Severe (Psychopathic) Personality Disorder: A Review

Severe (Psychopathic) Personality Disorder: A Review Kate Moss LLB(Hons); M.Phil; PhD and Herschel Prins M.Phil; Hon LL.D; Hon D.Sc. Midlands Centre for Criminology and Criminal Justice Dept of Social Sciences, Loughborough University, Leicestershire, LE11 3TU. Abstract The development of the concept, causes and management of severe (psychopathic) disorder is reviewed against the current background of government concern about the activities of a small group of individuals alleged to be showing the disorder to a dangerous degree. The authors acknowledge the problems involved in ‘labelling’ the disorder. The term psychopathic has, as we shall demonstrate, a somewhat chequered history. It did not enter UK legislation until the Mental Healthm Act 1959. To this extent, it is a legal term and does not equate to any exact degree with the clinical descriptions currently in use. However, for ease of expression, the term ‘psychopathic disorder’ will be used as a kind of shorthand for variants in everyday use. It is important to note that in this contribution we are only considering those ‘psychopaths’ who have come to the attention of the criminal justice and mental health systems. There are also of course ‘psychopaths’ who, for a variety of reasons have not come to official attention and a recent contribution by Board and Fritzon (2005) highlights some interesting common characteristics in business managers and a sample of forensic patients detained in high security establishments. Key Words Psychopathy, personality, mental disorder, dangerousness, risk. ‘A devil, a born devil, on whose nature nurture Can never stick; on whom my pains humanely taken, all, All lost, quite lost.’ (The Tempest, Act 4, Scene 1.) ‘ What’s in a name? That which we call a rose By any other name would smell as sweet,’ (Romeo and Juliet, Act 2, Scene 2.) ‘If a man will begin with certainties, he shall end in Doubts, but if he will be content to begin with Doubts, he shall end in certainties.’ ( Francis Bacon, 1st Baron Verulam and Viscount St Albans . ‘The Advancement of Learning.’ Book 1, Ch 5, Section 8, 1605.) Introduction The three quotations chosen to preface this contribution illustrate some of the problems that bedevil our understanding and management of the worrying phenomenon of psychopathic disorder. The first, from The Tempest, alerts us to the ever present nature v nurture debate. The second reminds us of problems of nomenclature and the third prompts us to be cautious before embarking on new forms of management before we have better developed information about the condition. The past fifteen years have witnessed an increasing, largely politically and media driven degree of concern with issues of public protection. Such concern has been given high priority in a veritable deluge of statutes supplemented by government circulars of prescription and guidance. Since the Criminal Justice Act 1991, rafts of statutes have made their appearance culminating in the mammoth-sized Criminal Justice Act 2003. In the mental health field, the scope of the Mental Health Act 1983 was broadened with the passing of the Mental Health (Patients in the Community) Act 1995. At the time of writing, a second Draft Mental Health Bill (2004) is now before Parliament. The current proposals to amend the law have had an astonishingly long gestation. (See Prins 2005). Such lengthy gestation no doubt reflects the degree of opposition to the proposals. Over twenty organisations reflecting a wide range of mental health interests have come together to form The Mental Health Alliance representing powerful and influential concerns. Some of these concerns relate to a number of proposals in the Draft Bill, notably the use of compulsory detention for those who might commit dangerous acts and in addition, the likely considerable broadening of the definition of mental disorder. Perhaps most worrying is the exclusion of the ‘escape’ clauses in the 1983 Act in respect of sexual and addictive behaviours. Of great significance in the current proposals is the introduction of a new label – Dangerous Severe Personality Disorder (DSPD). This, it should be noted is a political and not a clinical term and is perhaps the product of the kind of moral panic so ably described some forty years ago by Cohen (1972). It is therefore appropriate to place these concerns in some kind of short historical context. Psychopathic Disorder – A Complex History We make no attempt to provide a detailed historical account of the development of the concept. A very comprehensive history may however be found in Millon et al (2003). Although the nineteenth century French alienists (psychiatrists of today) Pinel and Esquirol and the Englishman Prichard are usually quoted as forerunners in the descriptive field, there is evidence that mental and moral philosophers were taking an interest in the topic well before the nineteenth century. Of course those showing what we would describe today as psychopathic characteristics appear throughout history. For example, the nobleman Gilles de Rais – a contemporary of Jean D’Arc - was a sadistic serial killer of children of both sexes. Vlad the Impaler would probably also be given the label of psychopath today. Shakespeare’s depictions of Richard III and Lady Macbeth might also be so described; the latter’s condition providing a useful illustration of the presence of co-morbidity – that is, possible severe personality disorder accompanied by depression. Today, no doubt, she would be given a dual diagnosis (see Prins 2001). An American academic, Dr Eric Altschuler, of the University of California, cites the Biblical Samson as having psychopathic characteristics. As a child he is said to have shown severe personality disorder ‘setting things on fire, torturing animals and bullying other children’. Altschuler also cites Samson’s mother as a possible pathogenic element in his development. Apparently, in the Book of Judges, ‘she is warned not to drink when she is pregnant.’ He concludes (perhaps somewhat tongue in cheek) that ‘recklessness and a disregard for others may have run in the family’. It is perhaps fair to Altschuler to point out that the triad of enuresis (which is not indicated in Altschuler’s account), cruelty to animals and fire setting have in the past been seen as precursors of later severe anti-social personality disorder. (See The Independent, 15 February 2002 citing an unsourced paper in The New Scientist). To continue with more recent history, reference has already been made to Pinel whose descriptions included a number of cases that would probably not be considered as falling within the category of psychopathic disorder today. Somewhat nearer today’s formulations would be that advanced by the English alienist and anthropologist Prichard with his description of moral insanity. Changes of name are often favoured since it is hoped that they may facilitate changes of attitude. Gunn for example (2003:32) suggests that such changes may make a condition less ‘horrid and worrying.’ He adds that ‘Perhaps the concept is a bit like that of ‘the privy’, the ‘water closet’, ‘the lavatory’, ‘the toilet’ or the ‘rest room.’ (See also our later discussion of the hoped for results of further name changes). Prichard (1835:85) described his concept of moral insanity thus: a madness, consisting of morbid perversion of the natural feelings, affections, inclinations, tempers, habits, moral dispositions and natural impulses, without any remarkable disorder or defect of the intellect or knowing or reasoning faculties, and particularly without any insane illusion or hallucination. (Emphasis added). In considering this quotation, we should note that ‘moral’ meant emotional and psychological and was not intended to denote the opposite of ‘immoral’ as used in modern parlance. This view of ‘moral insanity’ rested on the then, fairly widely held, controversial belief that there could be a separate moral sense that could, as it were, be diseased, however these views need to be seen against the background of the very rudimentary state of psychiatric and psychological knowledge during his lifetime. This notion does find resonance in Cleckley’s (1976) postulation that psychopathy was actually a form of ‘illness’. In 1891, Koch formulated the concept of constitutional psychopathy, implying that there was a considerable innate predisposition; a line of thinking much in keeping with the [then] contemporary interest in hereditary factors in the causation of delinquency. It is interesting to note a recent return to this in the study of neuro-physio-psychological processes in the causation of persistent deviancy. (See for example, Dolan 1994, Blair & Frith 2000 and Spence et al 2004). In the early 1900s the terms ‘moral defective’ and ‘moral imbecile’ found their way into the Mental Deficiency Act of 1913 (subsequently replaced by less pejorative descriptions in an amending Act of 1927). Explorations in the 1930’s were of importance. Findings from the disciplines of neurology and physiology were being applied to behaviour disorders – prompted no doubt by the behaviour disordered consequence of the widespread epidemics of illnesses such as encephalitis. Freudian perspectives were also being applied to deviant behaviour as evidenced by the work of psycho-analytically orientated medical and non-medical professionals such as Melitta Schmideberg; Kate Friedlander, Anna Freud, August Aichorn, George Lyward and Otto Shaw, all of whom were interested in the possible childhood roots of serious anti-social behaviour. For an interesting compilation of work in the thirties and forties in this field, see Eissler (1949). In 1939, Sir David Henderson – a distinguished British psychiatrist – published his famous work Psychopathic States. He considered (1939:19) that the psychopath’s ‘failure to adjust to ordinary social life is not a mere wilfulness or badness which can be threatened or thrashed out…but constitutes a true illness.’ The later work of Lee Robins (1966) is also seminal as are those by Bowlby (1979) and Rutter (1999). Since the 1960’s attention has been focused on the management of adult psychopathically disordered individuals within institutional settings, notably those adopting a therapeutic community or ‘social milieu’ approach. Figures in this field include psychiatrists such as Maxwell Jones (1963), Whiteley (1994) and Campling (1996). In summarising the foregoing, it is possible to trace three important themes in the development of the concept. The first as Coid (1993) has suggested, was the concept of abnormal personality as defined by social maladjustment – developed in France and later in the UK – leading to the current and somewhat contentious legal definition of psychopathic disorder (of which more later). The second was the concept of mental degeneracy, also originating in France. The third was the German notion of defining abnormal psychopathic personality types, as illustrated in the work of Schneider (1958). In addition, the concept has not been without attention from central government over the years. It was considered by the Butler Committee as long ago as the early 1970’s (Home Office & DHSS 1975), subsequently in a joint DHSS and Home Office Consultation Document (1986); by the Reed Committee (Department of Health & Home Office 1994) and most recently in the joint Home Office & Department of Health policy document concerning DSPD (1999). The topic was further considered by the Fallon Committee (1999) in its inquiry into the Personality Disorder Unit at Ashworth Hospital, Volume II of which contains extensive expert evidence on the nature of personality disorder. A representation of the stages through which the concept has passed is provided in Figure 1. Fig 1. From Pinel (1806) to the Home Office and Department of Health (1999) Manie sans delire (madness without delirium or delusion) ___moral insanity__ moral imbecility (defectiveness) Mental Deficiency Act 1913___(constitutional) psychopathic inferiority ___‘neurotic character’ ___psychopathy ___ sociopathy (USA) ____anti social personality disorder (DSMIV) ____ dissocial personality disorder (ICD10) ____dangerous severe personality disorder (Home Office & Dept of Health). Causes and Characteristics There is a vast literature concerning the postulated origins of psychopathic disorder and an equally vast literature on its characteristic features. No attempt is made here to review this literature at great length, merely to address certain aspects of it as a prelude to some discussion of the problems of management. Postulated origins have included genetic and hereditary factors and close familial and environmental influences. Coid, (1989:756) advocates caution in espousing the notion of psychopathic disorder as a single entity and suggests that; The sheer complexity and range of psychopathology in psychopathic disorder has previously led to the suggestion that these individuals could be considered to suffer from a series of conditions that would best be subsumed under a broad generic term ‘psychopathic disorders’ rather than a single entity. In recent times, interest has been revived concerning possible ‘organic’ causes, including both major and minor cerebral ‘insults’ in infancy and the consequences of obstetric complications. If such developments subsequently prove to have unequivocally firm foundations, one could envisage a situation where issues of responsibility (and notably diminished responsibility) may well have to be addressed by the courts. This is an arena already fraught with problems concerning the relationship between medicine (particularly psychiatry) and the law. See Spence et al. (2004). It has also been suggested that the environment plays a significant part in the aetiology of the disorder. It may well be that as with other mental disturbed states such as the schizophrenias, it is the interplay of social forces and pressures acting upon an already vulnerable personality (arising for whatever reason) that may tend to produce the condition. Some of the highly complicated and sophisticated neuro-physio-chemical research undertaken in recent years fosters speculation that some of the answers to the problem of aetiology may well be found in the area of brain structure and biochemistry. Other possibilities are of equal interest. For example, one cannot ignore the evidence, admittedly laboratory-based, of such factors as low anxiety thresholds, cortical immaturity (childlike patterns of brainwaves in adults), frontal lobe damage and perhaps most relevant of all, the true (as distinct from the wrongly labelled) psychopath’s need for excitement – the achievement of a ‘high’. Such a need is described graphically in Wambaugh’s (1989) account of the case of Colin Pitchfork. Pitchfork was convicted of the rape and murder of two teenage girls in Leicestershire during the period 1983-1986. In interviews with the police, it is alleged he stated that he obtained a ‘high’ when he exposed himself to women (he had previous convictions for indecent exposure prior to his two major offences). He also obtained a ‘high’ from the knowledge that his victims or likely victims were virgo intacta. He is said to have described an additional aspect of his excitement, namely obtaining sex outside marriage. As with others assessed as psychopathic, he also demonstrated a great degree of charm; for example, he was able to get his wife to forgive him for a number of instances of admitted unfaithfulness. (Pitchfork’s case is also of interest in that it involved the earliest attempts to use DNA profiling – a practice now fairly routine). Whether this disorder is inherited, acquired through some learning process or due to other neurophysiologic factors, whether organic or trauma induced, is unknown at this time. It is suggested that the characteristics of SPD individuals might be