Personality Disorder continued

6.1.65 This joint Department of Health/Home Office Working Group on Psychopathic Disorder32 was set up in September 1992 under the chairmanship of Dr John Reed CB with the following terms of reference:

"to consider the services needed for those people who present special problems of violent behaviour or repeat offending because of their personality, whether or not they are otherwise mentally disordered, taking account of both the interests of the individuals concerned and the protection of other people. In particular:

"to consider, in the light of present knowledge, what methods of management, or treatment, are likely to be most effective in reducing violent or offending behaviour;

to consider whether these require the provision of any new services in addition to, or in place of, those available at present;

to advise how the services, whether within the Prison Service, the health services, or elsewhere, may most effectively be made available to those in need;

to consider whether any changes are needed in the present legal provisions relating to psychopathic disorder in the interests of more effective provision of services;

to advise on any research which might facilitate the better understanding of the definition, management, or treatment, of this group of offenders;

to consider the resource implications of any proposals, including their cost effectiveness."

6.1.66 The Group identified three main issues: diagnosis and treatment ­ what is psychopathic disorder; service development ­ what services are needed, and who should deliver them; and legislation ­ is the present framework right? The Group commissioned a literature review by Dr Bridget Dolan and Dr (now Professor) Jeremy Coid and reviewed the current pattern of services.

6.1.67 The Working Group's initial conclusion is a melancholy one: from the evidence gathered, the group reached an initial conclusion that there was insufficient information available to answer in full the questions posed in the terms of reference. No firm conclusions could be reached about what methods of management, or treatment, were likely to be most effective in improving health and reducing violent or offending behaviour. Instead a pragmatic approach was needed in which a wide range of services in many settings (including the community) was provided (para. 4.8).

6.1.68 In the face of this lack of knowledge the Group duly recommended a variety of research programmes, on treatment interventions (using the multi-method criteria for categorising severe personality disorder recommended by Dolan and Coid) (paras. 6.12­14), on risk assessment (8.14) and on aetiology (9.2). The Group argued that specialised settings in prison and hospital should be developed, with greater flexibility for individuals to move from one to another. Research into the outcomes of the different services with particular sub-groups of patients was needed to illuminate effectiveness (paras. 9.13­15). They also proposed a service research and development project on the assessment of need for services for personality disordered individuals (paras. 9.23­25).

6.1.69 The Group was able to come to firmer recommendations in the legislative arena. First, they discussed the statutory definition of "psychopathic disorder". Three options were considered:

(i) to retain the existing statutory definition;

(ii) to adopt the Scottish definition; or

(iii) to replace the term "psychopathic disorder" with "personality disorder".

6.1.70 In favour of (i) there were two lines of argument. One was negative; there was no satisfactory alternative, however flawed the current situation might be. The other was more positive; the current term was comprehensible to lawyers and Ministers, was reasonably flexible and there was a fair measure of agreement amongst clinicians on the common traits of the condition.

6.1.71 The Scottish legislation does not mention psychopathic or personality disorder, but it does refer to "abnormally aggressive and seriously irresponsible conduct". (section 17 (1)(a)(i)). One might replace the legal categories in the Mental Health Act 1983 with a single category of mental disorder, leaving it to clinicians to interpret this. But the Working Group felt this might cause considerable confusion and even more inconsistency of practice.

6.1.72 The Working Group, like the Butler Committee before them, were attracted by (iii), the idea of replacing the inaccurate, stigmatising and unhelpful term "psychopathic disorder" with "personality disorder", but without seeking to define personality disorder in the statute and, like "mental illness" leaving it to clinical interpretation.

6.1.73 The Group then discussed the working of sections 37 and 41 of the Act and this aspect, of their deliberations is referred to again later in this Report where we address this topic.

