Briefing - Personality disorder

There are 10 recognised forms of personality disorder and only one of these - severe anti-social personality disorder - is linked to increased levels of violence. These are some of the most common types:

• Paranoid personality disorder - when someone is excessively suspicious of other people.
  
• Schizoid personality disorder - when someone is extremely withdrawn and is not interested in friendships or in social relationships. 
  
• Avoidant personality disorder - when someone is excessively self-conscious, afraid of being challenged, criticised or rejected. 
  
• Obsessive compulsive disorder - when someone is obsessed with orderliness and control, often in work and in relationships. Sometimes people with psychotic conditions will have obsessions or compulsions.
  
• Borderline personality disorder - is associated with the inability to maintain personal relationships, unstable moods and emotions. People with a borderline personality disorder may appear overly argumentative, sarcastic and be quick to take offence while hating being alone. 
  
• Anti-social personality disorder, or psychopathic disorder - when someone is extremely selfish, impulsive, insensitive to other people’s feelings and feels no guilt or shame about actions which harm others.

As with mental illness, there are no tests - like analysing a blood sample to check whether personality disorder is present. Psychiatrists look for signs and characteristics and may use classification systems to help them identify groups of traits as particular disorders. A range of therapies is available for personality disorders, including psychological treatments and drug therapy.
What separates a personality disorder from a personality trait is its unshakeable consistency and resistance to change. In Rethink’s experience, a diagnosis of personality disorder is sometimes given inappropriately to people who:

• Are ‘non-compliant’ or difficult to engage in treatment
• Do not respond to most treatments
• Are difficult to ‘manage’ in settings like a hospital ward
• Are difficult to diagnose.

This is a term invented by British civil servants to describe a small group of people who have a severe personality disorder (usually anti-social PD) and are thought to be dangerous. It is not a medical diagnosis or legal category and few mental health workers accept that it is a real category. Because most people in this group are regarded by doctors as ‘untreatable’ they may not be detained under the Mental Health Act 1983 in certain circumstances.

Through the draft Mental Health Bill, the government is planning to introduce a form of preventative detention for people with a dangerous and severe personality disorder who show a propensity to violence, even though no criminal conviction may have been secured. The exact numbers of people affected by these plans are unknown. The government has decided to pilot and evaluate the assessment process and treatments available for people who have a DSPD before taking final decisions. Pilots are already underway in a number of settings, including: Rampton Hospital, Whitemoor Prison, Frankland Prison and Broadmoor Hospital.

Estimates suggest that several thousand people could be subject to the orders, some of who are presently living in the community, some in prison and some in Special Hospitals. With such a weak understanding of personality disorder, there is concern that some people will be misdiagnosed, shifting between labels, treatments and care plans. Once diagnosed with a severe anti-social personality disorder, there is a danger that a person will be doubly stigmatised and labelled as untreatable.