capable of modification by the environment so that whilst some can be found at the most severe end of the spectrum of personality disorder, possibly engaged in crime or certainly having come to the attention of the criminal justice system in some way, others manage to live in a relatively normal and certainly law abiding way though they still make the lives of those around them miserable. The following brief notes may be helpful. A more extensive analysis of the current possibilities in relation to the genesis of SPD can be found in Millon et al (2003). It is worth emphasising that in terms of causation, the last decade has seen an increase in the number of likely postulations regarding the causal factors in relation to SPD. This must in part, be due to advances both in medical technology and in terms of a developing willingness on the part of society to accept that there may be a multiplicity of explanations for this complex condition. The reader is cautioned that what follows is neither an exhaustive nor definitive list. The Biochemical-Neurophysiologic Approach and the Limbic System It is a relatively recent suggestion that SPD might be caused by alterations of, or abnormalities in the normal chemical processes of the brain which in turn may adversely affect the motivational processes that guide thoughts and perceptions. Such alterations of the normal chemical processes of the brain, or brain activity can result from brain diseases such as cancer, nutritional deficiencies, brain injury, pollutants (such as lead) and even hypoglycaemia. In many instances such brain damage goes unnoticed since the brain has an innate capacity to compensate itself for damaged areas. This appears not to be the case however, where the limbic system is concerned. The limbic system is located in the upper brain stem and lower cerebrum portion of the brain. It is thought to be directly involved with brain processes relating to motivation and aggression. When the limbic system is damaged it can result in a person presenting with uncontrollable rage and violence. Such damage can be organic (such as the viral infection rabies which specifically attacks the limbic system) or alternatively non-organic resulting from brain injury or trauma. This approach is relatively new and unique since it moots the possibility that a person’s behaviour can be explained without necessarily having to refer to provocation by an external event. The Cerebral Cortex To date there has been relatively little systematic study of psychopathy from a neurobiological perspective. This is probably due to two reasons. First, since we have already mentioned that psychopathy as a term is controversial and difficult to define, it follows that empirical research regarding such a broad and ill-defined term is difficult to carry out. Second, studying the neurobiology of cohorts of psychopaths is difficult because a great many psychopaths will never find themselves in a clinical psychiatric setting. This said, since the work of Cleckley (1976) and Hare et al (1990) the development of a research scale (or Psychopathy Checklist ) now known as the PCL-R, has shown that valid and reliable research can indeed be carried out to predict recidivism in criminal populations. This is done using a two-factor structure consisting first, of personality traits such as glibness, lack of remorse and failure to accept responsibility and second, anti-social traits and aggression. In this context the possibility of adopting a neurobiological approach to psychopathy is possible. Neurobiological underpinnings to this condition have been furthered in the findings of studies of the cerebral cortex using the electro-encephalogram or EEG. These have tended to show that the ‘slow wave’ activity of the brain of some aggressive psychopaths bears some degree of resemblance to the EEG tracings found in children. Such findings have led to the formulation of a hypothesis of cortical immaturity which may explain why the aggressive behaviour of some psychopaths seems to become less violent with advancing years because, as is the case with children, the brain matures. Heredity It is by now fairly well established that some types of behaviour run in families. Notwithstanding this, the nature v nurture debate goes on. However, as McGuffin and Thapar (2003:215) report: ‘The evidence pointing to a genetic contribution to antisocial personality comes from three main sources.’ These are first, studies on animals which point to a genetic component to some temperamental features such as aggression; second, genetic research in relation to twins which have suggested that certain traits (including antisocial ones) are hereditary and third, studies of criminality within families which indicate an hereditary component to both juvenile delinquency and adult antisocial conduct. More recently the study of molecular genetics is furthering understandings of the biological bases of inherited personality traits. One of the difficulties regarding the application of genetics to this area of study is that it remains uncertain as to whether psychopathy is a ‘discrete entity’ or whether it is a continuum of behaviour ranging from the blatantly pathological to the normal. We would suggest that the latter is more likely but given the difficulty of defining this condition the application of research in relation to it remains uncertain and problematic. The study of molecular genetics may provide more certainty in the future. Notably the work of Brunner et al (1993) has gone some way in identifying a genetic marker associated with aggression which has helped to further understandings of seriously violent, unprovoked behaviour in some individuals. However, these conditions are rare and it remains difficult to generalise such findings to a wider population. Cortical Under Arousal Research in the field of neurobiology has also suggested that psychopathy may be linked with a defect or malfunction of certain brain mechanisms concerned with emotional activity and the regulation of behaviour. More specifically cortical arousal refers to the situation where the brain is wide awake, attentive to stimulation and working at its maximum. Conversely, low cortical arousal refers to a lack of attention, tiredness and lack of interest. It has been suggested that psychopathy may be related to a lowered state of cortical excitability and to the attenuation of sensory input, particularly input that would, in ordinary circumstances, have disturbing consequences. This may partially explain the apparent callous and cold indifference to the pain and suffering of others which is demonstrated by some seriously psychopathically disordered individuals. This may also go some way to explain why certain psychopaths (particularly the seriously aggressive), may seek stimulation with arousing or exciting qualities and have reported that they derive a ‘high’ from their actions. McCord (1982:28) states that ‘most psychopaths do not see security as a goal in itself; rather they crave constant change, whirlwind variety and new stimuli.’ Further, he suggests that Ian Brady and the late Myra Hindley illustrated the psychopath’s craving for excitement since the ways in which they behaved were ‘simply ways to attain new levels of excitement, a new ‘consciousness’ and a temporary escape from boredom.’ This craving may render the psychopath unaware of many of the more subtle cues required for the maintenance of socially acceptable behaviour and for adequate socialisation. Inability to Learn / Inconsequentiality It has been postulated that since human behaviour is flexible and not fixed, that both criminal and non-criminal behaviours stem from the same general social-psychological processes and that as such, many types of behaviour are learned, specifically through association with others. In the case of psychopathy however, it has been tentatively suggested that these individuals do not possess the same ability to learn what may be regarded as socially acceptable behaviour and in particular find it difficult to learn responses that are either motivated by fear or reinforced by fear reduction. There is experimental evidence to suggest that psychopaths are correspondingly less able to make connections between past events and the consequentiality of future behaviour. Long Term Substance Abuse It should be noted that the effects of long term substance abuse often bear a close resemblance to SPD. Such secondary personality disordered individuals can usually be distinguished from true or primary personality disordered individuals by the presence of anxiety or guilt in the secondary group. This can normally only be distinguished by qualified medical clinicians since the PD individual will demonstrate highly manipulative behaviour making this distinction hard to make. The close interrelationship between psychopathy and substance abuse has been acknowledged for some time and issues of co-morbidity are ever present for researchers involved in clinical studies. A prospective longitudinal study carried out by Knop et al (1993) in which an experimental cohort of 255 children with alcoholic fathers was identified, followed the children’s development until the age of thirty. At the conclusion of the study the social functioning of the group with substance dependence and/or APD was significantly poorer than that of all other diagnostic groups. It may therefore be possible to use this type of research to predict those individuals who may be at a higher risk of developing substance abuse disorders and/or APD later in life. What we do know is that those suffering from (or, to be more precise, making others suffer from) it are extremely difficult to work with and manage. Mann and Moran (2000:11) put the matter into perspective rather well when they state: Sadly, when looking for evidence to inform decision-making about the placement of personality disordered patients, our knowledge is lacking. Psychiatry has an unfortunate history of being characterized by opinions rather than facts, and in this regard, both the government and psychiatrists need to stand back from firm decisions until more is known …[they continue] … the whole diagnostic group of personality disordered patients is being judged by the difficulties and anxieties caused by one-sub-group (the so-called ‘severely personality disordered’). A sense of proportion is required. A Note on Personality There have always been difficulties in defining personality with any degree of consensus; it is a word used in a common parlance to cover a variety of attributes and behaviours. Trethowan and Sims (1983:9) offer the following statement: Personality may be either considered subjectively, i.e. in terms of what the [person] believes and describes about himself as an individual, or, objectively in terms of what an observer notices about his more consistent patterns of behaviour… Personality will include such things as mood state, attitudes and opinions and all these must be measured against how people comport themselves in their social environments. If we describe a person as having a ‘normal’ personality, we use the word in a statistical sense indicating that various personality traits are present in a broadly normal extent neither to gross excess nor extreme deficiency. Abnormal personality is, therefore, a variation upon an accepted yet broadly conceived, range of personality. When we consider what Trethowan and Sims (1983) describe as the extremes of personality, the two definitions of personality disorder as given in the DSMIV (Diagnostic and Statistical Manual of Mental Disorders) and ICD (International Classification of Disorders) amplify these. The DSMIV defines them as: An enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early childhood, is stable over time, and leads to distress or impairment. (As quoted in N.I.M.H.E. for England 2003:9) The ICD defines personality disorder in the following terms: A severe disturbance in the characterological condition and behavioural tendencies of the individual, usually involving several areas of the personality, and nearly always associated with considerable personal and social disruption. (Op.Cit.) (See also Tyrer et al 2003) Both these definitions indicate that personality disorders may present in a variety of forms. The ICD definition comes nearest to indicating the seriously deviant (and delinquent) end of the spectrum (‘considerable personal and social disruption’). It is this aspect that is given as an expression in the current Mental Health Act’s definition of psychopathic disorder: A persistent disorder or disability of mind (whether or not including significant impairment of intelligence) which results in abnormally aggressive or seriously irresponsible conduct on the part of the person concerned. (Mental Health Act, 1983, Section 1(2)) The modern concept of personality disorder seems to represent two interlocking notions. The first suggests that it is present when any abnormality of personality causes problems, either to the person themselves or to others. The second carries a more pejorative connotation; it implies unacceptable, anti-social behaviour coupled with a notion of dislike for the person showing such behaviour and a rejection of them (see later discussion). Sometimes, the word ‘psychopath’ is used for this purpose and we touch on this later in this paper. Some Key Characteristics Although some of these have already been alluded to in the previous section, this issue merits some further comment Sir Martin Roth (1990), a doyen of British psychiatry, has suggested (in summary form) that the key features of SPD are egotism, immaturity in various manifestations, aggressiveness, low frustration tolerance and the inability to learn from experience so that social demands are never met. Roth’s brief listing encapsulates many of the 16 detailed characteristics suggested by Cleckley in various editions of The Mask of Sanity (1976). Cleckley (1976:362-363) identified sixteen characteristic points. Whilst not suggesting that all of these characteristics would have to be present, in the chapters that follow his listing, he elaborates on each of them in turn. In our view those he lists as numbers 1-6, 8, 9, 11, 15, & 16 would continue to resonate powerfully with today’s professionals. We would emphasise the importance of the second and third of these alongside the capacity to create chaos, which is sometimes overlooked as an important ‘marker.’ Cleckleys original list appears as follows: Superficial charm and good ‘intelligence.’ Absence of delusions and other signs of irrational thinking. Absence of ‘nervousness’ or psychoneurotic manifestations. Unreliability. Untruthfulness and insincerity. Lack of remorse or shame. Inadequately motivated antisocial behaviour. Poor judgement and failure to learn by experience. Pathologic egocentricity and incapacity for love. General poverty on major affective reactions. Specific loss of insight. Unresponsiveness in general personal relations. Fantastic and uninviting behaviour with drink and sometimes without. Suicide rarely carried out. Sex life impersonal, trivial and poorly integrated. Failure to follow any life plan. To these items we would add the following three elements. First, the curious super-ego lacunae, rather than a total lack of conscience suggested by other authorities. Second, the greater than usual need for excitement and arousal to which we have already referred. Third, a capacity to create chaos amongst family, friends, and those involved in trying to manage or contain them. We would suggest that this last characteristic is one of the most accurate indicators of the true, as distinct from the pejoratively labelled, psychopath. It is often attested to by those who have extensive clinical experience in dealing with the psychopathically disordered. For example, the lack of true feeling (empathy) exhibited by the psychopath was