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6th International Conference on the Care and
Treatment of Offenders with a Learning Disability
2nd 3rd April 2007 University of Central
Lancashire
Service Provision for Personality Disorder in a
Forensic Learning Disability Service
Brendan OMahony Regi Alexander St Johns
House, Diss, Norfolk
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Personality Disorder (BPS)

• PDs are variations or exaggerations of normal
  personality attributes
• Although PD is often associated with antisocial
  behaviour, the majority of people with a PD do
  not display antisocial behaviour
• Many people with mental health problems also have
  significant problems of personality
  (BPS, 2006)

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Different Personality DisordersICD-10 DSM-IV
categories

• Paranoid
• Schizoid
• Dissocial
• Emotionally unstable
• Histrionic
• Anankastic
• Anxious (avoidant)
• Dependent
• Other / unspecified

• Paranoid
• Schizoid
• Schizotypal
• Antisocial
• Borderline
• Histrionic
• Narcissistic
• Avoidant
• Dependent
• Obsessive-Compulsive
• Other / not specified

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DC-LD

• The ICD-10 suggestion that diagnosis can be made
  by the age of 16-17 years is viewed as too young
  for such a diagnosis in a person with learning
  disability.
• A higher threshold (over 21 years) is considered
  more clinically appropriate
• (p74)

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Learning Disability

• Significant impairment of intellectual
  functioning (IQlt69)
• Significant impairment of adaptive and social
  functioning
• Onset before age 18 years
• BPS 2004 (Challenging Behaviours)

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PD diagnosis in LD is contentious-why is this?
There are arguments against

• Pragmatic reasons
• Overlap with other developmental disabilities

• Philosophical reasons
• Developmental theorists
• Stigma attached to additional labelling

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Importance of PD as a Clinical Issue

• influences the ability to place someone in the
  community (Reid Ballinger 1987)
• predicts future psychiatric morbidity (Goldberg
  et al 1995)
• predicts rate of referrals (Khan et al 1997)
• influences the mode of management (Wilson 2001)
• Predicts outcome of patients discharged from
  forensic settings (Alexander et al 2006)

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What is the size of the problem?

• In Community LD teams prevalence rate is 7
• In forensic services prevalence rate is over 50
• (Lindsay et al 2005, Bouras et al 2003, Naik et
  al 2002, Alexander et al 2002)

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Research to date

• Already looked at
• Mainly prevalence studies
• Some case reports

• Next phase
• What differences, if any, are there between
  the groups
• (LD PD)
• and
• (LD and no PD)

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Location of this Study

• Based on Norfolk / Suffolk border
• Independent sector
• Patients with mild LD
• Assessment and treatment (50 beds)
• Rehabilitation service (14 beds)

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Aims

• Service provision- baseline evaluation/ audit
• But where do we start?
• This study is an exploratory look at the PD and
  non-PD groups in this service with the aim of
  defining its unique characteristics

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Variables
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Participants

• N 114
• 93 males 21 females
• Mean FSIQ 62 (Mild Learning Disability)
• 63 (n101) had at least one (1) personality
  disorder (ICD-10)

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Age on admission to this hospital
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Personality Disorder Breakdown(percentages)
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Socio-Demographic (preliminary findings)

• Childhood Abuse (n42)
• No significant findings (chi-square)

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Clinical (diagnostic co-morbidity findings)

• higher association recurrent depression,
  substance abuse, higher FSIQ
• lower association PDD, epilepsy
• No significant association psychosis
• (N48)

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Forensic
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Ward Behaviour

• No significant findings to date on
• Physical interventions
• Observations
• Seclusions
• PRN

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Next Moves

• Offending behaviour summaries (criminal
  convictions / cautions)
• H scores on HCR-20

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Discussion points

• A) Need for structured assessment package for
  multi-axial diagnosis and for psychological
  formulation
• B) Psychological issues abuse not statistically
  PD related but high across the board
• Specific outcomes in relation to psychological
  input not looked at here but subject of study

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Discussion (continued)

• C) ? Separate (PD LD) units versus current
  system
• D) use of measures like PCL-R scores
  (psychopathy) would they differentiate better
  rather than ICD-10 diagnosis in respect of
  service planning?

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Contact details

• Dr Regi Alexander Consultant Psychiatrist
• Email RAlexander_at_partnershipsincare.co.uk
• Brendan OMahony Trainee Forensic Psychologist
• Email BOMahony_at_partnershipsincare.co.uk

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References

• Alexander, R.T., Crouch, K., Halstead, S.
  Piachaud, J. (2006) Long-term outcome from a
  medium secure service for people with
  intellectual disability Journal of Intellectual
  Disability Research, 50, 4, 305-315
• Alexander, R.T., Piachaud, J., Odebiyi, L.
  Gangadharan, S.K. (2002) Referrals to a forensic
  service in the psychiatry of ID. British Journal
  of Forensic Practice 4, 29-33

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References (continued)

• Bouras, N., Cowley, A., Holt, G., Newton, J.T.
  Sturmey, P. (2003) Referral trends of people with
  intellectual disabilities and psychiatric
  disorders. Journal of Intellectual Disability
  Research 47, (6), 439-446
• Lindsay, W.R., Gabriel, S., Dana, L., Young, S.,
  Dosen, A. (2005) Personality Disorders. In R.
  Fletcher, E. Loschen, P. Sturmey (Eds.),
  Diagnostic manual of psychiatric disorders for
  individuals with mental retardation. Kingston,
  NY National Association for Dual Diagnosis

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References (continued)

• Naik, B.I., Gangadharan, S.K. Alexander, R.T.
  (2002) Personality disorders in learning
  disability-the clinical experience. British
  Journal of Developmental Disabilities, 48, 2,
  95-100
• BPS Document
• Alwin, N., Blackburn, R., Davidson, K., Hilton,
  M., Logan, C., Shine, J. (2006) Understanding
  Personality Disorder A Report by the British
  Psychological Society (BPS)

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References (continued)

• Flynn, A., Matthews, H., and Hollins, S. (2002)
  Validity of the diagnosis of personality disorder
  in adults with learning disability and severe
  behavioural problems. British Journal of
  Psychiatry, 180, 543-546
• Goldberg, B., Gitta, M.Z., Puddephatt, A.
  (1995) Personality and trait disturbance in an
  adult mental retardation population Significance
  for psychiatric management. Journal of
  Intellectual Disability Research, 39, 284-294

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References Continued

• Khan, A., Cowan, C., Roy, A. (1997).
  Personality disorders in people with learning
  disabilities A community survey. Journal of
  Intellectual Disability Research, 41, 324-330
• Reid, A.H., Ballinger, B.R. (1987) Personality
  disorder in mental handicap. Psychological
  Medicine, 17, 983-987