- Society Guardian
- Wednesday April 17 2002
Personality disorder refers to patterns of behaviour or experience resulting from a person's particular personality that differ markedly from those expected by society and lead to distress or suffering to that person or to others. The government first introduced the term DSPD in a consultation paper Managing Dangerous People with Severe Personality Disorder in 1999, which proposed how to detain and treat a small minority of mentally disordered offenders who pose a significant risk of harm to others and themselves. Specialist services to deal with these people, most of whom are thought to be serious violent and sex offenders, were proposed in the white paper Reforming the Mental Health Act in December 2000.
What are the traits associated with DSPD?
The condition's characteristics have yet to be clearly defined. But it is thought to be an extreme form of antisocial personality disorder (ASPD) - the diagnosis most commonly associated with psychopathy. The key traits of ASPD include failure to make intimate relationships, impulsiveness, lack of guilt, and not learning from adverse experience. 'Psychopathic disorder' is a legal term used in the current mental health legislation to refer to people who have "a persistent disorder or disability of mind... which results in abnormally aggressive or seriously irresponsible conduct."
How many people have DSPD?
The white paper to reform the mental health act states that 2,00-2,400 people in England and Wales are estimated to have DSPD, although some government officials say there are up to 2,500. According to the Home Office, about 1,400 are estimated to already be in prison. A further 400 are estimated to be patients in high security psychiatric hospitals, with between 300 and 600 at large in the community. About 98% of those with DSPD are believed to be men. However, with the new disorder's definition still unclear, many psychiatrists contend these figures are just speculation.
Where will people with DSPD be treated?
By 2004 there will be 300-320 high security places to detain, assess and treat DSPD. The 92-bed unit on D-wing at Whitemoor prison, Cambridgeshire, began assessing prisoners last September, offering treatment from March. Another 80 places will be provided at a newly built unit at Frankland prison, Durham, from early 2004. There will be 140 additional places for those with DSPD in special hospitals by April 2004. A new 70-bed unit at Rampton hospital, Nottinghamshire, is due to open in October 2003. Another unit will be built at Broadmoor hospital, Berkshire. DSPD services will also be set up at medium secure prisons and hospitals and in the community to treat and support those assessed as safe to be released or discharged. Community programmes are expected to be piloted in south London and the north-east.
How is DSPD diagnosed?
Assessment on the DSPD unit at Whitemoor high security prison lasts 14 weeks. Inmates undergo psychometric tests to assess their dangerousness and to measure the severity of their personality disorder. They also have a series of interviews with a psychiatrist, while care staff record how disturbed and challenging their behaviour is from day to day. The clinical team then evaluates whether a connection can be made between dangerousness and severe personality disorder by examining the inmate's past and current offending behaviour and how they interact with other prisoners and staff. Jamie Bennett, head of the Whitemoor DSPD unit, said prisoners would need a long history of sex or violent offences to meet the criteria.
What treatment is there for DSPD?
Inmates at Whitemoor and Rampton receive a psychological therapy called dialectical behavioural therapy (DBT), which aims to help them respond to everyday situations in a problem solving manner rather than emotionally and aggressively. This more positive mindset should enable them to take part in rehabilitation programmes, such as reoffending reduction courses. However, DBT has predominantly been used to treat women with borderline personality disorder who deliberately harm themselves and there is little evidence it will prove effective in helping those with DSPD.
What prompted the DSPD programme?
Much of the impetus for the DSPD programme has come from high-profile cases such as that of Michael Stone, who in 1996 attacked Josie Russell and killed her mother and sister several years after his personality disorder was deemed untreatable. The Home Office regards those with DSPD as "a group hitherto poorly served by criminal justice or mental health services" and believes "the serious nature of the crimes they typically commit has a disproportionate impact on the public's fear of crime." The Mental Health Act 1983 only allows people to be committed to hospital where psychiatrists believe the person is treatable and many do not believe personality disorder is. But proposed reform of the mental health act would allow detention of people with PD - even, in some cases, if they had committed no crime.
How much will the programme cost?
The government has set aside £126m over three years to develop high security, medium security and community DSPD services. The prison service has been allocated £70m and the NHS £56m. Although Home Office officials were unable to estimate treatment costs in high security settings, Dr Ian Keitch, head of DSPD at Rampton, said treatment at the hospital was projected to cost £180,000 per bed per year. Although this is £30,000 more than current treatment costs for patients believed to have DSPD, Dr Keitch said this was less than treatment costs for female self-harmers - £200,000. However, he admitted the cost could not be justified on current evidence. Peter Tyrer, professor of community psychiatry at Imperial College, said a £2m three-year research programme to assess the effectiveness of the treatment programmes, should lead to improved cost efficiency.
Why is the term so controversial?
DSPD currently has no legal or medical basis and many doctors regard it as a political invention. A survey of nearly 1,200 psychiatrists published in the British Journal of Psychiatry in 2000 found almost two-thirds disagreed with the plan for detaining people with personality disorders, and almost a third said they might boycott it. There is no firm evidence base for the disorder or the new assessment and treatment programmes. The Royal College of Psychiatrists says there is no "entirely satisfactory" diagnosis of antisocial traits that threaten public safety. A recent study in the Lancet warned DSPD is so vaguely defined that six people would have to be detained to prevent one from acting violently, raising major concerns about civil liberties.