stated graphically some forty years ago by Johns and Quay (1962) in their comment that psychopaths ‘know the words but not the music’. Rieber and Green (1988) add four salient characteristics in support of this, namely thrill-seeking, pathological glibness, anti-social pursuit of power and absence of guilt. The presence of such characteristics has led to many difficulties for academics, lawyers, psychiatrists and other health care and criminal justice professionals (see for example Gayford and Jungalwalla, 1986). Over twenty-five years ago one of us made the following observations in a paper that appeared in the Prison Service Journal (Prins 1977:8-9) and the following imaginary scenario may give some indication of the scale of the problems involved in definition and management. Imagine, if you can, a top-level conference has been called to discuss the meaning of that much used and abused word psychopathy. You are privileged to be an observer at these discussions at which are present psychiatrists, psychologists, sociologists, lawyers, sentencers, theologians, philosophers, staff of penal establishments and special hospitals, social workers and probation officers. You have high expectations that some total wisdom will emerge from this well-informed and experienced group of people and that a definition will emerge that will pass the closest scrutiny of all concerned. After all, this is a gathering of experts. Alas, your expectations would have a quality of fantasy about them, for in reality you would find as many definitions as experts present. Let me just present one or two examples of this statement. There would be little agreement among psychiatrists, the term would be used to cover a very wide range of mental disorders, including those we might describe as neuroses in this country; for some psychiatrists (for example, from the United States), the term might include minor disorders of personality and for others the term might be synonymous with what we would describe as recidivism, The lawyers in the group would disagree also. Some might well accept the definition in the Mental Health Act, 1959 …(as it then was)… which describes psychopathy as a ‘persistent disorder or disability of mind (whether or not including sub-normality of intelligence) which results in abnormally aggressive behaviour or seriously irresponsible conduct on the part of the patient and requires or is susceptible to medical treatment…’ However, they would immediately begin to ask questions about the legal implications of the words ‘disability of mind’ and irresponsible conduct’. At this stage, the philosophers would no doubt chip in and also ask searching questions about the same terms. Later on in the discussion, a theologian might start asking awkward questions about the differences between ‘sicknesses’ and ‘sin’ and ‘good’ and ‘evil’. The representative from the field of sociology in the group might usefully remind us that psychopaths lack what they describe as a capacity for role-taking, i.e. seeing yourself in an appropriate role in relation to others in their roles in [their] environment. And so the discussion would go on and on. Don’t ever assume that it has been different. For one hundred and fifty years the arguments have raged over definition, classification and management. One might well ask ‘have things changed much since that was written’? To which we would be forced to answer ‘not much’. However a group such as the one described might well be somewhat more representative today. For instance, we could usefully find a space for a geneticist, a developmental paediatrician, representatives from the Home Office and Department of Health, the voluntary sector (who do so much to cope with these ‘hard to like’ individuals) and who knows, in this progressive day and age – a consumer of the service as well as a victim? A recent parallel to such an hypothetical group can perhaps be seen in the large conference prompted and attended by the Secretaries of State for Social Services and the Home Department in July 1999, when they highlighted for comment their joint proposals for dealing with the management of those persons exhibiting dangerous severe personality disorder. (Home Office and Department of Health, 1999 and Prins 1999). It is of particular interest to note that the government (perhaps wisely) only provided a loose definition of what they understood dangerous severe personality disorder to be and expressed the firm intention to fund major research into the problem – an intention currently being put into practice. Personality disorder is referred to in this document (1999:5) as ‘an inclusive term referring to a disorder of the development of personality’ … ‘and is not a category of mental illness.’ Further, (1999:9) the document states that the phrase ‘dangerous severely personality disordered (DSPD) is used to describe people who have an identifiable personality disorder to a severe degree, who pose a high risk to other people because of serious anti-social behaviour resulting from their disorder’. These definitions can reasonably be regarded as ‘loose’ and reflect the reservations of experienced psychiatrists such as Sir Martin Roth who commented that (1990:449) ‘in its present state of development the concept of psychopathy is fuzzy at the edges and in need of refinement’. For a useful commentary on some current concerns see Laing (1999). If we see psychopathic disorder as a process of disturbed psychological development (however caused) then we need not rely exclusively upon clinical descriptions. Its nature, early onset and manifestations are depicted clearly in the aged Duchess of York’s reviling of her son Richard III in Act IV scene iv of Shakespeare’s play. …Thou cam’st on earth to make the earth my hell. A grievous burden was thy birth to me; Tetchy and wayward was thy infancy; Thy school-days frightful, desp’rate, wild and furious. Thy prime of manhood daring, bold and venturous; Thy age confirm’d, proud, subtle, sly and bloody, More mild, but yet more harmful kind in hatred. What comfortable hour can’st thou name That ever grac’d me with thy company? Here we have the aged Duchess describing graphically some of the characteristics we regard as important in terms of both aetiology and presentation. For example, an apparent difficult birth and long-standing anti-sociality - a requirement of the DSM-IVR APA 1994, the ICD10 (W.H.O. 1992) and current mental health legislation in England and Wales - which then becomes more marked in adulthood. All of this is accompanied by a veneer of charm and sophistication which only serves to act as a mask for the underlying themes of chaos and the potential for destructiveness. It should be re-emphasised that neither the DSM nor the ICD10 refer to psychopathic disorder; the former refers only to anti-social personality disorder and the latter to dissocial personality disorder. As previously stated, neither descriptions equate exactly with the current legal description – psychopathic disorder – a word that numerous committees have suggested abandoning, preferring personality disorder – which has not been defined further. Although changing the name will not necessarily do away with our dislike for such patients/clients/offenders, describing and trying to delineate the disorder has the advantage of hopefully setting some boundaries to it. Creating typologies may also assist in management, even if the latter is very difficult. We should also note that a number of clinical and legal authorities consider that the current espousal of the term ‘psychopathic’ and all that this entails in practise, is unhelpful. See for example, Blackburn (1988), Cavadino (1998), Lewis and Appleby (1988), Maden (1999) and Solomka (1990). Some Problems of Management This section of our paper is divided into two subsections. Subsection one deals predominantly with legal aspects and subsection two with clinical issues. To a great extent the two elements