6.1.74 With reference to treatability, the Dolan and Coid review, influenced the Group's opinion that "the term psychopathic disorder does not represent a single clinical disorder but is a legal category describing a number of personality disorders which contribute to the person carrying out anti-social acts, usually of an episodic type" (para. 2.2). No change in the treatability criterion in the Act was recommended despite evidence of widely differing applications of the criteria, because they saw no viable alternatives, but recommended that section 48 of the Act (transfer from prison to hospital of remand prisoners), be extended to include psychopathic disorder.

6.1.75 This Working Group was the first since the Butler Report to make a serious attempt to address the problem of psychopathy and personality disorder. Dr Reed told us in evidence that from his considerable and lengthy experience this was by far the most difficult topic that he had taken on to review and in retrospect the Working Group had the wrong structure, with too many representatives from an extensive range of interests. It had proved extremely difficult to get agreement on a wide range of issues and, he said that is why the Report comes down insofar as its principal recommendations are concerned by simply saying "we need to know more".

"It is an extraordinarily difficult subject to produce very positive conclusions, it is very hard to reach agreement on its definition, we do not know what it is caused by, we do not know how to measure it, we do not know what interventions are effective and we do not know very well how to measure the consequences of intervention".

He felt, looking back, that a more effective Group would have had fewer members and would have taken expert evidence.

6.2.0 Psychopathic Disorder and Personality Disorder

6.2.1 Psychopathic disorder now has three meanings. It is a legal classification as one of the four categories of mental disorder in the Mental Health Act 1983; it is a clinical diagnostic construct or category in some classifications and it is used as a term of abuse in the vernacular. It has also acquired a pejorative connotation in clinical work (Higgins 1995)33, particularly when a patient is identified as "a psychopath" or as "psychopathic," with the implication that the patient is untreatable, has no proper place in a hospital and is disliked by clinical staff. The term has survived increasingly widespread criticism as recorded in many official Reports (see above) and professional publications and has attracted cogent arguments for its replacement.

Legal category of psychopathic disorder

6.2.2 The Mental Health Act 1983 defines psychopathic disorder as follows:

Section 1(2) "psychopathic disorder is a persistent disorder or disability of mind (whether or not including significant impairment of intelligence) which results in abnormally aggressive or severely irresponsible conduct."

The Royal Commission on the Law relating to Mental Illness and Mental Deficiency made clear in its Chapters 2 and 3 that groups of patients are defined in the law only in connection with compulsory powers of detention. With the development of clinical diagnostic classifications that do not have a direct correlation with the single legal classification there is clearly scope for increasing confusion.

Clinical Classifications of Personality Disorder

6.2.3 Gelder, Gath and Mayou (1989),34 authors of the leading textbook of psychiatry, begin their discussion of this topic with the observation that each category in any classification scheme represents an ideal type that few patients fit exactly. They quote Schneider (1950)35:

"Any clinician would be greatly embarrassed if asked to classify into appropriate types the psychopaths (that is abnormal personalities) encountered in any one year. There are only a few cases in which one of the characteristic types of description or combinations can be applied without further qualification. Human beings resist precise measurement and, unlike the phenomena of disease, abnormal individuals cannot be classified neatly in the manner of clinical diagnosis".

The International Classification of Disease-10 (ICD-10) (World Health Organization 1992)

6.2.4 The ICD-10 classification of personality disorders includes a variety of clinically significant conditions and behaviours each of which is classified according to clusters of traits that correspond to the most frequent or conspicuous behaviour manifestations. General diagnostic guidelines are given for specific personality disorders as follows:

"Conditions not directly attributable to gross brain damage or disease or to another psychiatric disorder, meeting the following criteria:

(a) markedly disharmonious attitudes and behaviour, involving usually several areas of functioning, e.g. affectivity, arousal, impulse control, ways of perceiving and thinking, and style of relating to others;

(b) the abnormal behaviour pattern is enduring, of long standing, and not limited to episodes of mental illness;

(c) the abnormal behaviour pattern is pervasive and clearly maladaptive to a broad range of personal and social situations;

(d) the above manifestations always appear during childhood or adolescence and continue into adulthood;

(e) the disorder leads to considerable personal distress but this may only become apparent late in its course;

(f) the disorder is usually, but not invariably, associated with significant problems in occupational and social performance.

