Personality Disorders: Assessment Applied In Forensic Psychiatry / Tulburari de personalitate: metode de evaluare aplicabile in psihiatria forensica - Laura Ghebaur, Carmen Bizdoaca, Claudia Boleac
Laura Ghebaur*, Carmen Bîzdoaca**, Claudia Boleac***
A bibliographic review was completed in order to outline convergences and divergences among different authors about the controversial issue of personality disorders, focusing mainly in antisocial personality disorder. The differences between antisocial personality disorder and psychopathy are highlighted. While anti-social personality disorder is a medical diagnosis, the term “psychopathy” (which belongs to the sphere of forensic psychiatry) may be understood as a “legal diagnosis”. The literature shows an expansion of services for individuals with personality disorders, including offenders. The evidence for the effectiveness of interventions for personality disorders remains limited and the extent to which they lead to a reduction in offending and improvements in long-term outcomes remains uncertain. Evidence supports the inclusion of a dimensional representation of personality disorder in DSM-V, possibly as an adjunct to the traditional categorical classification scheme. A dimensional approach would ameliorate many of the problems associated with the categorical approach. Issues that still need to be addressed are on how to integrate these dimensions into the current classification system in a way that they will be accepted by clinicians and psychopathologists.
Key words: antisocial personality disorder, dangerousness, risk assessment.
Am analizat datele din literatura despre tulburarile de personalitate si am evidentiat aspectele convergente si divergente ale opiniilor diferitilor autori, accordând o atentie speciala tulburarii de personalitate antisociale. Am prezentat deosebirile dintre tulburarea de personalitate antisociala si psihopatie. În timp ce tulburarea de personalitate antisociala reprezinta un diagnostic medical, termenul de psihopatie (care apartine domeniului psihiatriei forensice) poate fi înteles ca un diagnostic juridic. Datele din literatura arata o extindere a serviciilor pentru persoanele cu tulburari de personalitate, inclusiv persoanele delicvente. Dovezile de eficacitate ale interventiilor pentru tulburarile de personalitate ramân limitate, iar gradul lor de reducere a infractionalitatii si masura în care acestea duc la o îmbunatatire a parametrilor pe termen lung ramân neclare. Dovezile stiintifice sprijina includerea unei reprezentari dimensionale a tulburarilor de personalitate în DSM-V, ca o completare la clasificarea categoriala traditionala. O abordare dimensionala va putea ameliora multe dintre problemele generate de abordarea categoriala. Ramân însa de rezolvat problemele legate de modalitatile de integrare a acestor dimensiuni in sistemul de clasificare actual, în asa fel încât sa fie acceptate de clinicieni si psihopatologi.
Cuvinte cheie: tulburarea de personalitate antisociala, periculozitate, evaluarea riscului.
* medic specialist psihiatru, Institutul National de Medicina Legala “Mina Minovici”
**Asistent Universitar Universitatea de Medicina si Farmacie “Carol Davila” Bucuresti, medic specialist psihiatru Spitalul Clinic de Psihiatrie “Al. Obregia”, Bucuresti
*** medic rezident an III, Spitalul Clinic de Psihiatrie “Al. Obregia”, Bucuresti
Personality disorders involve the disharmony of affectivity and excitability, together with impaired integration of impulses, attitudes and conduct, which manifests in the interpersonal relations of the individual. Personality disorders (PDs) viewed as anomalies of the psychic development, in forensic psychiatry, they are considered mental health disturbances. Individuals with PDs are unproductive, when their life history is considered, and over the long term are unable to establish themselves. Their behavior is usually turbulent, their attitudes are incoherent, and their actions are ruled by a need for immediate gratification. Therefore, PDs translate into relevant interpersonal clashes, which occur due to the disharmony of the organization and integration of the affective-emotional life of the individual. On the forensic level, PDs acquire greater importance, since it is not rare for individuals presenting these disorders (especially those presenting antisocial characteristics) to become involved in criminal acts and, consequently, in judicial proceedings.