should be seen as a whole. However, in an attempt to achieve clarity, we have chosen to split them. Readers may consider that this is a largely artificial (and somewhat pedantic) distinction. Subsection One – Legal Aspects The nature of psychopathic disorder and the problems it has presented to courts and counsel are likely to bring to the fore powerful views and attitudes towards the disorder. As noted previously, in England and Wales, a legal definition of psychopathic disorder was first introduced in the Mental Health Act, 1959 (in Scotland and Northern Ireland the term psychopathic is not used, see Crichton et al 2001 and Darjee & Crichton 2003). In the 1959 Act, treatability was linked to the definition of the disorder… ‘and requires, or is susceptible to treatment’, Section 1(4). The definition of the disorder was left substantially unchanged in the 1983 Act, with the important exception of the removal of the sentence relating to treatability; the latter finds an expression in Sections 3, 37 and 45A of the Act, where it must be demonstrated that … ‘such treatment is likely to alleviate or prevent a deterioration of [the] condition’. In terms of possible disposals, section 45A of the 1983 Act (inserted by Section 46 of the Crime (Sentences) Act, 1997) makes provision for the so-called ‘Hybrid Order’. This enables a Crown Court to impose a sentence of imprisonment upon an offender (but only in cases where the sentence is not fixed by law, e.g. in convictions for murder). The patient must be diagnosed as suffering from psychopathic disorder and the court may direct that such an individual should be admitted to a specified hospital instead of to prison. This provision is known as a ‘Hospital and Limitation Direction’. Should the offender/patient no longer need, or be responsive to treatment before his or her release date, the Responsible Medical Officer may seek the offender/patient’s transfer to prison. The ‘limitation’ element has the effect of a Restriction Order under Section 41 of the 1983 Act. At the time of writing, it appears that courts have been slow to utilise this new provision. The change occurred due to a growing and understandable reluctance on the part of psychiatrists to manage such people. In the late nineteen-fifties there was a degree of optimism that psychiatry and psychiatrists had the answers not only to treatable mental illness, such as the major psychoses (e.g. the schizophrenias and affective psychoses) but that optimism (which was not wholly justified or eventually sustainable even for the psychoses) could be extended to forms of mental disorder such as psychopathy. As to whether personality disorder (psychopathy) is an illness or a disorder, Kendall (1999) has suggested that ‘the historical reasons for regarding personality disorders as fundamentally different from mental illnesses are being undermined by both clinical and genetic evidence. Effective treatments for personality disorders would probably have a decisive influence on psychiatrists’ attitudes.’ Gunn (1999) has suggested an additional reason for the change of emphasis regarding treatability. This lies in the parlous state of general psychiatric provision, and most particularly in large conurbations such as London. The legal connotations of treatment have also resulted in a number of court rulings in England, Wales and in Scotland. In the case of R. v. Canons Park Mental Health Review Tribunal ex parte A. [1995] QB60, the Court of Appeal held that the mere refusal of a patient to participate in group psychotherapy did not, of itself, indicate untreatability. A subsequent case in Scotland, Reid v. Secretary of State for Scotland [1999]2 WLR 28, re-opened the whole issue. In brief, this case concerned an offender patient detained without limit of time under the provisions of the Scottish Mental Health Act 1984. In a ruling the Law Lords held that under Section 145(1) of the Act, medical treatment was to be given a broad meaning and that supervised care which endeavoured to prevent deterioration of the symptoms, - but not the disorder itself - might justify liability to continued detention. In hearing this case the Law Lords appear to have decided inter alia that the Canons Park case had been wrongly decided. The current view therefore has been summarised thus by Eldergill (1997:225); It can be seen that the treatability condition is satisfied if medical treatment in its broadest statutory sense – which includes nursing care – is eventually likely to bring some symptomatic relief to prevent the patient’s mental health from deteriorating. There are few (if any) conditions which are not treatable in this sense. Unfortunately this saga did not end with that decision. There have been continuing concerns about possible loopholes in the law that would allow dangerous psychopaths to obtain their freedom and the case of Michael Stone illustrates this concern. Stone is alleged to have killed a mother, one of her children and their dog as well as grievously injuring a second child. His case is of interest because of the number of hearings it has engendered including a first trial and conviction, an appeal to the Court of Appeal and a second trial. His case was subsequently also re-referred to the Court of Appeal. This further appeal failed and he was returned to prison to serve the life sentences originally imposed. Of importance was the alleged reluctance of the psychiatric services to ‘treat’ Stone and this seems to have prompted the current proposals for the management of those showing dangerous severe personality disorder. It is worth noting however, that this move must be seen against a mounting background of political concern regarding dangerous behaviours engaged in by those showing various forms of mental disorder. (For a full judgement of the CA Criminal Division case, see Citation No. (2005) EWCA Crim 105 No. 200300595/B3. 21.1.05). In Scotland, the case of Ruddle (Ruddle v. Secretary of State for Scotland [1999] GWD 29 1395) led the Scottish Parliament to pass as a matter of urgency, the Mental Health (Public Safety and Appeals) (Scotland) Act 1999, which has added public safety to the grounds for not discharging patients under Scottish mental health legislation. The main effect of this legislation has been to change the definition of mental disorder to ‘mental illness (including personality disorder) or mental handicap however caused or manifested’ and to require continued detention of a restricted patient ‘if the patient is suffering from a mental disorder the effect of which is such that it is necessary in order to protect the public from serious harm’ Crichton (2001) suggests that one of the ‘incidental’ effects of this enactment has been to clarify the fact that personality disorder [had] always been included (but by implication only) within the meaning of mental disorder in Scottish mental health legislation. Further, he also suggests that the Act of 1999 merely plugged ‘a loophole’ and that further developments should wait upon any action that may be taken as a result of the two major reviews of Scottish mental health legislation and practice by the Millan (1999) and Maclean Committees (2000). For a discussion of some of the new arrangements under the recently implemented Scottish legislation, see Thomson (2005). Sub-Section Two – Clinical Issues From all that has been written so far, it should be obvious that those labelled as psychopathic present enormous psycho-socio-legal problems and that their day-to-day management causes the professionals involved both ‘headache’ and ‘heart-ache’. Some aspects of mental health and criminal justice professionals’ engagement in these ‘encounters’ have already been touched upon and the intention in this section is merely to highlight some of them further. Scott addressed some of these issues over twenty-five years ago in a very thought-provoking and under-referred to paper entitled Has Psychiatry Failed in the Treatment