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Fallon report will lead to an increase in psychiatrists role in personality disorder
- Adrian Warnock (24 January 1999)
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Treatability of personality disorder
- P V F Cosgrove (27 January 1999)
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Dangerousness, preventative detention and psychiatry
- Frank Holloway (7 February 1999)
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Antisocial personality disorder- Psychiatrist's role in management
- Dr.Kommu John Vijay sagar, Dr.Arockia Philip Raj , Tutor in Psychiatry. (28 November 2002)
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Adrian Warnock, SHO Psychiatry Royal London Hospital rotation
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Far from reducing psychiatrists responsibility for patients who are psychopaths1, if the recommendations of the Fallon report2 are enacted, doctors responsibility for personality disorder will increase. A key recommendation of the report is to ammend the Mental Health Act, replacing every instance of psychopathic disorder with 'personality disorder' whilst not defining the new legal term. This would have important implications. Firstly, there could then be no confusion as to the relevance of the act to individuals with personality disorder. Secondly, since the 'treatability clause' which lay at the heart of the controversy between the Home Secretary and the President of the Royal College of Psychiatrists3,4 will remain, it seems the law would attempt to end the controversy over the efficacy of treatment for personality disorder. Personality disordered individuals would be declared treatable, detainable and if not detained their psychiatrist would presumably be held to account for crimes they might commit.. If personality disorder is treatable, such treatment will require significant periods of time in specialised units with therapy playing a more important role than medication. This will need to take place away from the mentally ill, who in comparison need shorter periods with medicines playing a more important role. Currently there is a shortage of such specialist units, and most will not consider individuals on section. There will need to be a significant release of resources, and cultural change within psychiatry to allow this change to occur. An important human rights issue arises if large numbers of individuals will be detained for prolonged periods with at best an uncertain outcome in terms of improving their quality of life and reducing the risk to society at the end of the process. Research into the effectiveness of treating personality disorder in patients detained against their will is necessary. With the forthcoming Stone Inquiry likely to criticise preventative treatment of personality disordered individuals, resources as well as increased responsibility will be necessary to produce an improvement in the care of such individuals. 1. Eastman N. Who should take responsibility for antisocial personality disorder? BMJ 1999;318:206-7 2. Fallon P, Bluglass R, Edwards B, Daniels G. Report of the committee of inquiry into the personality disorder unit, Ashworth Special Hospital. (Full text also available at www.doh.gov.uk/fallon.htm) 3. Kendall R. Jack Straw and police under fire after Stone verdict. Times 1998;29 Oct:21. 4. Straw J. Straw's riposte on mental treatment. Times 1998;31 Oct:21. |
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P V F Cosgrove
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EDITOR - Eastman's editorial acknowledges "the poor state of research knowledge about treatability" of Antisocial Personality Disorder [1]. Gunn, in his Personal View, condemns the Fallon Enquiry for considering the nature and validity (and, therefore, treatability) of personality disorder [1]. These two psychiatrists represent the refusal of psychiatry to accept clinical responsibility for these patients. The greatest barrier to treatability is the universal fear amongst psychiatrists of using drugs which facilitate dopamine neurotransmission. There is published evidence for the treatability of personality disorder, but it has been overlooked by generations of adult psychiatrists. In 1944, Hill demonstrated that increasing dopamine neurotransmission in personality disordered patients (with a childhood history of hyperactivity) resulted in clinical improvements. He used the dopamine releasing agent, amphetamine [2]. In 1976, Wood et al found that improving dopamine neurotransmission resulted in significant improvements in control of rage and impulsiveness. They used the dopamine reuptake inhibitor, methylphenidate (Ritalin) [3]. In 1981, Wender et al demonstrated that the weak dopaminergic, pemoline, was more effective than placebo in regard to temper and impulse control and stress intolerance [4]. It is known that Antisocial Personality Disorder is ten times more likely to occur in adults who, as children, suffered from ADHD (ie hyperactivity) [5]. Since hyperactivity/ADHD is very responsive to treatment, it is likely that personality disorder will respond to the same improvement in dopamine neurotransmission. Unfortunately, adult psychiatrists know little about their patient's childhood behavioural antecedents. And even if they did discover hyperactivity or features of ADHD in their patient's developmental years, they would still never prescribe medicines that increase dopamine neurotransmission (such as Ritalin and Dexamphetamine). I hope that the Secretary of State for Health and the Home Secretary never let adult psychiatrists off the hook of responsibility, however much they and the President of the Royal College of Psychiatrists bleat about the untreatability of personality disorder. P V F Cosgrove Consultant Child & Adolescent Psychiatrist The Bristol Priority Clinic Bath Somerset BA2 5YD 1 Eastman N & Gunn J. Editorial & Personal View. BMJ 1999;318:206 & 271. (23 January.) 