Worldwide, the incidence of PDs in the general population ranges from 10% to 15% and each type of disorder accounts for 0,5% to 3%.[2,3] Among adult Americans, 38 million present at least one type of PD, corresponding to 14,79% of the population.
This specific type of disorder (PD) is characterized by insensitivity to the feelings of others. When this degree of insensitivity is high, leading marked affective indifference, the individual is apt to adopt a recurrent pattern of criminal behavior, and the clinical profile of the PD takes the form of psychopathy.
There are studies that indicate a lack of neuropsychiatric risk factors for the development of antisocial PDs. Organic factors, such as obstetric complications, epilepsy and cerebral infection, have been investigated. Abnormal electroencephalography findings have also been observed in individuals with antisocial PD who committed crimes. One of the abnormalities most often reported is the persistence of slow waves in the temporal lobes. According to Eysenck and Gudjonsson, who formulated the General Arousal Theory of Criminality , there is a common biological condition underlying the behavioral predispositions of psychopaths. These individuals are likely to be extroverted, impulsive thrillseekers, presenting a nervous system that is insensitive to low levels of stimulation (they are hard to please and are hyperactive in childhood). Therefore, in order to increase their level of stimulation, they participate in high-risk activities, such as crime.
In PDs, genes can be held responsible for the predisposition rather than for the disorder. Consequently, it is essential to consider the environment in which the individual lives, as well as the interaction established with this environment.
The concept of spectrum has been used in order to demonstrate that, according to the environmental interaction, even an individual presenting a determinant gene might not develop the predicted mental disorder or might develop it in a wide spectrum of clinical configurations.
Various studies  have confirmed the existence of genetically-determined personality traits. Studies with monozygotic twins have revealed very similar behavior in terms of personal, social and professional choices, even in individuals raised in different environments. Significant concordance has also been found in the development of PDs, much higher than that found in dizygotic twins. There are still biological aspects that are not of a genetic nature, but that also interfere with the development of the personality. As an example, behavior that is more aggressive can be related to higher testosterone levels. However, increased serotonin levels can generate behavior that is more sociable.
With regard to the interaction between the individual and the environment, special importance has been attached to early relationships, due to their influence on the formation of the individual’s nucleus of personality. It is known that negligence and abuse suffered by a child whose brain is being shaped by experiences create an anomaly in the brain circuits, which can lead to aggressiveness, hyperactivity, attention disorders, delinquency and drug abuse.
To date, psychiatrists have had difficulty in making a diagnosis of PD. This is aggravated by the fact that many psychiatrists manifest disinterest in disorders of this nature. Knowing that pathologies of this type are permanent and refractory to treatment, few psychiatrists consider it worthwhile to provide specialized treatment to individuals with PD. Quite often, a diagnosis of PD is only considered when the evolution of the mental disorder under treatment is unsatisfactory.
The diagnostic evaluation faces worldwide controversy centered on the divergence of opinion between those who believe that conducting open interviews is more valuable and those who believe in administering standardized tests. Although some professionals base their diagnosis on information provided by their patients and direct examination of how those patients manifest emotionally, others prefer to use standardized tests with directive questions. According to Western, the diagnostic investigation of antisocial PD is one that most benefits from structured interviews, because the indices regarding the behavior of the patients with this condition are quite objective.
The complete lifehistory of the individuals examined is investigated in order to determine whether or not the lifetime pattern of behavior is abnormal. No reliable instrument has yet been created for the diagnosis of PD. Consequently, the diagnostic reliability index is low, with a Kappa index of 0,51. Self-administered instruments have proven inefficient in identifying these disorders. The characteristics related to PDs manifest in specific circumstances, when the situations experienced by the subject have such significance that they trigger peculiar reactions, which, in turn, express the latent psychic dynamics. This disposition, however, can interfere in a more or less intense way with the subjective dynamics and with the various types of interpersonal relationships. It is important to consider that PDs can present as a spectrum of psychic dispositions that, to a highly pronounced degree, make it difficult to distinguish them from psychopathies, which do not constitute a medical diagnosis but a forensic psychiatry term. Nevertheless, it is plausible to configure significant pattern differences using data from the Rorschach test and the “cut-off point” of the Hare scale. In cases of psychopathy, the anomalous dynamism has proven to be more extensive, involving the psychic life of the individual in such a comprehensive way that this condition has special importance to forensic psychiatry, especially due to the fact that it presents great affective insensitivity and this would make rehabilitation processes difficult.
