In this CME, the link between personality disorders and violence is explored. Much still remains to be learned about the factors that mediate the link.
Premiere Date: October 20, 2021
Expiration Date: April 20, 2023
The goal of this activity is to update readers about the putative link between personality disorder and dangerousness.
1. Understand 3 cardinal elements contributing to legal definitions of dangerousness (namely, danger to self or others, inability to care for self, and, potentially, the need for treatment), and describe the empirical link between Cluster B personality disorders and violence.
2. Identify 3 limitations inherent in using risk assessment tools to verify the link between personality disorder and dangerousness (namely, categorical DSM classifications, the influence of social norms, and the redundancy of definitions that include aggression).
This accredited continuing education (CE) activity is intended for psychiatrists, psychologists, primary care physicians, physician assistants, nurse practitioners, and other health care professionals who seek to improve their care for patients with mental health disorders.
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Driven by a mandate to protect the public, many Western jurisdictions call upon psychiatrists, particularly forensic specialists, to evaluate dangerousness in individuals with mental disorders. Such evaluations occur for civil and criminal proceedings, bail and parole determinations, and hospital and emergency department discharges.1-3 While risk assessment has become a relatively uncontested part of criminal proceedings in places like the United States and the United Kingdom (UK), the influence of expert testimony on civil commitment, guardianship, sentencing or release, and the attendant civil liberties require a careful look at the accuracy and reliability of expert assessments,3 especially among the prevalent but commonly misunderstood personality disorders.4
This article examines the empirical literature on the link between personality disorders and dangerousness, the limitations inherent in using risk assessment tools to verify the link, and the ethical issues surrounding the assessment.
What Is a Personality Disorder?
The DSM-5 defines personality disorder as “an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in early adolescence or early adulthood, is stable over time and leads to distress or impairment.”5
This definition attests to the pervasive, persistent, and problematic nature of the disorder, not just how the individual is currently presenting. DSM-5 recognizes 10 types of personality disorder (apart from personality disorder not otherwise specified).5 These are classified into 3 well-known clusters: Cluster A (paranoid, schizoid, schizotypal); Cluster B (antisocial, borderline, histrionic, narcissistic); and Cluster C (avoidant, dependent, obsessive-compulsive).
Five major epidemiological studies in the United States showed overall prevalence rates of around 10% for any personality disorder.6 The comprehensive National Comorbidity Study Replication reported a past-year prevalence of 9.1% for any personality disorder among adults 18 years and older.7 The most common personality disorder was the avoidant type (5.2%), followed by schizoid (4.9%), schizotypal (3.3%), obsessive-compulsive (2.4%), paranoid (2.3%), borderline (1.6), antisocial (1.0%), and dependent (0.6%). The study recorded no cases of histrionic or narcissistic personality disorders. Although the National Epidemiologic Survey on Alcohol and Related Conditions did not report an overall prevalence rate for personality disorders, it did identify higher rates for histrionic (1.8%)8 and narcissistic (6.2%) personality.9
In contrast, European studies report lower prevalence rates. For instance, the British household survey of more than 8000 respondents found a prevalence rate of 4.4% in the general population, with higher rates being reported in men, the unemployed, those who were separated or divorced, and those living in urban areas.10
Notwithstanding variations in prevalence, personality disorders, particularly antisocial personality disorder (AsPD), exact a substantial health and economic burden, affecting health service utilization, unemployment, criminality, suicidality, and homelessness.11 AsPD has particularly strong effects on violence.10
What Is Dangerousness?
One challenge to linking personality disorder to dangerousness is that no universally accepted definition exists, although some commentators distinguish clinical and legal dangerousness.12 An early definition of clinical dangerousness regarded it as “a propensity to cause serious physical injury or lasting psychological harm.”13 More recent definitions are mainly legal, so they vary across jurisdictions. A notable exception intended to assess and treat individuals with Dangerous and Severe Personality Disorder (DSPD) is the UK’s DSPD Program, launched in 2001 in 2 high-security prisons and 2 high-security forensic hospitals. An individual was classified as having DSPD if they showed evidence of both dangerousness (defined as a high risk of harm to others) and severe personality disorder, as well as a functional link between the 2. Severe personality disorder was operationalized as high scores (25 or above) on the well-established Psychopathy Checklist–Revised, in conjunction with at least 1 personality disorder other than antisocial, or 2 or more personality disorders.14,15 The program was a costly one that catered to the needs of only a few hundred individuals with DSPD who were detained in maximum security. There was little or no provision for those living in the community. It was eventually ended in favor of a new community-based strategy for managing personality-disordered offenders. The new strategy adopted a whole-systems approach across the criminal justice and health systems, recognizing the various stages of an offender’s journey from sentence through community reintegration.16
Legal definitions tend to be prescriptive. For example, in the United States, the evolution of dangerousness is most clearly seen in statutes on civil commitment, where dangerousness ultimately replaced illness as a standard for hospitalizing individuals against their will.17,18 Often traced back to the passage in the District of Columbia of the influential Ervin Act of 1964 (an early piece of influential legislation named for US Senator Sam Ervin of Watergate fame), dangerousness usually required an imminent threat, generally interpreted as physical harm to oneself or others. A right to treatment based in the US Constitution’s due process clause never materialized. Many states instead followed the District’s commitment model, emphasizing the specific link between mental illness and danger. The US Supreme Court ultimately underscored the risk of harm, adding the inability to care for oneself and intimating that treatment may be required as well.19
Under the UK’s Criminal Justice Act 2003, an offender is classified as dangerous “if the court is of the opinion that there is significant risk to members of the public of serious harm occasioned by the commission by him of further specified offenses.”20 A “specified offence” is a violent, sexual, or terrorism offense, and “serious harm” means “death or serious personal injury, whether physical or psychological.”20
A consideration common to most legal definitions is that dangerousness is a relatively stable attribute of the individual,12 although scientific evidence shows that human behavior is influenced by a complex interplay of individual and environmental factors.21 This is a conflict that calls for a comprehensive clinical assessment for any individual facing a concern for violence, including a review of protective factors.
