DSPD or 'Don't Stigmatise People in Distress': Invited commentary on ... Challenges in the treatment of dangerous and severe personality disorder

Working with people who have criminal convictions for endangeringothers is certainly challenging. The place of psychiatric orpsychological intervention is still uncertain but for some people,for example those who have a background of physical or sexualabuse, it seems reasonable to provide them with access to interventionsthat seem to benefit those who do not have such convictions.The dangerous and severe personality disorder (DSPD) systemprovides an environment to do this. However, if it is ever tobe successful in enabling future safe community placements,it has to address issues of stigmatisation.

How has the term ‘dangerous and severe personality disorder’(DSPD) ever found currency in scientific and political circles?Although it is necessary to use diagnostic terms to discriminatefor the purposes of research, teaching, management and publicprotection, such a term, focusing as it does on dangerousness,seems designed to be stigmatising as well. No individual shouldbe summarised by one such characteristic. This makes changeless possible because of the associated invocation of society’sstigmatising attitudes and automatic social exclusion.

Indeed ‘personality disorder’ in itself could andshould be described as a term of abuse. It damns an individual’score being – their personality – as disordered,thus perpetuating and amplifying the abusive experiences thatso many have experienced in childhood. Appleby, before takinghis current position of influence, was co-author of an excellent,thought-provoking paper suggesting personality disorder to bea diagnosis used for those patients psychiatrist’s dislike(Lewis & Appleby, 1988). To add the terms ‘dangerousand severe’ labels the individual inexorably for a lifetimeof ostracism and denigration. As psychiatric diagnoses, DSPDand, broadly, personality disorder lack precision, validityand reliability (Laptook et al, 2006) although this is certainlynot a unique position in current classification systems. Asit becomes clearer that schizophrenia and depression can havefeatures originating in childhood (Schiffman et al, 2004) andcertainly can have enduring effects on relationships, the customarycriteria for ‘personality disorder’ also differentiateless and less. The positive findings of follow-up studies ofpersonality disorder suggest that this is not necessarily alife-long disorder (Zanarini et al, 2003), although some characteristicsmay persist in some people, again as with schizophrenia anddepression.

The government does now seem to be restraining itself from usingthe term DSPD in its legislative forays, gradually retreatingtowards positions of consensus and common sense. But it continuesto be used in the context of the treatment units establishedin its more ‘gung-ho’ days as described by Howells and colleagues (2007,this issue). We have argued that naming is very important inaddressing stigma (Kingdon et al, 2007) in the context of schizophreniaand would argue similarly here. ‘What’s wrong withyou?’ cannot be adequately answered symptomatically with,for example, ‘I experience paranoia’ or ‘Ihave a behaviour disorder’ or even less ‘I havean individualised formulation’, however important thatmay be therapeutically. The group identified for interventionare those who have been convicted by the courts. Many have acombination of criminal behaviour and features of post-traumaticstress disorder (PTSD) (Spitzer et al, 2006). They differ frompeople presenting with PTSD in some ways, generally becausetheir traumatic experiences have been repeated – oftenbecause of accompanying parental neglect – and a moresuitable descriptor for these individuals, as with many describedas having personality disorder, might be either PTSD (repeatedepisodes), i.e. PTSD following repeated traumatic episodes,or what Spitzer et al(2006) call complex PTSD (Box 1).

Box 1 Diagnostic criteria for complex PTSD
Impairment of affectregulation, including impulse dyscontrol and self-destructivebehaviour

Altered states of consciousness, with amnesia anddissociative symptoms

Alterations in self-perceptions, includingintense feelings of guilt and shame

Distorted relations toothers, with isolation and distrust

Somatisation

Alterationsin one’s system of meanings

(Spitzer et al, 2006)

