What to look for…

A diagnosis in the file

The first place to start is to identify whether there is already a diagnosis somewhere in the file documentation.

  • In psychological or psychiatric reports, the diagnosis is most frequently found in the Conclusion or Recommendation sections towards the end of the report.
  • Be aware that if a psychiatric report states that there is no evidence of mental illness, this does not necessarily rule out the presence of personality disorder.
  • Other reports which may contain relevant information about personality disorder might include risk assessments, such as the Historical Clinical Risk – 20 (HCR-20), or Structured Assessment of Risk and Need (SARN) which may include sections on psychopathy or PD more broadly.
  • Diagnoses given in childhood such as Conduct Disorder and Attention Deficit Hyperactivity Disorder (ADHD) are often risk factors for developing personality disorder in early adulthood.

Review the offence history

An individual’s offence history provides useful information about their personality functioning, which should be considered in the context of what else is known about the case.

Personality disorder cannot be determined by an individual offence

BUT

  • Diverse offence profiles
  • Entrenched (persistent) offending
  • High levels of instrumental violence
  • High levels of callousness
  • Persistent non compliance
  • Rapid community failure.

…may be suggestive of personality problems

Factors which might be indicative of PD could include:

  • Diverse and entrenched offence histories: Where an individual has displayed a pattern of offending over time, this might suggest personality problems. A diverse offence history may be reflective of a general antisocial orientation and is also a diagnostic feature of psychopathy.
  • A high level of instrumental violence may indicate a sense of entitlement, and a lack of empathy which might otherwise serve to inhibit such acts and is also characteristic of psychopathy.
  • Excessive use of violence or unusually callous offences may also be associated with personality problems. Such offences may arise through a marked lack of empathy, a thrill seeking motivation, emotions which are out of control, or the use of violent fantasy to regulate self esteem.
  • Non compliance or failure: Failures such as breaches, recalls, non-compliance with supervision, and offences while on supervision may also indicate personality problems. Where failure is rapid and/or persistent, personality disorder is more likely. Non-compliance or failure may be associated with an inability to control impulses, or to learn from experience or may simply reflect a conscious and wilful decision not to comply. Evidence of behaviour in custody should also be considered, with particular attention being given to high numbers of adjudications, attacks on staff, ‘dirty protests’, bullying, frequently being placed in segregation and hunger strikes.

A history of contact with Mental Health Services

It has already been suggested that personality disorder should be regarded as a vulnerability factor for experiencing other mental health problems. Consequently, personality disordered individuals are heavy users of mental health services. This may be particularly so for individuals with borderline personality features, who may be more treatment seeking than other personality disordered individuals. Consideration should be given to:

  • Previous suicide attempts or self harming behaviour. This might also include, periods on suicide watch in custody and being subject to Assessment, Care in Custody and Teamwork procedures (ACCT, previously F2052SH).
  • Frequent emotional crises perhaps manifesting in regular contact with Community Mental Health Teams, GP’s or Accident and Emergency departments.
  • Childhood contact with mental health services may also indicate early emotional or conduct problems, which may later develop into adult personality disorder. For example there is a particularly strong relationship between childhood Conduct Disorder and Attention Deficit Hyperactivity Disorder (ADHD) and antisocial personality disorder in adulthood.
  • Detention in secure psychiatric facilities may suggest mental illness, but might also indicate personality disorder. Obviously, if the offender has received treatment in specialist personality disorder facilities (such as the Dangerous and Severe Personality Disorder facilities in the NHS or Prison Service), personality disorder is highly likely to be present.
  • Residence in a Democratic Therapeutic Community (DTC). Although DTC’s were not originally designed specifically as treatment facilities for personality disordered individuals, many of such facilities now either explicitly or implicitly provide services to this group. Where an offender has spent time in a DTC, either in the NHS, or the Prison Service, personality disorder may also be present.

Childhood difficulties

A range of childhood difficulties are associated with the development of personality disorder in later life. These include being the victim of adverse experiences, as well as emotional and behavioural problems during childhood.

  • Although the experience of trauma alone is neither a necessary nor sufficient explanation of the development of personality disorder, individuals with personality disorder frequently report having experienced a range of adverse childhood experiences, examples of which are listed below.
  • It is also important to consider the presence of emotional and behavioural problems in childhood. These symptoms may provide evidence of the early onset of personality problems.

Possible childhood precursors to adult PD

Victimisation: Emotional or behavioural problems:
Sexual abuse Truanting
Physical abuse Bullying others
Emotional abuse Expelled/suspended
Neglect Running away from home
Being bullied. Deliberate self harm
Prolonged periods of misery.