Antisocial personality disorder

1. Antisocial personality disorder Implementing NICE guidance 2009 NICE clinical guideline 77

2. What this presentation covers • Background • Scope • Key priorities for implementation • Costs and savings • Discussion • Find out more

3. Characteristics • Antisocial personality disorder is associated with: • disregard for and violation of the rights of others • social impairment and offending behaviours • increased risk of mental and physical health problems, particularly substance misuse. • Risk factors include: • conduct disorder in childhood or adolescence • family factors including abuse.

4. Relationship with criminal behaviour • Criminal behaviour is central to the definition of antisocial personality disorder: • many people have a criminal conviction or die prematurely as a result of reckless behaviour • nearly half of prisoners have antisocial personality disorder. • But there is more to it than criminal behaviour alone: • nearly half of people affected have no convictions.

5. Demand on primary care, general psychiatry and other services • People with antisocial personality disorder make heavy demands on services – many services are involved. • Most will be in contact with primary care – but their needs are often not recognised. • Secondary mental health services treat many – but often for other disorders. • Forensic mental health services and inpatient services – if too complex for secondary mental health services. • Greater awareness and coordination are needed.

6. Scope • The treatment and care of adults with a diagnosis of antisocial personality disorder in the NHS and prison system. • Preventative interventions with children and adolescents at significant risk of developing antisocial personality disorder. • Covers the care provided by primary, community, secondary and specialist health care services within the NHS • Is relevant to the work, but does not cover the practice, of those in; occupational health services, social services and the independent sector

7. Key priorities for implementation • Developing an optimistic and trusting relationship • Cognitive behavioural interventions for children aged 8 years and older with conduct problems • Assessment in forensic/specialist personality disorder services • Treatment of comorbid disorders • The role of psychological interventions • Multi-agency care

8. Developing an optimistic and trusting relationship A positive and rewarding approach is more likely to be successful in engaging and retaining people in treatment. Staff should: • explore treatment options in an atmosphere of hope and optimism, explaining that recovery is possible and attainable • build a trusting relationship, work in an open, engaging and non-judgemental manner, and be consistent and reliable .

9. Cognitive behavioural interventions for children aged 8 years and older with conduct problems Cognitive problem-solving skills training should be considered for children aged 8 years and older with conduct problems if: • the child’s family is unwilling or unable to engage with a parent-training programme • additional factors, such as callous and unemotional traits in the child, may reduce the likelihood of the child benefiting from parent-training programmes alone.

10. Assessment in forensic/specialist personality disorder services • Healthcare professionals should consider, as part of a structured clinical assessment, routinely using: • a standardised measure of the severity of antisocial personality disorder • a formal assessment tool to develop a risk management strategy

11. Treatment of comorbid disorders People with antisocial personality disorder should be offered treatment for any comorbid disorders in line with recommendations in the relevant NICE clinical guideline This should happen regardless of whether the person is receiving treatment for antisocial personality disorder

12. The role of psychological interventions • 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 focused on reducing offending and other antisocial behaviour

13. Multi-agency care (1) • Services should ensure clear pathways so that the most effective multi-agency care is provided • These pathways should: • - specify the various interventions that are available at each point • enable effective communication and provide the means to resolve differences and disagreements • Establish local criteria to facilitate transfer of care between services; develop shared objective criteria relating to comprehensive assessment of need and risk

14. Multi-agency care (2) Consider establishing multi-agency antisocial personality disorder networks, where possible linked to other personality disorder networks These should actively involve people with antisocial personality disorder and should: • take a significant role in training staff • have resources to provide specialist support and supervision for staff • take a central role in the development of standards for and the coordination of clinical pathways • monitor the effective operation of clinical pathways

15. Costs per 100,000 population

16. Discussion • Does our current provision for children with conduct problems match the guideline’s recommendations? • How is severity and risk measured? Which tools are we using to assess and develop strategies for service users? • What interventions do we offer to people with antisocial personality disorder who have a history of offending behaviour? • How do we ensure that patient care pathways between agencies are effective for people with antisocial personality disorder? • What communication is there between agencies? How well do these compare with the guideline recommendation on networks?

17. Find out more • Visit www.nice.org.uk/CG77 for: • the guideline • the quick reference guide • ‘Understanding NICE guidance’ • costing report and template • audit support