According to Hare, psychopaths are fundamentally different from other criminals. The author carried out a study in order to identify parameters that distinguish the psychopathic condition and created a research instrument: the psychopathychecklist-revised (PCL-R) scale. This scale is a 20-itemchecklist with scores ranging from zero to two points for each item, with a maximum of 40 points. The cut-off point is not rigidly established, but a score of over 30 points would characterize a typical psychopathy. The scale comprises the following 20 elements: 1)loquacity/superficial charm; 2)inflated self-esteem; 3)need for stimulation/tendency toward boredom; 4)pathologicallying; 5)control/manipulation; 6)lack of remorse or guilt; 7)superficial affect; 8)insensitivity/lack of empathy; 9)parasitic lifestyle; 10)fragile behavioral control; 11)promiscuous sexual behavior; 12)early-onset behavioral problems; 13)lack of long-term realistic goals; 14)impulsiveness; 15)irresponsibility; 16)inability to assume responsibility; 17)many short conjugal relationships; 18)juvenile delinquency; 19)revocation of parole and 20)criminal versatility.
In a recent study, Morana et al., through the cluster analysis of criminal subjects classified as having antisocial PD, established two types of antisocial PDs: global PD and partial PD. These two types were found to have statistical equivalence with psychopathy and nonpsychopathy as established by Hare et al. The study was carried out using the cut-off point obtained on the PCL-R. The PCL-R score ranges for the forensic population studied were as follows: noncriminal (0 to 12); partial PD (12 to 23); and global PD (23 to 40). The group presenting partial PD, according to their scores on the PCL-R scale, presents a form of the characteriological manifestation that is significantly attenuated in relation to that seen in the psychopath group. The cluster analysis can confirm that partial PD is an attenuated form of global PD.
In the expert-subject relationship itself, it is possible to notice some signs that reveal a disordered personality with antisocial or even psychopathic characteristics. Psychopaths are frequently described as indiiduals who lack empathy. Some authors  have made the following references regarding the (in)capacity of psychopaths to empathize and to have an emotional response:
1)Psychopaths understand the facts very well but do not care.
2)It is as though the emotional processes were a second language for them.
3)They know the words but not the music.
The patients examined can understand what others feel, from an intellectual viewpoint, since their sense of reality does not alter under these conditions, but they are incapable of feeling as normal people do in terms of more differentiated feelings.
Psychological evaluations can be very useful for the diagnostic investigation of PDs. Since individuals presenting antisocial PD are typically manipulative, they might try to choose their words carefully during the expert evaluation, simulating, dissimulating and in short, manipulating their responses to the questions asked. Psychological tests make this manipulation difficult and provide complementary diagnostic elements. Another element that can be very useful in the expert investigation of PDs is conducting interviews with family members, which can reveal important facts regarding the lifehistory of the subject, such facts being essential for the diagnosis.
WHAT ARE DANGEROUS AND SEVERE PERSONALITY DISORDERS?
The British government introduced the term “dangerous and severe personality disorder” (DSPD) in the context of proposals to reform the Mental Health Act 1983. The introduction of this “political diagnosis” was driven by cases involving serious crimes by personality disordered individuals from whom the public, in the government’s view, was inadecquately protected. Concerns have been raised regarding the ethical implications of the detention of personality disordered patients for public protection in light of the dearth of robust evidence of effective interventions for this patient group.
The Planning & Delivery Guide  for DSPD specifies patients with DSPD:
a. is more likely than not to commit an offense that might be expected to lead to serious physical or psychological harm;
b. has a severe disorder of personality; and
c. there is a link between the disorder and the risk of offending.