6.2.5 There are ten categories of specific personality disorder in this grouping (the category F60) as follows:

"F60.0 Paranoid personality disorder

F60.1 Schizoid personality disorder

F60.2 Dissocial personality disorder

F60.3 Emotionally unstable personality disorder

.30 Impulsive type

.31 Borderline type

F60.4 Histrionic personality disorder

F60.5 Anankastic personality disorder

F60.6 Anxious (avoidant) personality disorder

F60.7 Dependent personality disorder

F60.8 Other specific personality disorders

F.60.9 Personality disorder, unspecified."

F60.2 dissocial personality disorder equates with the limited descriptive elements of psychopathy in the legal definition. Indeed, a footnote indicates that dissocial personality disorder includes: amoral, anti-social, psychopathic, and sociopathic personality disorder. It has the following characteristics:

"A personality disorder, usually coming to attention because of a gross disparity between behaviour and the prevailing social norms, and is characterised by:

(a) callous unconcern for the feelings of others;

(b) gross and persistent attitude of irresponsibility and disregard for social norms, rules and obligations;

(c) incapacity to maintain enduring relationships, though having no difficulty in establishing them;

(d) very low tolerance to frustration and a low threshold for discharge of aggression, including violence;

(e) incapacity to experience guilt or to profit from experience, particularly punishment;

(f) marked proneness to blame others, or to offer plausible rationalisations, for the behaviour that has brought the patient into conflict with society."

The Diagnostic and Statistical Manual (DSM-IV; American Psychiatric Association)

6.2.6 The American Psychiatric Association has developed a multi-axial system to assist clinicians to plan treatment and predict outcome. There are five axes included in the DSM-IV multi-axial classification:

Axis I Clinical Disorders

Other Conditions That May Be a Focus of Clinical Attention.

Axis II Personality Disorders; Mental Retardation.

Axis III General Medical Conditions.

Axis IV Psychosocial and Environmental Problems.

Axis V Global Assessment of Functioning.

6.2.7 A multi-axial evaluation will describe the patient in terms of the presence of disorders on one or more Axes, or the principal, secondary and other diagnoses are simply listed as are relevant to the care and treatment of the patient. Personality Disorders in this classification are coded on Axis II. The diagnosis of Personality Disorders according to the Manual (p630) requires an evaluation of the individual's long-term patterns of functioning, and the particular personality features must be evident by early adulthood. The personality traits that define these disorders must also be distinguished from characteristics that emerge in response to specific situational stressors or more transient mental states.

The clinician should assess the stability of the personality traits over time and across different situations. Although a single interview with the person is sometimes sufficient for making the diagnosis, it is often necessary to conduct more than one interview and to space these over time. Assessment may also be complicated by the fact that the individual may not consider the characteristics that define a Personality Disorder problematic. To help overcome this difficulty, supplementary information from other informants may be helpful.

6.2.8 DSM-IV describes 10 specific personality disorders grouped into three clusters based on descriptive similarities:

"Cluster A Personality Disorders

301.0 Paranoid Personality Disorder

301.20 Schizoid Personality Disorder

301.22 Schizotypal Personality Disorder

"Cluster B Personality Disorders

301.7 Anti-social Personality Disorders

301.83 Borderline Personality Disorder

301.50 Histrionic Personality Disorder

301.81 Narcissistic Personality Disorder

"Cluster C Personality Disorders

301.82 Avoidant Personality Disorder

301.6 Dependent Personality Disorder

301.83 Obsessive-Compulsive Personality Disorder

301.9 Personality Disorder Not Other wise Specified

6.2.9 Of the above, 301.7 Anti-social Personality Disorder correlates most closely with psychopathy, the diagnostic criteria for which is as follows:

A: there is a pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years, as indicated by three (or more) of the following:

