Dangerous And Severe Personality Disorder (DSPD)

In 1999 the U.K. government introduced a new concept in relation to personality disorders (which, as we know, are much more likely to occur in individuals who have suffered extreme and repetitive interpersonal childhood trauma) called DANGEROUS AND SEVERE PERSONALITY DISORDER (DSPD) and a treatment and assessment program was developed with the aim of ameliorating this newly constructed condition. In order to be deemed to be suffering from DSPD an individual needs to fulfil the following three criteria:

  1. have a severe disorder of personality.
  2. present a significant risk of causing serious physical or psychological harm from which the individual would find it difficult or impossible to recover.
  3. the risk of offending should be functionally related to the personality disorder.

However, with compassion and insight, Kingdon (2007) argues that in order for any treatment to be effective, the issue of stigma needs to be addressed. Pointing out that the term ‘personality disorder’ itself is already an insulting and abusive term (ironically as those labelled as having a personality disorder have very frequently already suffered from abuse in childhood and hardly need to be abused further) and to add the adjectives ‘dangerous’ and ‘severe’ compound the problem further. Indeed, Kingdon entitles the article in which he expresses this view: ‘DSPD or ‘Don’t Stigmatize People in Distress.’

Indeed, we have seen in other articles that I have published on this site that the diagnosing of a personality disorder is fraught with problems in terms of both reliability and validity (e.g. What Are The Differences Between BPD And Complex PTSD?);  Should BPD Be Renamed Emotional Intensity Disorder?;  ‘Unhappy With BPD Diagnosis? Is Formulation The Answer?; ‘Traumatized As A Child And Wrongly Diagnosed With BPD?’ and ‘Labelling People With BPD May Adversely Affect Their Treatment.’).

According to Spitzer et al. (2006), many of those who have received DSPD treatment have a combination of complex PTSD and a documented criminal history.

Treatments:

Notwithstanding the above, a very eclectic approach has been taken to the treatment of DSPD and therapies that have been trialled in treatment units include dialectical behaviour therapy (this therapy was initially devised to treat those suffering from borderline personality disorder), schema-focused therapy, cognitive behavioural therapy, occupational therapy, cognitive interpersonal therapy (in relation to the treatment of past trauma), mindfulness. Treatment units have also provided psychoeducation (e.g. boundary setting, emotion modulation); the teaching of psychological skills (e.g. social skills, anger management, coping skills, stress reduction and emotional management) and programs to specifically address sexual offending, violent offending and drug/alcohol abuse.

Controversy:

Like other personality disorders, DSPD has no real medical basis and the argument for adhering the label to individuals is based upon circular argument i..e. the person behaves as s/he does because s/he has DSPD and has been labelled as having DSPD due to his/her behaviour (by the way, I write ‘s/he’ and ‘his/her’ although only about 2% of those labelled as having DSPD are female. It has also been pointed out that the UK government brought in the concept of DSPD as a way of legally detaining a tiny section of society whom they previously had no legal way removing from society and for political reasons following some particularly heinous crimes that had attracted a great deal of media coverage. Indeed, recently the initial enthusiasm for the DSPD approach to treatment/incarceration in psychiatric hospitals has been in decline.

Is the treatment effective? 

According to the IDEA (Inclusion for DSPD Evaluating Assessment and treatment) study of four pilot DSPD units, based at Oxford University, in the U.K., formal treatment of DSPD patients lasted, on average, for less than 2 hours per week whilst structured activities occupied approximately nine hours per week. Unfortunately, the study was unable to answer the question as to whether or not DSPD units and the treatment they provided ‘worked’ or not as there was no comparison group of individuals who fulfilled the criteria to be admitted to a DSPD unit for treatment but did not do so. However, some initial conclusions were drawn from the study including that treatment was more successful for single men than for married men; treatment was more successful for those from ethnic minorities; increased treatment time was associated with more positive outcomes.

Insights gained from interviews with recipients of treatment in DSPD units:

  • importance of relationships with staff, especially in relation to consistency of staff behaviour
  • importance of relationships between patients (a problematic dichotomy between vulnerable patients and violent patients was described)
  • however, patients interacting with each other seemed to reduce hostility, though not eliminate it
  • access to telephone, television and papers may reduce hostilities
  • the route through the program and ultimate re-emergence into society was opaque which reduced patient motivation
  • patients receiving the DSPD program in hospital settings was associated with a self-perception of being unwell and entitled to treatment
  • patients receiving the DSPD program imprison settings were much less demanding and had fewer entitlements and less control over their situation. 

Further research:

The study concluded that the only way of determining whether the DSPD program works is by implementing a random controlled trial or, failing that, a case-control trial. Long-term follow-up of patients treated at DSPD units into the discharge period and analyzing their recidivism rates is also necessary, concludes the study.

Reducing patients’ distress:

Kingdon emphasizes that whilst reducing the risk of patients/prisoners reoffending, it is also vital not to overlook the need to reduce their personal distress irrespective of whether the individual is in a hospital or prison setting.

The need for empathy:

Kingdon also recognizes that empathy with the patient is necessary in order for treatment to be helpful and whilst some might find this problematic its development is more likely to occur when one considers the often tragic childhoods patients have endured. Given the importance of staff genuineness and their ability to empathize with, and validate, patients feelings and emotions, such qualities, when selecting staff, may be of greater importance than their technical knowledge.

Ethics:

Given that the DSPD program makes it easier to detain individuals against their will and the difficulty in defining what DSPD actually is it is of ethical importance to assess properly its overall benefits.

 

REFERENCES:

  • Kingdon, D., DSPD or ‘Don’t Stigmatise People in Distress’. Advances in Psychiatric Treatment (2007), vol. 13, 333–335  doi: 10.1192/apt.bp.106.003426
  • Tony Maden, Peter Tyrer. Dangerous and Severe Personality Disorders: A New Personality Concept from the United Kingdom. Journal of Personality Disorders 2003 17:6489-496.
  • Spitzer, C., Chevalier, C., Gillner, M., et al (2006) Complex posttraumatic stress disorder and child maltreatment in forensic inpatients. Journal of Forensic Psychiatry and Psychology,
  • 17, 204–216.
  • IDEA (Inclusion for DSPD Evaluating Assessment and treatment) study

David Hosier BSc Hons; MSc; PGDE(FAHE).