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Psychiatric Quarterly, Vol. 73, No. 4, Winter 2002 (°

C 2002)

PERSONALITY DISORDERS IN PRISON:

AREN’T THEY ALL ANTISOCIAL?

Merrill Rotter, M.D., Bruce Way, Ph.D.,

Michael Steinbacher, M.A., Donald Sawyer, Ph.D.,
and Hal Smith

The provision of mental health services in the correctional system is challenging

at best for various clinical, administrative, and structural reasons. Among the
complicating factors is the assessment and management of character pathology
which either confounds the treatment of more “serious” mental illnesses, e.g.
Axis I disorders, and/or presents itself as the primary focus for intervention. In
this paper we review the prevalence of personality disorders on the prison men-
tal health services caseload in New York State. We compare inpatient and out-
patient rates among the various disorders documented in the prison system, as
well as look at these rates within the context of the rates of personality disorder
in the state mental health system generally. Assessment of personality disor-
der will be addressed with particular attention to the confounding influence of
the prison environment. Finally, treatment options will be discussed, including

Merrill Rotter, M.D., is Associate Clinical Professor of Psychiatry, Department of Psy-

chiatry, Albert Einstein College of Medicine, 1500 Waters Place, Bronx, NY.
Bruce Way, Ph.D., is affiliated with Central New York Psychiatric Center, New York.
Michael Steinbacher, M.A., is affiliated with Sing Sing Correctional Facility.
Donald Sawyer, Ph.D. and Hal Smith are affiliated with Central New York Psychiatric
Center, New York.
Address correspondence to Merrill Rotter, M.D., Associate Clinical Professor of Psychi-
atry, Department of Psychiatry, Albert Einstein College of Medicine, 1500 Waters Place,
Bronx, NY 10461; e-mail: mrotter@omh.state.ny.us.
337

0033-2720/02/1200-0337/0 °
C 2002 Human Sciences Press, Inc.
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338 PSYCHIATRIC QUARTERLY

discussion of new initiatives that attempt to address inmates with serious men-
tal illness and personality traits that lead to disciplinary housing.

KEY WORDS: personality disorders; antisocial personality disorder; correctional men-

tal health.

INTRODUCTION

“10% mad, 15% bad and 75% sad,” Speed’s 1973 characterization of
inmate populations, captures three essential truths about the condi-
tions in correctional settings (1). First, individuals who are “mad” (ie.
seriously mentally ill) are overrepresented among inmates when com-
pared to the general population (2). Second, the “bad” (ie. sociopaths)
are underrepresented when compared to the generally accepted notion
that all criminals must be sociopathic (3). Third, correctional institu-
tions are noxious and inescapable environments that affect all the rest
(the “sad”) even if they do not fall into one of the former categories (4).
In addition, with these three broad strokes, Speed anticipated the focus
in the literature in correctional psychiatry to date: the assessment and
treatment of serious mental illness; the limited targeting of personality
disorder to those associated with disruptive and dangerous inmates (5);
and the impact of the correctional environment.
In this paper we present findings from our own review of person-
ality disorder prevalence on a correctional mental health service. To
fully appreciate the data presented, we will first review the literature
to date. It is a literature with specific limitations, given the legal, clin-
ical, and correctional contexts within which the research has been un-
dertaken. It is these contextual influences which have driven the fo-
cus toward Axis I disorders and primarily limited attention on Axis II
to those disorders (i.e. antisocial and borderline) with the most seri-
ous behavioral manifestations and consequences. We begin with legal
context.

Legal Context

The threshold for minimally acceptable legal standard of clinical care

for sentenced inmates was first set by the US Supreme Court in 1975.
In the landmark case, Estelle v. Gamble, the Court ruled that the cor-
rect standard of care in assessing the adequacy of a correctional sys-
tem’s response to an inmate’s injury was whether the system showed
“deliberate indifference to serious medical needs” (6). This standard
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MERRILL ROTTER ET AL. 339

was further defined and narrowed by the Court in 1994, when it ruled
that “deliberate indifference” required actual knowledge of the serious
medical needs that were then ignored (rather than a lower, malprac-
tice like standard in which physicians may be held liable for what they
should have known) (7).
Legal definitions of the “serious medical needs” to which correctional
institutions must attend have included parameters such as pain, med-
ical necessity, and risk of significant impairment or injury (8). Thus,
personality characteristics that are associated with intra psychic dis-
tress alone would not rise to the level of emotional disturbance for which
the law requires treatment in correctional settings.