Severity of the disorder is defined as having a. a psychopathy checklist-revised (PCL-R; psychopathy) score of over 30;
b. a PCL-R score of 25-29 with at least one DSM-IV personality disorder diagnosis other than antisocial personality disorder (ASPD); or
c. two or more DSM-IV personality disorder diagnoses.
There is no agreement in the scientific literature on how to identify those with severe personality disorders. Tyrer and Mulder  note the necessity to identify a group of patients with “complex and severe” personality disorders as the presence of such complexity has a negative impact on treatment outcome. The authors suggest that more severe personality disorders constitute those of different categories, often in more than one of the three DSM-IV clusters, and that the presence of cluster B personality disorders is a further marker of severity. Severe behavioural disturbance, particularly violence, might be another useful indicator to delineate severity of the disorder. Furthermore, high levels of comorbidity with axis I disorders have been identified in violent personality disordered offenders.
“Dangerousness” is the second component in the notion of DSPD. It has been defined as “a propensity to cause serious physical injury or lasting psychological harm”. An association between personality disorders and violent offending has been established in a number of epidemiological studies. In community samples, those with personality disorders are more likely to act violently than nonpersonality disordered individuals , and the prevalence of personality disorders in criminal justice settings is high . Nevertheless, the term “dangerousness” may be misleading as individuals are not “dangerous” per se but rather present as a risk in specific circumstances and towards particular victim groups.
Almost any personality disorder can be associated with violent behavior; however, antisocial, paranoid and borderline personality disorders (BPDs) are particularly pertinent. Stone , analysing a large number of serious violent offenders, further emphasizes the importance of narcissistic traits. Despite the apparent association between personality disorder and violence, the exact nature of this relationship is poorly understood. Howard  has argued that any such link is not a direct one but mediated by early-onset alcohol abuse, which leads to deficits in frontal lobe function and increased impulsivity.
A range of new measures in both criminal law and mental health legislation have been introduced in recent years to address the issue of “dangerousness” in offenders, both with and without mental disorder. Common to the initiatives from criminal justice acts is the shift from a retributive to a preventive detention model, whereby individuals can be released only if a reduction in risk can be demonstrated. Recent developments in mental health legislation have paralleled those in the criminal justice system in that they have extended provisions for compulsory measures. In the UK, the latest reform of the Mental Health Act 1983, which came into effect in November 2008 , adopted a broader definition of mental disorder while abolishing the “treatability test” for personality disorders. This test specified that individuals with personality disorders could be detained in hospital only if the treatment was likely to alleviate the condition or prevent deterioration. Under the new Act, it is only necessary that medical treatment is “available”, regardless of whether it has any benefit to the specific patient. A further significant change in the amended Act is the introduction of compulsory community treatment.
The assessment of individuals with DSPDs consists of a detailed clinical, risk and need assessment. These different elements of the assessment in turn guide the formulation of specific treatment plans.
The clinical assessment of personality disorders has been reviewed by Duggan and Gibbon  and Tyrer et al. . The former authors note three approaches to the assessment: clinical interview, self-report and semistructured interviews. The clinical interview has to be guided by detailed knowledge of traits associated with specific personality disorders and should endeavour to understand the reasons behind the trait identified. Self-report questionnaires are easy to administer but may lack reliability, particularly in forensic populations. Semistructured interviews can be time-consuming and may require specific training. Their use is strongly recommended in the assessment of severe personality disorders in forensic settings. The most commonly used semistructured instruments are the Personality Assessment Schedule (PAS), which derives 13 personality disorder categories, the Structured Clinical Interview for DSM-III-R (SCID-II) for DSM personality disorder diagnoses and the Standardized Assessment of Personality (SAD) and International Personality Disorder Examination (IPDE), which allow for a diagnosis according to DSM or ICD to be made. Even though these schedules provide the interviewer with a detailed structure of the clinical interview, great clinical skill is required when making a personality disorder diagnosis, as the distinction as to whether a particular trait is present or not remains a clinical decision, based not only on information revealed during the interview but also on observation and collateral information. A thorough assessment of axis I disorders, including a detailed drug and alcohol history, should also be conducted.
