor 1, reflecting core interpersonal and affective features of psychopathy, predicted group membership. CONCLUSION: The DSPD group emerged as having higher psychopathy scores, but as there is currently no evidence that the core personality features of psychopathy are amenable to treatment, there is little justification for treating high-psychopathy forensic patients differently from those with other disorders of personality. Copyright © 2011 John Wiley & Sons, Ltd. Language: en

Aim This paper presents a preliminary investigation of dedicated and specialist personality disorder services in three counties within the East Midlands in England (Nottinghamshire, Lincolnshire and Derbyshire). We examined (1) the levels of dedicated National Health Service, independent and voluntary service provisions for people with personality disorder in these counties and (2) the psychological and psychosocial treatments on offer. Method Searches were conducted to identify dedicated and specialist personality disorder services, and senior clinicians within each service were asked to complete a survey about their facility. Results Our findings suggest that dedicated and specialist service capacity within this region is inadequate to meet the needs of both offenders and non-offenders with personality disorder. In addition to this, we found that there is significant disparity in the therapeutic interventions on offer across this region. Conclusion It is likely that similar observations apply throughout England. This suggests that the configuration and accessibility of services for people with people disorder requires a major review if these services are to meet their intended objectives. Copyright © 2011 John Wiley & Sons, Ltd.

It has been argued that some of the difficulties in the Diagnostic and Statistical Manual of Mental Disorders (DSM) personality disorders might be overcome by examining their association with measures of general personality such as the Neuroticism, Extroversion and other Five-Factor Inventory (NEO-FFI) model. The study explored associations between the NEO-FFI and DSM personality disorder in 85 male offenders referred to a personality disorder unit. Although simple correlation showed the expected associations, multivariate canonical correlation revealed more complex and novel associations such as the finding that borderline personality disorder has a more robust conceptual relationship than antisocial personality disorder with the NEO-FFI. Overall, the NEO-FFI can be used to conceptualize most DSM personality disorders. Copyright © 2010 John Wiley & Sons, Ltd.

SummaryThere are many difficulties associated with the diagnostic guidelines for personality disorder in the current international classificatory systems such as ICD–10 and DSM–IV. These lead not only to significant overlap with DSM Axis I disorders, resulting in high rates of diagnoses of comorbidities and multiple personality disorders, but also to lack of adequate capture of core personality pathology. The current classifications are also unhelpful in treatment selection, presumably the prime reason for assessing individuals in the first place. In this article we highlight various deficits and inadequacies related to the nosology of the current systems and suggest some strategies for dealing with these. We offer an integrated model of assessing and diagnosing personality disorders. We attempt to demonstrate how using a more integrated approach minimises or even eliminates some of the key problems highlighted in the current systems.

Background In 1966, Megargee separated individuals with violent behaviour into those who either overcontrolled or undercontrolled their hostility and suggested that this typology might be helpful when considering their treatment. Method We compared the criminological and psychopathological features of those with a single violent offence (SV) and with those who were repeatedly violent (RV). Results Fifty-one violent personality disordered offenders detained in medium- or high- secure care were examined (19 in the SV group and 32 in the RV group). In comparison to the RV group, the SV group were less antisocial and psychopathic and showed greater anger and behavioural control. However, these differences appeared to be due to the undercontrolled nature of the RV group, rather than the overcontrolled nature of the SV group. Conclusion There was little evidence to support an overcontrolled hostility pattern in the SV group in this sample. Copyright © 2010 John Wiley & Sons, Ltd.

Background: Whilst women admitted to secure care are believed to require gender-specific services, there is limited research to inform their provision. Method: Clinical and forensic characteristics and outcomes on 93 women were obtained from multiple data sources and compared with 502 men admitted to the same medium secure unit over a 20-year period. Results: Compared to the men, the women were more likely to have more mental health needs and less criminality. At discharge, women were more likely to be transferred to secure care and less likely to be transferred to prison. Following discharge, the women had a higher rate of mortality. While reconviction rates were similar for the two groups for serious offenses, violent or arson incidents not leading to conviction were more likely for women. The women were more likely to be readmitted, and to be readmitted to high secure care. Conclusion: Despite more favorable criminological characteristics at baseline, our data suggest a poorer outcome for women overall...

Background Specialist treatment programmes for personality disordered offenders suffer from high rates of non-completion. This has important consequences for service providers and individual patients. Method Data from hospital records and the Offenders Index were compared for groups of treatment completers (n = 22) and non-completers (n = 59) discharged from a specialist treatment programme. Results Twenty-seven per cent of patients completed treatment, 37% were expelled for rule breaking and 35% disengaged early from treatment. Psychometric assessments of anger expression and anxiety showed no differences between the groups, however, treatment completers showed lower levels of impulsivity and psychopathy than either of the non-completer groups. Rates of post-discharge offending for grave and standard list offences were 56.8 and 10.8%, respectively. Conclusions Despite careful selection methods, a large proportion of personality-disordered patients admitted to specialist units failed to complete treatment. Psychometric assessments of anger expression, anxiety and impulsivity showed limited utility in differentiating treatment completers and non-completers. Sample size limitations in this naturalistic follow-up impacted on the interpretation of differences observed between the groups on the primary outcome measure of re-offending after discharge. Copyright © 2010 John Wiley & Sons, Ltd.

