Last updated on 31st January 2009
Yesterday NICE - the National Institute for Health and Clinical Excellence in England & Wales - published guidance on a diverse range of fifteen clinical, technology, interventional and public health subjects. Their clinical guidance on Medicines Adherence interested me, as too did their public health guidance on Promoting Physical Activity for Children and Young People. The subject of this post is the clinical guidance on Antisocial Personality Disorder and in my next post, I'll talk about their guidance on Borderline Personality Disorder. As Dr Tim Kendall, Joint Director, National Collaborating Centre for Mental Health, states: "Approximately 2 million people in the UK have personality disorders, with antisocial and borderline disorders being the most common. We have largely ignored this problem or have been too dependent on drug treatments that don't work and in some cases (for example the use of antipsychotics) can be harmful."
In a press release, NICE comment "Antisocial personality disorder is a condition that affects a person's thoughts, emotions and behaviour in a way that is disruptive to, and may be harmful to, other people. People with ASPD exhibit traits of impulsivity, anger and associated behaviours including irresponsible, recklessness and deceitfulness. They have often grown up in fractured families in which parental conflict is typical and parenting is harsh and inconsistent. Many people with antisocial personality disorder have a criminal conviction and are imprisoned or die prematurely as a result of reckless behaviour. Antisocial personality disorder is not usually diagnosed before the age of 18 but characteristics of the disorder can be recognised in younger people as conduct problems. Early treatment of children (aged 5-11 years) and young people (aged 12-17 years) with conduct problems may help to prevent antisocial personality disorder from developing later." One of the authors of the guidance, Professor Conor Duggan writes "Many people with antisocial personality disorder have a criminal conviction and are imprisoned. There is often too much focus on what the person has done wrong rather than why. The prevalence of ASPD in prisoners is 50%. The cost of keeping a young offender in institutes can be up to £192k per annum per individual. Because 70% of all prisoners released reoffend within 2 years, there are potentially huge savings to be made by investing in behavioural and psychological therapies to prevent people with ASPD from reoffending thereby benefiting the person and society as a whole." while another author, Dr Stephen Pilling, comments "There is evidence to show that working with children who are at risk of developing conduct disorder and their families could prevent them from developing ASPD as adults. It is important that we make these investments early on to realise the benefits to these families and society in the future."
In the 393 page full guidance (pages 21 & 22), the commoness of antisocial personality disorder is discussed: "The prevalence of antisocial personality disorder in the general population varies depending on the methodology used, and the countries studied, but all show that the condition is much more prevalent among men. For instance, the lifetime prevalence in two North American studies was 4.5% among men and 0.8% among women (Robins et al., 1991) and 6.8% among men and 0.8% in women (Swanson et al., 1994). Conversely, two European studies found a prevalence of 1.3% in men and 0% in women (Torgensen et al., 2001) and 1% in men and 0.2% in women (Coid et al., 2006). Despite these relative differences, the rates of antisocial personality disorder reported indicate that even with the most conservative estimates antisocial personality disorder has the same prevalence in men as schizophrenia, which is the condition that receives the greatest attention from mental health professionals. While the incidence of antisocial personality disorder in women may be lower and the threshold for entry to services such as forensic services or the criminal justice system higher, there is some evidence to suggest that women with antisocial personality disorder (Yang & Coid, 2007) have greater severity of problems characterised by more complex comorbidities for both Axis I and Axis II disorders and corresponding poor outcomes (for example, Galen et al., 2000)."
Key recommendations from the guideline include: 1.) Staff working with people with antisocial personality disorder should recognise that a positive and rewarding approach is more likely to be successful than a punitive approach in engaging and retaining people in treatment. 2.) Cognitive problem-solving skills training should be considered for children aged 8 years and older with conduct problems. 3.) For people with antisocial personality disorder with a history of offending behaviour who are in community and institutional care, consider offering group-based cognitive and behavioural interventions (for example, programmes such as ‘reasoning and rehabilitation') focused on reducing offending and other antisocial behaviour.
NICE also publish an associated 38 page Costing Report on the training, cost (and savings) implications of putting their guidance on Antisocial Personality Disorder into practice.