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Personality disorders are common conditions in society. The diagnostic definition of personality disorder is: ‘An enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment.'
Between 5% and 13% of people living in the community, 40% and 50% of psychiatric in-patients and 50% and 78% of prisoners are diagnosable with a personality disorder (PD).
PD is very often rooted in childhood abuse, deprivation neglect or trauma, which results in an inability to function effectively as an individual or in society. PD is not usually diagnosed during childhood but emerging PD in adolescents is increasingly being recognised. People with PD may present with a range of physical, mental health and social problems such as substance misuse, depression and suicide risk, housing problems, offending and long-standing interpersonal problems.
The most common types of personality disorder are:
Borderline personality disorder, anti-social personality disorder, and emerging personality disorder.
Borderline personality disorder (BPD) is characterized by significant instability of interpersonal relationships and self-image and is associated with substantial impairment.
The cluster of symptoms and behaviour associated with BPD include striking fluctuations in self-perception ranging from over-confidence to self-loathing, a tendency to self-harm and suicidal ideation, uncertain identity, periods of intolerable distress, and occasional brief psychotic episodes. It is present in just under 1% of the population, with greater frequency in early adulthood. Women present to services more often than men.
People with antisocial personality disorder (ASPD) exhibit impulsive, irresponsible and exploitative behaviours, and highly negative emotions. People with antisocial personality disorder have often grown up in fractured and insecure families where their development may have been disrupted and they may have individual, family and community risk factors and a history of childhood conduct disorder. Many people with ASPD have criminal convictions or die prematurely as a result of reckless behaviour.
A history of aggression, unemployment, promiscuity, substance misuse and housing and social problems are more common than serious crimes among people with ASPD. The prevalence in the general population is 3% in men and 1% in women.
Young people with disrupted or abusive childhoods and those who have been placed away from home in care or custody settings are at an increased risk of developing personality disorder in adulthood. There is increasing evidence that intervening early with children and families can reduce this risk. Services for children with emerging PD and their families are at early stages of development and need to be planned in a partnership between child and adult mental health, children’s and youth justice services.
A number of evidence-based approaches are being developed, in line with NICE guidance, including Dialectical Behaviour Therapy and Multisystemic Therapy. Young people with emerging PD can be some of the most vulnerable at transition to adulthood.
A review of early interventions for antisocial personality disorder was commissioned by DH in 2006 (Utting et al). Following this review, cross government agreement was given to fund pilot sites of Multisystemic Therapy to work with young people with severe conduct disorder and their families, including one pilot working with young people with problem sexual behaviour. A Randomised Controlled Trial is currently underway to look at the outcomes of these pilots.
Further details can be found at the following websites:
Fundamental in improving outcomes for people with a personality disorder is the response they receive from staff. There is a great deal of stigma attached to the diagnosis of PD and this often translates to discrimination and exclusion. Staff working with people with a personality disorder can find it difficult to understand and cope with what can be challenging and risky behaviours. In order to address this problem the Department of Health and the Ministry of Justice commissioned a comprehensive training and development programme for personality disorder, the Knowledge and Understanding Framework (KUF).
The key goal of the KUF is to improve service user experience through developing the capabilities, skills and knowledge of the multi agency workforces in Health, Social Care and Criminal Justice who are dealing with the challenges of personality disorder.
Among the most challenging prisoners NOMS and the DH deals with are those with a personality disorder. This is a recognised mental disorder that affects two-thirds of prisoners and a high proportion of cases managed by probation. For a relatively small number, in its most severe forms, it is linked to a serious risk of harm to themselves and to others.
These offenders have highly complex psychological needs that create challenges in terms of management, treatment and maintaining a safe working environment. Challenges are being addressed successfully through the Dangerous and Severe Personality Disorder Programme (DSPD), which is piloting services at HMP Whitemoor, HMP Frankland and for women at HMP Low Newton, in addition to those at secure hospitals Rampton and Broadmoor and in the community.
The units have demonstrated the ability to manage the most difficult offenders safely and constructively, and deliver high quality therapeutic approaches. Although it is too soon to establish the reoffending outcomes of these pilots, evidence is developing that shows a significant decrease in adjudications and violent incidences. Also, the outcome measures used by the units show a steady trend in the direction of risk reduction in this population of offenders.
Following a review of the DSPD Programme and the Labour government’s Bradley Delivery Plan a new cross departmental Offender PD Strategy is being prepared for Ministerial consideration in October 2010.