Assessment of Dangerousness
Current approaches to assessment of dangerousness rely on violence (including sexual) risk assessment tools, which fall into 3 broad categories (Table 1): unstructured clinical, actuarial, and structured professional judgment. While the unstructured clinical approach performs better than chance in predicting future violence, it has been criticized for lacking reliability and validity.22
Actuarial approaches rely heavily on static (unchangeable) risk factors (ie, sex, prior offenses, age at release) and provide probabilistic estimates of the risk of future violence within a specified time period.23 Actuarial approaches have been criticized for leaving no room for clinical discretion and for relying on factors that are not amenable to change.24 Additionally, their accuracy in predicting rare events has been contested because they rely on information derived from group data to assess risk for an individual.3
Structured professional judgment approaches rely on a constellation of actuarial and dynamic (changeable) risk factors that have been empirically associated with future violence. While they help bridge the gap between clinical and actuarial approaches, structured judgments are resource intensive and their predictive value is often less than robust.24
While each approach has its advocates and critics, none is wholly satisfactory.12 A problem common to actuarial and structured professional judgment is the difficulty inherent in predicting a behavior with a low base rate. To illustrate the point, Singh et al reported significant variations in actual rates of violence in individuals identified as high risk by structured instruments, likely due to failure to account for local base rates for violence.25 Although collateral information about violence rates in the geographic area may be useful, the issue of how to obtain and incorporate this information into risk assessments is yet to be determined.
Another problem is the variability in predictive accuracy of these tools. In 74 samples totalling 24,847 individuals, for example, Fazel et al assessed the predictive validity of the 9 most commonly used tools assessing the risk of violence, sexual, and criminal behavior (Table 2).26 The authors reported that although violence risk-assessment tools performed better than those designed to predict sexual and general offending, they had a median predictive value of only 41% with a corresponding median number needed to detain of 2 (range, 2-4). The evidence did not support the use of these tools as sole determinants of decisions related to detention, sentencing, and release.
Similarly, Buchanan and Lesse reported on the sensitivity and specificity of actuarial and structured tools used to predict future violence among adults in the community.27 They reported a mean sensitivity of 0.52 (essentially a coin toss) and mean specificity of 0.68; the corresponding number needed-to-treat for these tools was 6. These are hardly encouraging numbers for assessments that carry significant dangers of detention, stigma, and criminalization.
What is the Link?
The association between personality disorders, particularly Cluster B, and violence is well-documented.28,29 For example, the British Household Survey found that individuals with a Cluster B personality disorder were 10 times more likely than those without to have a criminal conviction, whereas individuals with a Cluster A or C personality disorder were no more violent than the general population.30 Indeed, Yu et al reported an odds ratio of violence of 12.8 for those with AsPD compared with the general population.28
Despite the association between some personality disorders and violence, the mechanisms which mediate the link remain poorly understood. Any analysis must begin with the distinction between risk and causal factors. A risk factor is one that consistently predicts an outcome, while causality requires that certain criteria are actually met. These criteria are (1) covariance between the predictor and outcome (a measure of how much 2 factors vary together); (2) temporal precedence (ie, the predictor preceding the outcome); (3) exclusion of other plausible explanations; and (4) a logical connection between the predictor and outcome.31
In applying these criteria to the relationship between personality disorder and violence, Duggan and Howard found no unequivocal evidence to support a causal relationship, emphasizing the need to specify an understandable mechanism by which the disorder causes violence.4 They suggested that other variables like comorbidity with both DSM-IV Axis I and II may mediate the relationship.