This study tests the hypothesis that the negative relating of men with a forensic history can be reduced by psychotherapeutic intervention. The Person's Relating to Others Questionnaire (PROQ), a measure of negative relating, was administered to two male forensic therapy samples, one in a medium secure unit and one in a prison therapeutic community. In the first it was given at assessment prior to admission, at three and nine months after admission, and at follow-up, one year after discharge. In the second it was given on admission, after nine months, and after 18 months. There were significant improvements in mean scores on a number of scales in both samples. Over a fifth of both samples demonstrated reliable improvement. In both samples the major improvement in mean scores occurred relatively early in the period of stay, and thereafter the improvement was sustained. In the first sample, it was still apparent at follow-up.

We welcome the opportunity to reply to the criticisms of Ramsay and his colleagues (2009) and to set our work in the context of the assessment and treatment programme for dangerous and severe perso...

The dangerous severe personality disorder (DSPD) programme in England provides high security services for offenders with a personality disorder who have a high risk of re-offending. The cost and economic value of the programme is unknown. The aims of this study were to examine patterns in the service use of prisoners in assessment, to evaluate the cost and outcomes of prisoners in DSPD assessment compared to controls, and to identify the clinical and personal characteristics of prisoners with high costs. Individual-level service use data were collected from prisoner files and individual total costs estimated. Prisoners in DSPD assessment had contact with a variety of professionals and group activities. The DSPD group cost £3,500 more on average than those in the control prisons over six months (£25,150 vs. £21,963; p = .094). There were no significant differences in outcome, although there was a consistent trend for the DSPD assessment group to have worse outcomes than controls. In a cost-function analysi...

Randomised controlled trials are difficult to carry out in high security prisons and very few have succeeded. We describe here a randomised controlled trial of early versus late assessment for the pilot phase of the new DSPD programme for dangerous and severe personality disorder, which assessed prisoners (n = 75) at baseline, then six months, and then one year after randomisation. The trial enjoyed 100% success in getting records and obtained useful qualitative data that helped to explain the findings, but the trial was compromised by repeated protocol violations on grounds that were seldom acknowledged openly but which we conclude were primarily due to ignorance of the purpose of such trials. This led to such contamination of the two arms of the trial that no clear conclusions could be drawn from the trial itself, except that relative costs showed expected differences. However, the trial also showed that the assessment programme was associated with better quality of life in terms of social relationships...

Although the care of forensic patients in the community has been partly taken over by specialist community forensic services (CFS), there are few data assessing their efficacy. The aim of this study was to compare the reconviction rates of patients discharged from a medium secure unit (MSU) either to a specialised community forensic service (CFS) or to a generic service (GS). We compared all patients discharged from Arnold Lodge MSU between 1983 and 2003 to mental health services in Nottinghamshire and Leicestershire, UK, on their rates of reconviction. The clinical and forensic characteristics of the two groups (70 discharged to CFS and 93 to GS) were broadly similar. Median time to reconviction was significantly lower for CFS than for GS (5 and 14+ years respectively, p = .014). Thus, contrary to expectations, patients discharged to the more specialised service had a shorter time to reconviction and this difference could not be explained by the clinical variables measured in the study, other than that t...

Resumen Aunque la evaluacion de cualquier trastorno es esencial para informar al medico de cual es el tratamiento mas conveniente y el pronostico probable, muchos psiquiatras no efectuan de modo apropiado la evaluacion de un trastorno de la personalidad. En el presente articulo se revisan los diferentes metodos de evaluacion y se sostiene que cualquier interpretacion juiciosa de los datos adquiridos necesita la informacion de unos conocimientos adecuados sobre la estructura de la personalidad. Una formacion sistematica con un instrumento semiestructurado proporciona de forma optima estos conocimientos. Si dicha formacion se ofreciera sistematicamente durante los anos de estudio de la especialidad de psiquiatria, el ejercicio de esta profesion mejoraria considerablemente.

The aim of this study was to examine the impact of interpersonal style and psychopathy on treatment non-completion and aggressive behaviour. Participants were patients with personality disorder admitted for treatment to a structured group program operating within a medium secure psychiatric hospital. Assessment of personality disorder and psychopathy occurred prior to admission. Interpersonal style was assessed on admission with the Impact Message Inventory (IMI), a self-report transactional inventory. Files were subsequently reviewed to determine whether patients were aggressive during their hospital stay and whether they were prematurely expelled from the unit and therefore did not complete treatment. Results showed that patients who completed treatment were more nurturing and help-seeking. Aggressive patients were more competitive and dominant. Psychopathy did not differentiate treatment completers from non-completers or aggressive from non-aggressive patients. Clinical implications and opport...

Aims and MethodTo study the views of staff and patients on the use of sniffer dogs to detect illicit drugs and the prosecution of in-patients suspected of taking illicit drugs. A 15-item self-report questionnaire was given to all in-patients and staff who had any contact with patients in a medium-secure unit. Responses to the individual statements were measured on a five-point Likert scale and staff and patients' responses were compared.ResultsWe achieved a response rate of 63% (patient response rate, 71.6%; staff response rate, 60.7%). Overall there were fewer differences than anticipated, although, as expected, staff viewed the impact of illicit drugs more negatively than patients, and on the other hand, patients viewed the use of sniffer dogs and police involvement more negatively than the staff did.Clinical ImplicationsNotice ought to be taken of the discordance between staff and patients' views (particularly in relation to consent and confidentiality) when attempting to detect and manage illicit drug use among psychiatric in-patients.