Clinical Context

There are unique confounds in applying the criteria for personality

disorders in jails and prisons. DSM IV defines personality disorder as
an “enduring pattern of inner experience and behavior that deviates
markedly from expectations of the individual’s culture” (9). Jails and
prisons have their own cultures and norms for adaptation. Charac-
teristics such as suspiciousness, hostility, social withdrawal and self-
centeredness may represent adaptive and expected patterns of behav-
ior in a culture where looking out for oneself and distrusting others
are necessary to survive (4). Furthermore, jail and prison populations
turnover rapidly. Even for inmates with long sentences, there is fre-
quent movement between institutions. The appropriate focus of treat-
ment therefore is acute rather than ongoing symptoms of psychiatric
disturbance. A correctional clinician is less likely to have a relationship
with a patient long enough to identify an “enduring pattern.” Finally,
as one of the most underserved outposts in public psychiatry, the pri-
orities of correctional mental health services are the identification and
treatment of conditions that absolutely require clinical intervention,
ie. Axis I disorders with their attendant dysfunction and the Axis II
disorders which are associated with dangerous behavior.

Correctional Context

An understanding of the correctional environment and its inmate and

corrections rules also sheds significant light on the personality disor-
der literature and the limitations thereof (10). Inmates learn a code
of conduct that confounds the diagnosis of all but the most obvious
personality disorders. Examples of this “inmate code” and associated
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340 PSYCHIATRIC QUARTERLY

behaviors include: “Do your own time” (mind your own business, look
out only for yourself, keep to yourself), “Don’t snitch” (don’t report other
inmates, don’t trust staff) and “Don’t show weakness” (look tough, ap-
pear dangerous, act violently if necessary). These behaviors often look
very much like symptoms of personality disorder, particularly paranoid,
narcissistic, antisocial and borderline (4).
The Department of Corrections also has a code of conduct and associ-
ated regulations. These regulations, which are largely, if not exclusively
designed to promote safety and security, require that primary atten-
tion be paid to potentially dangerous inmate behavior. And, therefore,
as with the other factors noted above, they conspire to drive a clini-
cal focus on those personality disorders with the greatest potential for
disruption.

LITERATURE REVIEW

Prevalence Studies

There is a large literature on the identification of mental illness in

correctional settings. Several articles include personality disorders in
their reviews and a few focus exclusively on personality disorder preva-
lence (11–22) (Table 1). However, the literature is limited by several

TABLE 1
Literature Review

Sample APD BPD PD

Guze (1978) Sentenced males 78%

Sentenced females 65%
James (1978) Sentenced males 11% 35%
Daniel (1988) Sentenced females 29%
Cote (1990) Sentenced males 62%
Gunn (1991) Sentenced males 10%
Teplin (1994) Presentenced males 49%
Birmingham (1996) Presentenced males 07%
Brooke (1996) Presentenced males 11%
Jordan (1996) Sentenced females 12% 28%
Teplin (1996) Presentenced females 14%
Brinded (1999) Presentenced males 71%
Sentenced males 71%
Sentenced females 39%
Rass (1999) Sentenced males 22%
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MERRILL ROTTER ET AL. 341

factors. Most of the articles focus on the presence or absence of antisocial

personality disorder alone. The studies were done in different settings
(jails and prisons) and with varying populations (males, females,
presentence detainees, and convicted inmates) and with different meth-
ods (some studies were done by clinical interview and others by struc-
tured interview). Each of these different settings, cohorts and methods
create a cultural and sampling bias that limits generalization.
Not surprisingly, therefore, the data is quite variable. Personality
disorders in males ranges from 7–35%. Antisocial personality disorder
in males was found in 11% in one study (12) and as high as 78% in
another (11). In females, the prevalence of APD ranged from 12–65%.
Comorbidity among the personality disorders was a frequent finding.
There was very limited data on noncluster B personality disorders.