However, a major obstacle to research and analysis is the problem inherent in the assessment and diagnosis of personality disorder itself. Current psychiatric classification systems like the DSM-5 are categorical and heavily influenced by prevailing social norms, whereas personality traits are dimensional in nature.12 This means that categorical measures of personality disorder are of limited validity, and that diagnosis may vary from one assessment method to another.32 This distinction between approaches (whether conditions fit neatly into a category or along a spectrum) continues to confound diagnosis because conditions overlap and differ in their range of impairment and severity. The DSM itself in 2013 described dimensionality as an emerging model, encouraged further research, and included dimensional approaches alongside the traditional categorical approach.
Another obstacle is the issue of circularity or redundancy.4 This arises because the diagnostic criteria for some Cluster B personality disorders include attributes that are already associated with criminality, namely aggression, anger outbursts, hostility, impulsivity, and callousness. The relationship between personality and violence is further confounded by comorbidity. Individuals with personality disorder typically present with more than 1 personality disorder, as well as other common disorders such as substance misuse, depression, and anxiety.33,34 Similarly, personality disorders, particularly cluster B, are highly prevalent among individuals with substance use disorders, with an overall prevalence rate of 56.5% reported among patients treated for addictions.35 These may all contribute to violence risk and further confound the link between personality disorder and violence.
A commonly reported comorbidity in forensic populations is the co-occurrence of antisocial and borderline personality disorders, alongside psychopathy. This has been linked to a wide range of antisocial outcomes, including both the severity and versatility of violent offending, as well as substance misuse.36,37
A persistent conundrum is the mechanism through which personality disorder, including personality comorbidity, is linked to violence. It has been suggested that factors linking personality disorder to violence may include emotional dysregulation, deficits in self-regulation, early-onset alcohol abuse (18 years or younger), and impulsivity.38-40 Influential factors can be protective as well, since some have been associated with desistence from crime. These include employment, marriage, association with prosocial peers, developing prosocial values and behaviors, and others.41
Beyond matters of scientific uncertainty, the ethics of working where psychiatry and the law overlap is bound to give rise to tensions between safety and liberty, and between the individual and the community. Denying one’s liberty on the grounds of a clinical opinion (diagnosis) couched in legal language (dangerousness) goes well beyond definitional uncertainties. Practitioners must be explicit about their inferences and opinions because the patient’s best interest matters to both law and psychiatry.3 At the same time, the community’s safety is a time-honored consideration as well. Balancing these influences is neither a medical nor legal exercise alone.
The traditional ethics question posed to psychiatrists assessing violence risk is this: Do they serve medicine or the law? Newer perspectives on forensic agency take views that advocate more clearly for the dignity of individuals and the professionalism of practitioners when pitting vulnerable patients against large social systems.42,43 It is important to remember that patients require support and advocacy when facing assessments that threaten their freedom, including appropriate informed consent and robust warnings on the limits of confidentiality.
Risk assessment itself is bound to raise ethical issues. As neither a medical nor psychological concept, it is not yet an exact science. There is disagreement about ethical values and what constitutes a risk to the community. There may be differences between professionals like judges and physicians, between professionals taking an actuarial or structured approach, and between plaintiffs and defendants. These are the tensions of an evolving science that incorporates medical, legal, and psychological concepts all at once (Table 3). Sadly, the community retains unrealistic expectations that psychiatrists can protect society with accurate assessments of rare events like physical or sexual violence.3
Although the link between some personality disorders and violence is well documented, much still remains to be learned about the factors that mediate the link. Indeed, some of these factors may be outside the sphere of medicine. The limitations are therefore manifold.
First, current measures of personality disorder are of limited validity and are heavily influenced by prevailing social norms.
Second, dangerousness is neither a medical nor psychological concept. It is primarily legal and varies across jurisdictions.
Third, current assessment tools are far from perfect. Certainly, the current evidence suggests that their use as sole determinants of dangerousness is fraught with difficulty.
Fourth, professional ethics require acknowledging the uncertainty of scientific methods, methods that enter a social forum like the courts where nonmedical standards of morality and culpability apply.
Finally, a determination of dangerousness carries a heavy stigma for the individual concerned, alongside the potential denial of liberty.
Ultimately, risk assessments are more appropriately conducted as part of a broader clinical process aimed at developing risk management plans for high-risk groups.3,26 For individual assessments, they require robust informed consent, warnings on the limits of confidentiality, and a strong understanding of low base-rate phenomena and the jurisdiction’s definition.
Dr Khalifa is an associate professor in forensic psychiatry at Queen’s University, Kingston, Ontario, Canada. He is also the regional psychiatry lead for the Ontario Region of Correctional Service Canada. Dr Candilis is director of medical affairs at Saint Elizabeths Hospital in Washington, DC, and professor of psychiatry and behavioral sciences at The George Washington University School of Medicine and Health Sciences.
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