Personality as manifested through temperament and characteris an important consideration in any stress–vulnerabilitymodel of mental and behavioural conditions, probably as themajor mediator of genetic effects, and different aspects ofpersonality can present as strengths or weaknesses, dependingon circumstances. ‘Personality disorder’ is thereforean anomalous, and for the most part unhelpful, term which hasprobably survived because of a reluctance to use a diagnosisof ‘mental illness’ in a group of people who untilrelatively recently did not seem to benefit from psychiatricinterventions. However, this is also due to confusion aboutwhat a diagnosis of ‘mental illness’ may mean andthe mixed messages given – if they are ill, shouldn’tthey be absolved of responsibility for their actions; if bad(or ‘personality disordered’) they should be fullyresponsible. The use of the broader and more neutral term ‘mentalcondition’ might reduce such confusion (Kingdon & Young, 2007).Management issues are not dependent on whether someone is ‘ill’but whether they can benefit from interventions – as isthe case in this instance with complex PTSD. It does not excludebehavioural intervention (e.g. custodial sentences) where protectionof the public is warranted and individuals are given the opportunityto learn from the consequences of their actions.

Gender issues are relevant. Broadly speaking, following similarlife experiences, men present with a combination of complexPTSD, criminal conviction and aggression equating to a diagnosisof antisocial personality disorder; women with borderline oremotionally unstable personality disorder. None of these termsis particularly accurate. People who attract these diagnoses,male or female, can be very sociable and charming individualswho unfortunately include in their repertoire of emotional copingskills activities that involve breaking the law or causing harmto themselves. And ‘borderline’ with what? Thereis certainly overlap with psychosis, merging into a ‘traumaticpsychosis’ (Kingdon & Turkington, 2005) but on a continuum,not just sitting near some arbitrary border. Emotionally unstablelikewise is a strange term for use in classification and soundsquite judgemental – labile maybe, especially when understress, but unstable?

Integrate or separate?

TOP

Integrate or separate?

The location in which treatment is offered is a very importantissue for the individual. It also affects the hospital and prisonstaff who manage them and the patients who are managed withthem. Vulnerability of people with other mental conditions,male and female, needs to be taken into account, as does thesafety of staff. There is therefore a sound basis, as describedby Howells et al, for using separate units for people with combinedcomplex PTSD and criminality for managing risk and providingfocused appropriate intervention. Locating these in both prisonsand hospitals allows for more individualised treatment and canassist in balancing the therapeutic and risk issues.

The argument against separate units is that this involves discriminationagainst a group who are not therefore being treated with theirpeers. This can perpetuate the stigmatisation described aboveand deprive them of access to services available locally intheir community. Balanced against this is that if they remainedin standard prison facilities, treatment would be much moredifficult and if they were transferred to hospital, risk toothers would be more difficult to manage. However, the DSPDlabel will make it more difficult for this group to move oninto local services when they are judged to be ready and thisis a very important practical reason to change the terminology.

Distress deserves treatment

TOP

Distress deserves treatment

Treatment, as described by Howells et al, focuses primarilyon reducing criminal behaviour. This is very understandablein view of the individual’s offences, but work with individualdistress and disability then seems secondary, unlike that increasinglybeing offered, albeit relatively recently, to this group’scommunity counterparts. A case can be made that reducing unacceptabledistress and disability should be the primary therapeutic focus,regardless of where an individual with mental health problemsis situated (Kingdon et al, 2004). Discussing the offences andreducing reoffending will be a part of this broad holistic approachand the latter may – or may not – be a consequenceof it. Developing empathy is an issue but can be easier if theoften very sad past histories of individuals are understood.Management plans need to take full account of the evidence thatthe criminal behaviour is frequently deeply ingrained and althoughchange can occur over time, repetition of such behaviour canbe catastrophic. But, despite this, reduction in distress, overtand covert, is a perfectly reasonable focus whether or not itleads to a reduction in reoffending. The complex PTSD unitsand secure treatment units do seem to be offering this in high-securitysettings but they should be evaluated on treatment as well asoffending outcomes.

Declaration of interest

TOP

Declaration of interest

None.

Footnotes

See pp. 325–332, this issue.

References

TOP