Psychopathic disorder

The Report into the Personality Disorder Unit at Ashworth Hospital (the Fallon Report) has stimulated a debate about the diagnosis, classification, and treatability of some categories of patients suffering from personality disorder, particularly the more severe forms and those who are dangerous. Psychiatrists, psychologists, and other experts on this subject are sharply divided on these matters (see Cope,(2!) Volume II of the Fallon Report,(!3,) and the Royal College of Psychiatrists Council Report(22)).

The category of 'psychopathic disorder' and its definition in the Mental Health Act 1983 for England and Wales is widely regarded as unsatisfactory, restrictive, distant from clinical usage and practice, and often pejorative. It is proposed that it is replaced by 'personality disorder' and that its interpretation is left to clinicians, as is 'mental illness' in the Act.

The use of Hospital Orders for offenders with personality disorder should be discontinued and new legislation should permit hospital treatment for offenders with severe personality disorder only when they have been transferred from prison after receiving a prison sentence. Those offenders who present a continuing risk to others should be subject to a new form of reviewable sentence (first proposed in the Butler Report(!,5)) which would mean that the prisoner would be subject to a periodic independent judicial review and if he or she presents a continued risk the prison sentence would continue for further periods of 2 years at a time.

The treatability reference in the current Act with respect to psychopathic disorder restricts detention in hospital on a Hospital Order (for individuals suffering from psychopathic disorder or mental impairment) to those for whom treatment would 'alleviate or prevent deterioration' of the patient's condition (see for instance Section 3 (2) (b) of the Mental Health Act 1983). The extent to which available treatment for psychopathic disorder will meet this requirement depends on the opinions of individual doctors, although it can also be said that by providing secure care, deterioration (to a return to violent behaviour for instance) will always be prevented simply by being detained in a secure setting. The uncertainties arising from these disputes and anomalies has resulted in the Home Secretary expressing his concern that 'dangerous psychopaths' are apparently refused treatment by psychiatrists. He has indicated that he intends to introduce legislation to allow the detention of some individuals with personality disorders even though they have not committed an offence and are not detainable in terms of the current Mental Health Act. It is a new form of preventive detention without trial (whereas the Fallon proposals only apply to those who have been sentenced by a court). It is not clear how this might be achieved without contravening civil rights.

There is general agreement from the reports cited above that individuals with severe forms of personality disorder should be managed in units that are separate from other groups although this group has a high level of comorbidity with other conditions and segregation can only apply to a limited group of very difficult patients. The Fallon Inquiry recommended small special units linked to high-security hospitals and special units in prisons, with a substantial input from consultant forensic psychologists supported by a clinical team, which would include forensic psychiatrists. A joint Department of Health- Home Office Group has suggested the possibility of a 'third way' to manage these patients which would be in new units under the auspices of both departments, units which are neither hospital facilities nor prisons, but which would be partly modelled upon units in The Netherlands and Germany.

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