(1) failure to conform to social norms with respect to lawful behaviours as indicated by repeatedly performing acts that are grounds for arrest;

(2) deceitfulness, as indicated by repeated lying, use of aliases, or conning others for profit or for pleasure;

(3) impulsivity or failure to plan ahead;

(4) irritability and aggressiveness, as indicated by repeated physical fights or assaults;

(5) reckless disregard for safety of self or others;

(6) consistent irresponsibility, as indicated by repeated failure to sustain consistent work behaviour or honour financial obligations;

(7) lack of remorse as indicated by being different to or rationalizing having hurt, mistreated, or stolen from another,

B: The individual is at least age 18 years.

C: There is evidence of conduct disorder with onset before the age of 15 years.

D: The occurrence of anti-social behaviour is not exclusively during the course of a schizophrenic or a manic episode.

Dimensional Models for Personality Disorders

6.2.10 An alternative to the categorical approach to classification is the dimensional perspective described in the DSM-IV Manual which is based upon the hypothesis that Personality Disorders represent maladaptive variants of personality traits that merge imperceptibly into normality and into one another.

Hare's Psychopathy Checklist (PCL- Revised)

6.2.11 Hare (1991)36 took 16 criteria delineated by Cleckley (referred to above) as characteristic in the diagnosis of psychopathy and, with further refinement, developed a 20-item check-list consisting of characteristic traits found typically in psychopathy and which can be used in making a diagnosis according to Hare's scheme. This classification is particularly useful for research purposes and for determining severity. The items are a compromise between what the patient self-reports and what the clinician observes about his behaviour. There are other classifications and typologies of importance and they are discussed in detail in the book by Dolan and Coid (referred to above).

6.2.12 The evidence of the British Psychological Society advised us that the reliability of diagnosis using the DSM and ICD classifications is poor, the high levels of co-morbidity of personality disorders make discrimination difficult and that diagnosis has little predictive validity in terms of providing information about likely treatment outcome or in terms of indicating the appropriate treatment type.

Diagnosis of Personality Disorder

6.2.13 In their paper Marlowe and Sugarman (199737) note that it is generally agreed that the diagnosis of personality disorder of any type should not be made unless certain conditions are met. Based upon the "clusters" described above in DSM-IV:

Cluster A ­ Patients often seem odd or eccentric (such as paranoid or schizoid). Schizotypal disorder is often included in this cluster.

Cluster B ­ Patients may seem dramatic, emotional, or erratic (such as dissocial, histrionic, or borderline type of emotionally unstable personality).

Cluster C ­ Patients present as anxious or fearful (such as dependent, anxious, anankastic.

6.2.14 The DSM-IV Manual lists general diagnostic criteria for a Personality Disorder:

"A. An enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individuals culture. This pattern is manifested in two (or more ) of the following areas:

(1) cognition (ie, ways of perceiving and interpreting self, other people and events);

(2) affectivity (ie, the range, intensity, liability, and appropriateness of emotional response);

(3) inter-personal functioning;

(4) impulse control.

B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations.

C. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.

D. The pattern is stable and of long duration and its onset can be traced back at least to adolescence or early adulthood.

E. The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder.

F. The enduring pattern is not due to the direct physiological effects of a substance (e.g. a drug of abuse, a medication) or a general medical condition (e.g. head trauma)."

6.3.0 The "Lottery"

6.3.1 Whether or not a convicted offender is diagnosed as suffering from psychopathic disorder and becomes the subject of a hospital order is, to a considerable extent, a matter
of chance. If it is thought that an accused person may be suffering from a mental disorder
a psychiatric assessment is requested by the prosecution or defence, or both, prior to
the hearing for the purpose, usually, of giving advice with reference to criminal
responsibility and disposal in the event of conviction. There are not uncommonly two assessments, one for each side.