Dimensional Approaches

Even without considering issues specific to an inmate population, the

co-morbidity among the personality disorders associated with impul-
sivity and aggression has led some authors to suggest alternative cate-
gorization (23). The significant institutional confounds and the need to
identify individuals with potential for disruptive behavior in a correc-
tional setting has also led authors, whose focus is on an offender popula-
tion, away from DSM IV diagnosis-based approaches to categories based
on dimensions of character and/or institutional adjustment. Examples
of the dimensional approach include the work by Brinded who found
that whereas antisocial personality disorder was a broad brush covering
more than 70% of the male inmate population, a more discriminating
differentiation based on the work of Muldar and Joyce distinguished
a much smaller group of “impulsive sociopathic” individuals from oth-
ers who were dependant or obsessive or odd (21). Blackburn’s exten-
sive research on violent offenders similarly found that the dimensional
rather than diagnostic approach better differentiated between types of
“psychopaths,” as well as identified other personality types whose clin-
ical needs and environmental responses would also be different (24).
Significantly, at least half the groups categorized by both Brinded and
Blackburn were not identified as antisocial, sociopathic or psychopathic.
A more specific focus on the identification of character traits associ-
ated with institutional maladjustment is found in the work of Megargee
(25,26). Beginning in the 1960’s Megargee and his colleagues used the
MMPI in an attempt to predict risk of disruptive behavior in individual
inmates. The research produced ten characterologic profiles of inmates.
As in the dimensional approach described earlier, several of the inmate
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342 PSYCHIATRIC QUARTERLY

types exhibit antisocial-like tendencies, however these same types

are distinguished from one another both by the other aspects of the
profile as well as by the variability in their institutional adjustment.
Megargee’s findings have not been universally replicated, raising ques-
tions about their validity in general and, perhaps, their specificity to
the medium security correctional environment in which research was
undertaken (27).
A precursor of Megargee’s work is found in the MMPI-based research
of Panton in the 1950’s (28). Panton created a 36-item Adjustment to
Prison (Ap) scale to identify inmates at risk for disruptive behavior
based on their personality inventory. Panton used the MMPI to find
distinguishable characteristics among disruptive inmates who in ad-
dition to institutional disciplinary infractions also had self mutilat-
ing behavior while in solitary confinement. A positive score on the
Ap Scale plus MMPI ratings indicating “greater inner turmoil,”
“hostility,” “bizarreness” correctly identified this latter, difficult to man-
age group (29). Such specific, adjustment focused personality profiling
helps explain, in part, why all inmates do not respond to the penal
environment and disciplinary housing in similar fashion.
However varied, the literature on personality disorders in prison is
clear on several points. Structured diagnostic or personality profiling
is more revealing than clinical interviews alone. There is significant
co-morbidity among the personality disorders found in inmates, to the
point where DSM IV-based categorization may be less helpful than
other approaches. The literature on personality disorders in prisoners,
whether DSM IV based or not, is focused on the potential for disrup-
tion. Finally, there are no specific studies of personality disorders among
mentally ill offenders. This latter group is of particular importance inas-
much as most of the individuals with personality disorders we are likely
to be asked to treat in a prison setting are those with comorbid serious
mental illness for which they were placed on the correctional mental
health caseload.
In New York State the State Office of Mental Health (SOMH) pro-
vides psychiatric services to the state prison population. SOMH’s
Central New York Psychiatric Center (CNYPC) provides psychiatric
services for the approximately 70,000 sentenced inmates in state prison,
as well as for a limited number of individuals in county jails awaiting
trial. It operates an acute care 206 bed inpatient hospital in Marcy, New
York and outpatient services in approximately 35 state prisons located
throughout New York State.
On admission to state prison, all inmates are screened for the pres-
ence of mental illness and a decision is made whether they should be
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MERRILL ROTTER ET AL. 343

placed on the mental health caseload. Approximately 10% of prison in-

mates are on the CNYPC caseload at any given time. It is this group
that we chose to study.

METHOD

Inpatient and outpatient admission records on all inmates on the SOMH

caseload as of 8/1/01 were extracted for examination. These included in-
patient admission histories for the prior 5 years. The SOMH record con-
tains a primary and secondary psychiatric diagnosis. The inmates were
grouped into 4 different Personality Disorder (PD) categories based on
the DSM-IV diagnoses as follows: PD antisocial PD borderline, PD nos,
and PD other. Patients without personality disorder diagnosis were cat-
egorized as non-PD.

RESULTS

Prevalence

As of 8/1/01, CNYPC’s caseload consisted of 159 inpatient and 7383 out-

patients. Thirty-six percent (n = 58) of the inpatient population at
CNYPC had a primary or secondary personality disorder diagnosis.
By contrast only 11% of the civil hospital inpatients had a PD disor-
der (Table 2). For the CNYPC outpatients being served in prison, 21%
(1552) had a PD diagnosis. The prevalence in civil outpatient settings
was about 7% (Table 3).