of Offenders? (1975). Scott suggested that we most frequently fail those who need us most. Such individuals often fall into two (perhaps overlapping) categories, the ‘dangerous offender’ and the ‘unrewarding’, ‘degenerate’ and ‘not nice’ offender. Of such ‘embarrassing’ patients Scott (1975:8) maintained that he/she is the patient who is ‘essentially the one who does not pay for treatment, the coin in which the patient pays being ‘(i) dependence – i.e. being manifestly unable to care for themselves, and thus appealing to the maternal part of our nature; (ii) getting better (responding to our “life-giving” measures); (iii) in either of these processes, showing gratitude, if possible cheerfully’. In other words, those patients/clients/offenders that Scott had in mind are just the ones who reject our ‘best efforts’, are manipulative, and delight in giving us a pretext for rejecting them so that they can continue on their ‘unloved’ and ‘unloving’ way. In Scott’s terms, ‘the “not nice” patients’ are the ones who ‘habitually appear to be well able to look after themselves but don’t and [as stated above] reject attempts to help them, break institutional rules, get drunk, upset other patients, or even quietly go to the devil in their own way quite heedless of nurse and doctor’. Scott went on to suggest other factors which are relevant to any consideration of the management of so-called psychopaths (emphasis added). We emphasise the word so-called because Scott did not feel there was much merit in distinguishing psychopaths from hardened chronic (recidivist) criminals – a minority view. Further, he states (1960:9) that: There is a natural philanthropic tendency to extend help to the defenceless – probably an extension of parental caring … if this fails so that embarrassing people or patients are seen to accumulate, then anxiety is aroused and some form of institution is set up to absorb the problem … Not all embarrassing patients like being tidied up and these tend to be compulsorily detained … Within the detaining institution two opposing aims being to appear – the therapeutic endeavour to cure and liberate on the one hand, and the controlling custodial function on the other. Scott (1960:10) goes on to suggest that although these functions should be complimentary ‘there is a tendency for them to polarise and ultimately, to split, like a dividing cell, into two separate institutions’. However, he also suggests that ‘neither of the two new institutions can quite eliminate the tendency from which it fled, so that the therapeutic institution now begins to miss the custodial function and tries hard to send some of its patients back to custody, and the custodial institution is unable to tolerate being unkind to people all the time and begins to set up a new nucleus of therapy’. His perceptive ‘management’ observations might well be considered carefully by those involved in implementing the future institutional care for DSPD individuals envisaged in the policy development paper previously referred to. These are the unlikeable clients/patients/offenders and often this dislike will operate at an unconscious level. Three quotations from the views of psychiatrists are useful in illustrating this problem and their words are applicable to all professionals working in the field of criminal justice and forensic psychiatry. Maier (1990: 776) suggests; Could it be after all these Freudian years, that psychiatrists have denied the hatred they feel for psychopaths and criminals, and thus have been unable to treat psychopaths adequately because their conceptual bases for treatment has been distorted by unconscious, denied feelings from the start? A somewhat similar view has been proffered by Treves-Brown (1977: 63) who stated that; As long as a doctor believes that psychopaths are mostly ‘bad’, his successful treatment rate will be dismal. Since it takes two to form a relationship, an outside observer could be forgiven for suspecting that a doctor who describes a patient as unable to form a relationship, is simply trying to justify his own hostility to his patient. Finally Winnicott (1949:71) – a doyen of child psychiatry, writing over fifty years ago about the ‘anti-social tendency’ – has given further support for such views as follows: However much he loves his …[hard to like] … patients he cannot help hating them and fearing them, and the better he knows this the less will hate and fear be the motives determining what he does for his patients. These three quotations indicate that the mechanism of ‘denial’ is not merely the prerogative of patients and offenders and for a very useful account of denial more generally, see Cohen 2001. Despite the unattractiveness of such patients and the sometimes unconscious reactions of therapists, a number of forensic-psychiatric and criminal justice professionals have expressed a degree of optimism about treatment. Some years ago Tennent et al (1993) sought the opinions of psychiatrists, psychologists and probation officers about treatability. The survey was admittedly small, as was the response rate. However there was reasonable evidence to suggest that although there were few clear-cut views as to the best treatment modalities, there were clear indications as to those felt to be helpful. For example, there were higher expectations of treatment efficacy with symptoms such as chronically anti-social’, ‘abnormally aggressive’ and ‘lacking control over impulses’ and much lower expectations for symptoms such as ‘inability to experience guilt’, ‘lack of remorse or shame’ and pathological egocentricity’. Support for the findings of this modest survey can be found in a much more extensive survey by Cope (1993) on behalf of the Forensic Section of the Royal College of Psychiatrists. Cope surveyed all forensic psychiatrists working in Secure Hospitals, units and similar settings in England and Wales. The majority of her respondents (response rate 91%) were in favour of offering treatment to severely personality disordered (psychopathic) patients. Some explanation for this optimism derives from another source. In a fairly recent attempt to ascertain the motivations of consultant forensic psychiatrists for working in forensic psychiatric settings, one of us discovered that one of the attractions of the work was the challenge presented by psychopaths. (Prins 1998). Another fact that emerged from this survey was the need for forensic psychiatrists to work with and encourage their colleagues in general psychiatry to deal with such patients. This is a point emphasised very cogently by Gunn (1999) in a recent paper for, as he implies, someone has to deal with such individuals and psychiatry should play its full part. For a recent study of work specifically with DSPD patients from the psychiatrists’ point of view see Haddock et al (2001) and from a forensic nursing perspective see Bowers (2002). Some other statements made by a number of Prins’ survey respondents were very illuminating. One of them enjoyed the challenge presented by the severity and complexity of the cases which produced ‘a kind of appalled fascination’. Another attraction was the chance to work with a wide range of agencies and disciplines and to pursue a more eclectic approach to patient care. Stimulation was another important factor (a factor shared with the psychopathic – see earlier discussion). Perhaps it takes one to recognise one! One stated ‘I could not envisage twenty years of listening to the neurotic and worried well’; ‘after forensic psychiatry, other specialities seemed very tame and had much less variety and challenge’. Whatever form of professional training is eventually formulated in order to deal more effectively with psychopathically disordered individuals, understanding and management will only be successful through the adoption of a truly multi-disciplinary approach ( as implied in the ‘imaginary’ seminar quoted earlier). Such an approach would not only serve to take