6.3.2 After conviction the Judge will consider any recommendations including any evidence justifying consideration of a hospital order (section 37, Mental Health Act 1983) made by two doctors, one of whom must be approved for the purposes of section 12, Mental Health Act 1983. Medical recommendations must specify the class of mental disorder present and the doctors must agree. After he has considered all the facts and if he has it in mind, the Judge may make an order. A bed must be available in an appropriate hospital. (At the High Security Hospitals, their Admissions Board must accept the recommendation for admission). After hearing oral evidence from one of the doctors, the Judge may, if he considers it appropriate, make a hospital order under section 37 of the Act. He may also add to the hospital order a restriction order under section 41. The consequences of a restriction order are that the patient can not be discharged, be given leave of absence or be transferred to another hospital without the agreement of the Home Secretary.

6.3.3 Psychiatric assessments are frequently given following one interview, they are
not always carried out by psychiatrists trained in forensic psychiatry, the doctors do not
always have access to all the previous documentation relating to the history of the
patient. In addition, it is believed that psychiatrists have widely differing views and degrees of optimism or pessimism about the diagnosis and treatability of psychopathic disorder
(see for instance Cope (1996)38 who carried out a survey of the opinions of forensic psychiatrists on this subject).

6.3.4 So that for the convicted man the outcome depends upon:

(i) his presentation being recognised as possibly related to psychopathic disorder;

(ii) the views of the assessing medical practitioners, their experience and training, (and, we heard in evidence, an important factor can be the interest of a particular patient to the doctor);

(iii) the availability of an appropriately secure bed;

(iv) the decision of the judge, taking all the circumstances into account.

6.3.5 The grounds for the clinician's diagnosis are rarely challenged. As Dr Chiswick (1992)39 has said, of the Mental Health Act classification of psychopathic disorder: "There has been little legal exploration of its meaning and no authoritative testing of terms such as 'abnormally aggressive' or 'seriously irresponsible'. Its legal interpretation is whatever a particular court decides at a particular time."

6.3.6 Dr Chiswick, in the same paper, refers to the 'very elasticity' of the personality disorder category. Because its definition is legal, not clinical, and is unlikely to be the subject of scrutiny, it is possible for almost any violent offender to slip into this category. He continues:

"What is special about those classified and accepted for admission by a special hospital psychiatrist? Tens of thousands of men are convicted of violent crimes every year; a handful find their way into Special Hospitals ­ how do they get selected? Do the 400 psychopaths detained in Special Hospitals share common clinical features that are absent in the thousands of violent men who are processed through the penal system?"

6.3.7 Bearing in mind the indeterminate nature of such an order with respect to psychopathic disorder (which we will discuss further) it may not always be perceived as the most desirable outcome by the individual offender himself. Indeed, as Hoggett (1990)40 points out (p. 52), far from amounting to an excuse, the label 'psychopath' is likely to do an offender more harm than good. If a hospital order is not recommended or a hospital place cannot be found, the court may be tempted to impose a prison sentence at the top of the range because, by definition, he is more than usually dangerous.

6.3.8 The uncertainties in this process have been called a "lottery" and many witnesses were in agreement that there are substantial and important steps that can be taken to minimise the element of chance which presently determines the placement of some offenders. (We address this in our recommendations).

6.4.0 Terminology and Diagnosis of Personality Disorder

Expert Evidence to this Inquiry

6.4.1 It was crystal-clear from an early stage of this Inquiry that opinion on these topics was not likely to be straightforward or unanimous. As is evident from the history of this subject as outlined above there is an extensive record of differing views and disagreement and a lack of definition and scientific objectivity about personality disorder. It is also evident from the difficulties that the Royal College of Psychiatrists encountered in preparing evidence for this Inquiry. The College was unable to give us any guidance in our endeavour to elucidate the definition and treatment of personality disorder:

"There has been a wide spectrum of opinion within the College and particularly within the Forensic Psychiatry Section about this . . ." (Dr Anton Obholzer.)