TABLE 2
Personality Disorder Prevalence Inpatient

CNYPC inpatient Civil inpatient

% n % n

Antisocial 26.4 42 4.8 215

Borderline 3.1 5 2.4 109
NOS 4.4 7 2.7 120
Other 2.5 4 14.0 62
All PD 36.5 58 11.2 506
Not PD 6.5 101 88.8 3996
Total 100 159 100 4502
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344 PSYCHIATRIC QUARTERLY

TABLE 3
Personality Disorder Prevalence Outpatient

CNYPC outpatient Civil outpatient

% n % n

Antisocial 13.9 1024 1.0 229

Borderline 2.1 155 1.6 379
NOS 4.0 292 3.0 709
Other 1.1 81 2.1 492
All PD 21.0 1552 7.5 1809
Not PD 79.0 5831 92.5 22184
Total 100 7383 100 23993

The differences between CNYPC and civil patient percentages were

statistically significant. These differences are primarily due to the sub-
type PD antisocial in CNYPC inpatient and outpatient settings. The
differences between inpatient and outpatient groups within the CNYPC
caseload were also significant.
In terms of PD subtype, 69% have an antisocial classification, 10%
borderline, 19% NOS, and 5% other. This subgroup distribution is simi-
lar for both inpatients and outpatient. Of the 5% “other” category in the
outpatient group, the most frequent personality disorders were para-
noid and schizotypal (Table 4).

TABLE 4
Personality Disorder Prevalence “Other” Personality
Disorders (Total Outpatient = 7383)

CNYPC outpatient
% n

Paranoid 27.3 24
Schizoid 13.6 12
Schizotypal 19.3 17
Dependent 11.4 10
Histrionic 8.0 7
Narcissistic 6.8 6
Avoidant 4.5 4
Passive-aggressive 4.5 4
Obsessive-compulsive 4.5 4
Total 100.0 88
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MERRILL ROTTER ET AL. 345

Demographic and Diagnostic Characteristics

Accompanying Diagnosis

Most of the CNYPC patients with PD also had an additional major men-
tal illness (schizophrenia or mood disorder), but there were significant
differences between the CNYPC inpatient and outpatient settings. Most
(62.1%) of the inpatients with a PD diagnosis also had a schizophrenia
diagnosis, whereas among the outpatients with PD only 29% had an
accompanying schizophrenia diagnosis. Seventeen percent of PD inpa-
tients also had a mood disorder, while 37% of the PD outpatients also
had a mood disorder.
Among the outpatients, patients with PD were significantly more
likely to have an accompanying schizophrenia diagnosis than persons
without PD, but persons without PD were more likely to have a mood
disorder.

Gender

Males (22.4%) were significantly more likely than females (14.5%) to

have a PD diagnosis ( p < .01). While this difference was significant
for both inpatient and outpatient populations, it was more pronounced
for inpatients (39% of male inpatients and 16% of female inpatients).
Among the PD subtypes, significantly more females had a borderline
PD than men ( p < .01).

Ethnicity

Overall, there was not a significant difference between the groups on

ethnicity. Equal percentages (about 21%) of white, blacks, and Hispanics
had a PD disorder. However, among the PD subgroups, patients with
antisocial PD were significantly more likely to be black ( p < .01).

Age

No age difference was found between individuals with personality dis-

orders and those not having this diagnosis. The mean age was 36 years
of age for both groups. However, among the subtypes, patients with
borderline PD were significantly younger ( p < .01).
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346 PSYCHIATRIC QUARTERLY

Treatment Course

Length of Time in Current Episode

Length of time on the mental health caseload for the current episode
was longer for patients with PD in both inpatient and outpatient set-
tings. The mean for inpatients is (325.24 days vs 137.7 days, p = .07)
and for outpatient (780 versus 462 days, p < .01). Within subtype, the
antisocial PD group in outpatient had a nearly significant ( p = .07)
longer length of stay.

Inpatient Admissions at CNYPC

Current inpatients with PD at CNYPC had significantly larger number

of inpatient admissions over the previous 5 years than non-PD patients
(3.10 versus .49; p < .01). The outpatients with PD also had a signifi-
cantly larger number of inpatient admissions.
Consistent with the number of inpatient admissions, the outpatients
with PD spent on the average more days in inpatient services than
outpatients without PD.