It is widely accepted that the use of structured risk assessment instruments increases the accuracy of prediction compared with unaided clinical judgement alone. Two main approaches of structured risk assessment tools have been described.  Actuarial assessment tools provide statistical calculations of probability of future violence using algorithms developed on the basis of data from particular samples while excluding clinical judgement. Examples of actuarial risk assessment tools are the Violence Risk Appraisal Guide (VRAG),  which uses 12 static (unchangeable) items, and the Level of Service Inventory (LSI-R), which considers 54 static and dynamic (changeable) factors. Structured clinical judgement instruments, such as the Historical/Clinical/Risk management 20-item (HCR-20) scale,  which includes both static and dynamic risk factors, offer a structure for clinical assessment, but do not provide numerical probabilities of future events. Structured clinical judgements are generally accepted as the best approach to risk assessment in clinical samples, whereas actuarial tools have been criticized for being of very limited use in estimating an individual’s risk of future violence. 
The PCL  was designed to measure psychopathy, but it has also been widely used as a risk assessment tool. The PCL-R has been shown to have good psychometric properties in a wide range of different populations.[34,35] The predictive properties of the PCL-R for both community and institutional antisocial and violent behavior seem to be mainly related to the factor 2 comprising the antisocial lifestyle dimension, as demonstrated in a recent meta-analysis by Leistico et al.
Although the assessment tools described are used purely to predict future behaviour, the more recently developed Violence Risk Scale (VRS)  integrates the assessment of risk, need, responsivity and treatment change in one tool, using 6 static and 20 dynamic variables. The VRS bridges the gap between risk assessment and risk management in that it identifies targets for intervention, which can be measured at regular intervals during treatment. Risk assessment is not a one-off affair but an ongoing process.
DIMENSIONAL MODELS OF PERSONALITY DISORDER
Diagnostic manuals of mental disorders continue to represent the personality disorders in a categorical way, coded as either present or absent. DSM-IV-TR does acknowledge that “an alternative perspective to the categorical approach is the dimensional perspective that personality disorders represent maladaptive variants of personality traits that merge imperceptibly into normality and into one another.” A joint committee of the American Psychiatric Association and the National Institute of Mental Health charged with identifying issues for DSM-V concluded that “there is a clear need for dimensional models to be developed and for their utility to be compared with that of existing typologies.”. They emphasized, in particular, the development of a dimensional model of personality disorder.
The five-factor model of personality is a popular way to conceptualize major personality traits. The five major domains of this model are typically referred to as neuroticism versus emotional stability, extraversion versus introversion, openness versus closedness to experience, agreeableness versus antagonism, and conscientiousness versus negligence. The hierarchical structure of FFM traits (higher order domains and lower order facets) has been replicated across both nonclinical and clinical populations and across cultures. Evidence suggests a heritable and biological basis for both higher order and lower order FFM traits,  indicating that these traits may be important etiological factors with treatment implications. A large number of studies have demonstrated relations between FFM constructs and personality disorders , and most of the personality disorders are associated with elevations on neuroticism, introversion, antagonism and negligence.
Mental health and criminal justice initiatives have been dominated by concerns about risk in recent years demonstrated by a number of legislative and policy documents for public protection from so-called “dangerous” offenders with and without personality disorders. Grounds  stated: “The shift was from having the welfare of the individual patient as the primary purpose and reduction of their risk as a means to that end, to having risk reduction as the primary purpose with welfare as a means to that end.”
Treating PDs, especially those of the antisocial type, still represents a formidable challenge for the forensic psychiatrist. This is not only because of the difficulty in identifying PDs, but also because of the need to advise the justice system regarding the most appropriate place to house patients with this condition and how to treat them.
Personality disorder researchers have begun to formulate ways to combine personality trait information with evidence of distress or impairment in order to help redefine personality pathology and disorder.
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