6.4.2 The College, as the body which represents psychiatry and psychiatrists in the United Kingdom might have been expected to provide us with a clear and contemporaneous view about the diagnosis and treatment of severe personality disorder. We understand and sympathise with the problems they faced in trying to do so. Instead they urged "caution against coming to hard and fast conclusions about matters which are of considerable professional debate throughout the world and where research evidence to date is lacking in many areas".

6.4.3 It has been our objective to attempt to clear the water and to make our eventual recommendations with as much understanding as possible of the opinion and experience of British practitioners and researchers today.

6.4.4 There is no doubt that more research is needed, a great deal more, to improve the validity and reliability of clinical diagnosis and classification, treatability, and types of treatment, the assessment of need for this patient group, to define the services that are required and to redefine this field of social policy. That is all true; but in the meantime, we believe the time has come to grasp the nettle and recommend the way forward in the light of our understanding at the present time, bearing in mind the need to provide a framework that is capable of change in the light of developments in the future.

6.4.5 We decided to invite statements from a range of expert opinion and to set aside two weeks of our public hearings to allow questioning and cross-examination of many of them. We also received statements from many other witnesses relevant to this subject. We particularly canvassed opinion about the validity of the diagnosis of severe personality disorder, the value of treatment, the services needed to meet the needs of individuals suffering from severe personality disorder and the relevance of the legal category of "psychopathic disorder". We discussed many other issues with those who were good enough to respond to our invitation to appear before us in person, and we are most grateful to them for their assistance.

Definition

6.4.6 There is no simple and generally accepted definition of severe personality disorder, as Professor John Gunn explained, and a number of witnesses noted, it is not a term that appears in any of the existing classifications.

6.4.7 The terms used to define psychopathy have moral and political overtones and "psychopath" is now in disrepute. The Hare Checklist is a long string of pejorative adjectives derived from Cleckley's description of psychopathy and although this diagnostic system is increasingly used there was criticism of it from a number of witnesses. Professor Pamela Taylor, for instance, felt that although there is evidence for reliability, the nature of the
terms used might be reflecting the personal prejudices of the interviewers and therapists. Others, however, considered it a valuable tool in the assessment of risk of causing
serious harm to others.

6.4.8 "Psychopath" is stigmatising and to be avoided, but because of its association with anti-social behaviour it is seen in a moral as well as a medical context.

6.4.9 Is personality disorder "a disease"? Applying one model, the justification for this interpretation depends upon the use of criteria given by Scadding (1990)41 who described diseases as conditions which place an individual at biological disadvantage. Professor Gunn, who drew our attention to this concept, also referred us to his and Professor Taylor's edited textbook42 where concepts of disease (and its differentiation from "illness", "disorder" and other terms) are discussed in detail. They argue for and adopt the term "disease" in preference to the term "disorder" in their book, but confess that "not all our authors share the editors' enthusiasm for this perspective and some . . . have refused to call personality disorders diseases". In their oral evidence it was common ground among the psychiatrists who gave evidence that some personality disordered individuals proved to be treatment resistant.

6.4.10 The morbidity and mortality, suicide rates and response to ameliorative measures (rather than cure) justify regarding personality disorder as a disease and properly as a medical problem of management in the opinion of Professors Gunn and Taylor. We are aware from evidence from a variety of sources that personality disorder presents a serious and costly public health problem in terms of its consequences such as alcoholism, drug abuse, criminality, child abuse or neglect, HIV transmission, violence and high level of medical consultations. Others drew attention to established evidence from long-term follow-up studies that demonstrate that conduct disorders in childhood have high predictive value for the development of psychopathic and related personality disorders in later life (e.g. Robins 1966,43 West 1969,44 Scott 197745).

6.4.11 Another recent approach, said Professor Blackburn in evidence, is that the common feature of illnesses is that they are disabilities or dysfunctions that are harmful to the individual, or others, and within those terms, personality disorders can be regarded as illnesses to be dealt with as mental health problems.