the broadest possible view of the topic but, at a narrower clinical level, should help to obviate potential missed diagnoses (for example, the importance of organic factors such as brain damage).Scott (1960:1645) has some interesting observations to make on this aspect. He stated that: This may be the point at which to acknowledge that, with psychopaths, highly refined psychotherapeutic procedures applied by medical men, are often no more successful, sometimes less successful, than the simpler and less esoteric approaches of certain social workers, probation officers, [and others] … some workers intuitively obtain good results with certain psychopaths; it should be possible to find out how they do it… Sadly, little research information is available to answer Scott’s implied question about treatment success. However, what we do know is that severely dangerous and deviant behaviour requires calm and well-informed confrontation. In the words of the late George Lyward – a highly gifted worker with severely personality disordered older adolescents – ‘Patience is love that can wait’. Coupled with this is the need to tolerate, without loss of temper, the hate, hostility, manipulation, and ‘splitting’ shown by such individuals together with an ability not to take such personal affronts as attacks. The psychiatrist and psychotherapist Penelope Campling (1996) has provided an excellent account of the management of such behaviours and for a very recent research-based exposition of the potential value of psychosocial therapy for severe personality disorders see Chiesa & Fonagy (2003). It is also essential for professionals to have more than an ‘intellectual’ understanding of what the patient has done. Sometimes, this can be ‘stomach-churning’ and offers many opportunities for denial on the part of the professional. Such understanding also requires a degree of what has been described in another context as ‘intestinal fortitude’, an expression used by Michael Davies, Leader of the BBC Symphony Orchestra, in relation to the playing of certain problematic orchestral works. (BBC2 broadcast, 10 July 1999). It is worth re-emphasising the importance of the phenomenon of denial which is not the sole prerogative of our clients/patients/offenders. For, as Pericles says in Shakespeare’s play of that name, ‘Few love to hear the sins they love to act, (Act I, Scene 1). The more troublesome and anxiety-making the relationship, the more the need not to go it alone. This is not an area of work that should be characterised by ‘prima donna’ activities by professionals of either sex, for there are dangerous workers as well as dangerous clients/patients/offenders. In our view there are three qualities that are of paramount importance in dealing with severely personality (psychopathically) disordered individuals. These are consistence (the capacity to take a firm line in deflecting activities on the part of the client); persistence ( expending efforts over very considerable periods of time, perhaps even years – a view that is supported by the belief in the occurrence of cortical maturation and the longer term benefits of team therapy in institutions such as those at Grendon Prison described by Taylor (2000) and Coughlin (2003); and finally insistence (the capacity to give clear indications that requirements of supervision are to be met in spite of resistance on the part of a client). Such insistence must take priority when expectations of what supervision requires of the client are initially set out in the professional/client relationship. A Final Cautionary Tale The problems of trying to legislate for persons suffering from severe personality disorder which may, from time to time, make them a danger to themselves and to others, are exemplified in the extraordinary Australian case of Gary David as told by Deirdre Greig in her disturbing book – Neither Bad nor Mad (2002). Her account demonstrates the inability of both the criminal justice and mental health care systems to deal with such individuals and this story may be told here very briefly. Gary was born in November 1954 and had a disturbed family history. He died of severe complications arising from grievous self-inflicted injuries in June 1992. Gary’s severe personality disorder gave rise to many years of dramatic and highly persistent disruptive and manipulative behaviours. These included serious and highly bizarre episodes of both self harm and harm to others. The inability of both systems to deal with him effectively led to numerous political manoeuvres to affect his indeterminate detention on the basis of his ‘dangerousness’. This included the passing of a single piece of legislation to deal solely with his case. Over the years, numerous psychiatric professionals who had dealings with him could not agree on the nature and extent of his mental disorder or, in fact, whether or not he was mentally disordered at all. Limitations of space preclude a detailed discussion of the sad saga of the various commissions of inquiry, court hearings and appeals that dealt with this case but what they do signify is the highly complex nature of the fluctuating relationships between health care and penal institutions which have already been referred to in this paper. One of the more important (but unsurprising) findings in Greig’s account (2002:151) is suggested by one of her commission sources: One lesson to be learned from legal history is that hard cases make bad law and that there is a risk that a hasty and ill-conceived response to one particular case … can seriously disturb a larger and well thought structure. The UK government is much concerned about ‘Managing Dangerous People with Severe Personality Disorder’ and have set out various possibilities, the most disquieting being the apparent possibility of detaining someone on the basis of what it is felt they might do. Other weaknesses include the expectation that criminal justice and mental health professionals have fool-proof skills in predicting future behaviour and its risks. At present, we are trying to treat/manage a very problematic group of people with vast gaps in our knowledge base, coupled with a significant lack of capacity for self examination when trying to engage with such people. Psychopathic disorder is not going to go away whatever we call the condition in the future; and it has been rightly called the ‘Achilles Heel’ of criminal justice and psychiatry. Conclusion We have emphasised in our contribution that the group of people that we identify as ‘psychopathic’ arouse strong emotions in those who are charged with managing them. Discussion about these troubled and troubling individuals tends to generate more ‘heat’ than ‘light’; we trust that our review of the topic will aid more considered discussion. The degree of success (or otherwise) of the four pilot DSPD centres (at HM Prisons Frankland and Whitemoor and the High Security Hospitals Broadmoor and Rampton) will be followed with much interest. Bowers et al (2005) have already begun to identify some of the difficulties facing staff and an encouraging sign of the move to more ‘joined up working’ may be found in a recent paper by Sizmur & Noutch (2005). In our view Professor John Gunn (1999:75-76) provides what is still a useful and critical summary of the work which may still need to be done. In England and Wales we have an uphill struggle on our hands. We need to persuade our Home Office not to drop its interest (and we would add to this the Department of Health) and particularly [the] resource allocation for a needy, hitherto neglected group of patients, but at the same time to back away from new types of …preventive detention laws and focus instead on the well-tried arrangements we already have. It is true that our prisons can do with more psychiatric resources, we have secure hospitals that also need more resources…we certainly do not need new and restrictive laws. 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