2 Hill D. Amphetamine in psychopathic states. Brit J Addiction 1944;44:50-54. 3 Wood RD, Reimherr FW, Wender PH. Diagnosis and treatment of minimal brain dysfunction in adults. Arch Gen Psychiat 1976;33;1453-1460. 4 Wender PH, Reimherr FW, Wood RD. Attention deficit disorder (minimal brain dysfunction) in adults. Arch Gen Psychiat 1981;38:449-456. 5 Mannuzza S, Klein RG, Bessler A, Malloy P, LaPadula M. Adult outcome of hyperactive boys. Educational achievement, occupational rank and psychiatric status. Arch Gen Psychiat 1993;50:565-576. Dr Cosgrove has no competing interest and does not in any way represent drug companies manufacturing dopaminergics. |
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Frank Holloway, Consultant psychaitrist Maudsley Hospital
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Sir, Eastman’s (1) discussion of the Fallon Report rightly identifies the dangers for the practice of psychiatry inherent in current public policy in the U.K., as psychiatrists are increasingly looked to as arbiters of public safety. We have previously proposed that mental health legislation needs to be viewed in a radically new light (2). We have proposed separating interventions aimed at treating people in their own best interests, who (because of mental incapacity) are unable to take treatment decisions for themselves, from interventions aimed at promoting the safety of the public. The former, but not the latter, can readily be ethically justified on paternalistic grounds. Moreover decisions about dangerousness, either before or after the fact of an offence, are not obviously linked to the expertise of psychiatrists; the overwhelming preponderance of violent, socially unacceptable or dangerous acts are committed by people who do not have a mental illness. Psychiatrists can properly advise the courts about the presence of mental illness, its likely prognosis and appropriate treatment. The evidence base for this advice is strongest for psychotic disorders and weakest, as Eastman points out, in the case of disorders of personality. It may, of course, also be possible for psychiatrists to infer links between the offending behavior and the presence of mental disorder: however judgments about the impact of any such linkage on the degree of responsibility that the offender holds for the act are a matter for society and the courts as its agent. If society is moving towards the (illusory) goal of eliminating violent or socially unacceptable acts it is surely a matter for legislators to delineate what actions are to be taken and for the courts to enforce these actions. Consistent with the Fallon proposals, we have argued that decisions about the management of people identified as dangerous should come before the courts in a framework of generic dangerousness legislation. Only after a decision is made to exclude the person from society on the grounds of dangerousness should consideration be made as to the appropriate disposal. This decision would necessarily involve expertise from a range of professions, including the probation service, social work, clinical psychology and psychiatry, but remain a judicial decision subject to rules of evidence, appeal, due process and review. One potential outcome of the process would be disposal to psychiatric treatment. But the determination of whether there is an illness to be treated should come after the decision to detain, not the other way round. Apart from the ethical advantage that all dangerous persons, mentally ill or not, would be treated equally, such an approach would free us up to design new psychosocial interventions for dangerous persons with personality disorders to be conducted by those with the necessary expertise, and without first needing to label such persons as mentally disordered so that the Mental Health Act can be used to preventatively detain them and thus force psychiatrists to take responsibility for their ‘treatment’. (1) Eastman N. Who should take responsibility for antisocial personality disorder? BMJ 199; 318, 206-7. (2) Szmukler G and Holloway F. The Mental Health Act is now a harmful anachronism. Psychiatric Bulletin 1998; 22, 662-665. Frank Holloway, Consultant Psychiatrist George Szmukler, Medical Director Bethlem and Maudsley NHS Trust, Maudsley Hospital, Denmark Hill, London SE5 8AZ |
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Dr.Kommu John Vijay sagar, Lecturer in Psychiatry Christian medical college,Vellore,INDIA, Dr.Arockia Philip Raj , Tutor in Psychiatry.
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In the developing countries , especially India ,there are no clear rules as in developed nations regarding role of Psychiatrist in the management of Antisocial personality .If the person is sent by a magistrate to a Psychiatrist(who works in a goverment hospital setup) ,he would be assessed for Fitness to stand trial . Once the Psychiatrist comes to a conclusion and gives a report to the court ,he is absolved of the responsibility of management of the patient . Competing interests: None declared |
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