6.4.12 The problem is not so much the validity of diagnostic systems, which are established, but the poor quality of training in diagnosis in the United Kingdom, and a lack of consensus about which system should be used (according to Professor Coid). It is notable, as Professors Coid and Blackburn have both said, that those classified as "psychopathic disorder" under the Act often in fact have more than one personality disorder in terms of diagnosis and are a heterogeneous group.

6.4.13 Questions about the treatability of "legal psychopaths" have to be distinguished from questions about "clinical psychopaths". No single clinical category of personality disorder predominates and only some "legal psychopaths" meet the criteria for anti-social personality disorder. Indeed, Professor Coid told us that in 1992 he found that only 23 per cent of males and 31 per cent of females detained as suffering from psychopathic disorder under the Act met the PCLR (Hare) criteria. Many legal psychopaths have suffered from mental illnesses in the past and many patients within the legal category of mental illness meet the diagnostic criteria for personality disorder. In short, the legal categories are often arbitrary, the reliability (that is to say the consistency or agreement between clinicians) of diagnosis is poor, with the exception of anti-social personality disorder, and diagnosis has little predictive reliability with respect to treatment outcome (according to the evidence of Professor Coid, Professor Blackburn, and Dr Thomas-Peter among others). Dr Snowden considered that the replacement of "psychopathic disorder" with "personality disorder" would achieve a closer correspondence between the legal classification and the clinical diagnostic category increasingly now described in terms of ICD-10 and DSM-IVR.

What is a personality disorder?

6.4.14 Dr Chiswick, in his evidence to us made clear that personality disorder exists as a clinical entity and he quoted a summary of its key features given by Marlowe and Sugarman (1997)46 in a paper in the British Medical Journal which is likely to command broad professional agreement and which seem to us simple and useful:

The patient: displays a pattern of behaviour, emotional response, perception of self

which is: evident in early life, persistent into adulthood, pervasive, inflexible, a deviation from the patient's cultural norm

and leads to distress to self, others or society

but is not attributable to: other psychiatric disorder (e.g. schizophrenia or drug misuse, or to other physical disorder (e.g. intoxication or brain disease)).

32 Department of Health, Home Office. Working Group on Psychopathic Disorder (1994). Report. Department of Health/Home Office (Chairman: Dr John Reed CB)

33 Higgins J (1995) Crime and mental disorder II, Forensic aspects of psychiatric disorder. In Chiswick D and Cope R eds. Seminars in Practical Forensic Psychiatry. Gaskell Press, London

34 Gelder M, Gath D and Mayou R (1989) Oxford Textbook of Psychiatry, 2nd ed. Oxford University Press, Oxford

35 Schneider K (1963) Psychopathic Personalities (translation of 9th ed. By M W Hamilton). Cassell, London

36 Hare RD (1991) The Hare Psychopathy Checklist. Revised. Multi Health Systems, Toronto

37 Marlowe M and Sugarman P (1997) Disorders of Personality. British Medical Journal, 131, 176­179

38 Cope R (1992) A survey of forensic psychiatrists'views on psychopathic disorder. Journal of Forensic Psychiatry; 4: 2

39 Chiswick D (1992) Compulsory treatment of patients with psychopathic disorder: an abnormally aggressive or seriously irresponsible exercise? Criminal Behaviour and Mental Health; 2: 2.106­113

40 Hoggett B (1990) Mental Health Law 3rd ed. Sweet and Maxwell, London

41 Scadding JG (1990) The semantic problems of psychiatry. Psychological Medicine, 20 243­8

42 Gunn J and Taylor P (eds) (1993) Forensic Psychiatry. Clinical, legal and ethical issues. Butterworth-Heinemann, Oxford

43 Robins L (1966) Deviant children grown up; a sociological and psychiatric study of sociopathic personality. Williams and Wilkins, Baltimore

44 West DJ (1969) Present conduct and future delinquency. Heinemann Educational books, London

45 Scott PD (1977) Assessing dangerousness in criminals. British Journal of Psychiatry, 131, 127­142

46 Marlowe M and Sugarman P (1997) cited above