DISCUSSION

A large portion of the patients seen in both outpatient and inpatient

forensic environments have a personality disorder with antisocial as the
predominant subtype. Personality Disorder (PD) prevalence in these
forensic settings is about 3 times larger than seen in non-forensic set-
tings. Most of the patients with PD also have an accompanying major
mental illness (schizophrenia or mood disorder) diagnosis. Still, the
numbers are, as in previous studies, nowhere near the 100% antiso-
cial personality disorder prevalence a naive observer might expect in a
criminal population. They are not all antisocial.
There were significant differences among the PD subgroups with re-
gard to gender, ethnicity and age that merit future examination, but
the overall PD group and non-PD groups were similar on these three
demographics.
Individuals with PD use significantly more mental health resources
than non-PD patients. Their lengths of stay in the current episode, and
number of acute inpatient admission and number of acute inpatient
days over the last 5 years were significantly higher.
However, all of the findings must be tempered by at least four impor-
tant caveats. First, the information presented above came exclusively
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MERRILL ROTTER ET AL. 347

from a clinical database. While such data reflects behaviors and symp-
toms that were of concern to clinicians, research-based diagnostic in-
terviewing would likely provide more accurate prevalence numbers.
Second, a focus on behaviors of concern will skew the findings towards
those personality disorders with the greatest likelihood for institutional
disruption. Third, the symptoms of personality disorders overlap, often
seamlessly, with behaviors that are both understandable and adaptive
in the incarceration setting (4). Indeed, there are authors who see these
behaviors as part of a “game” that inmates and officers “play” (30). Fur-
thermore, one classic in vitro study demonstrated that normal subjects
placed in artificially created incarceration-like circumstances will adopt
behaviors that might otherwise be labeled antisocial (31).
Finally, inmates often deny having a mental illness while in prison
for many reasons. For instance, being labeled as a mental patient may
put them at risk from predators. These inmates may suffer from Axis I
symptoms but deny them. Associated behaviors may be misread by clin-
icians as representing Axis II pathology. A patient with Schizophrenia,
for example, who is feeling, but denying, paranoid ideation, may act ag-
gressively in response to his delusions. This aggression may be misin-
terpreted as an antisocial or borderline propensity to violent acting out
rather than a manifestation of underlying lack of reality testing. Fur-
ther complicating matters, many inmates suffer from both Axis I and
Axis II pathology, making these distinction all the more difficult (32).
This distinction takes on practical significance on a daily basis as
clinicians and prison administrators are called upon to make deci-
sions regarding the appropriate management and placement of these
individuals. The decision often comes down to whether an inmate be-
longs in disciplinary housing or a mental health unit. The controversies
these cases generate are frequently saddled with weighty philosophi-
cal and clinical questions, including who should be held responsible for
their actions and how we understand the diagnostic category of per-
sonality disorders with respect to behavioral control, free choice and
responsibility.
Fortunately, in New York State, as in some other jurisdictions there
are attempts being made to create innovative programming that can ad-
dress both the clear mental health issues and the murkier personality
disorder-related behavioral problems without forcing a choice between
an overly punitive disciplinary setting or an inappropriately excusing
clinical environment. New York State programs such as the Special
Treatment Program at Attica Correctional Facility (a maximum secu-
rity men’s prison) and the Re-Entry Program at Bedford Correctional
Facility (a maximum security women’s prison) provide active mental
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348 PSYCHIATRIC QUARTERLY

health treatment and behavior-specific interventions (e.g., Dialectical

Behavioral Therapy at Bedford) in segregated units at the inmates
home facilities. Such programs can help clinicians and prison admin-
istrators parse out symptoms of distress from disruptive behavior and
address both in a more focused, and hopefully increasingly success-
ful way.
The management of mentally ill offenders with accompanying person-
ality disorders is often tricky. Both the literature to date and our study
reflect the complicated nature of the assessment work that must in-
form management decisions. We can be sure, however, of several truths
regarding personality disorders in prison. Patients with personality dis-
order are overrepresented in correctional settings relative to their civil
counterparts. They are not, however, all antisocial. While Cluster B per-
sonality disorders predominate, many other personality disorders may
be present if looked for. In diagnosing the Cluster B group, particularly,
it is imperative that clinicians understand and incorporate a knowl-
edge of the correctional environment into their assessment of mentally
ill offenders. Further work, incorporating such an understanding and
utilizing structured diagnostic interviewing would be most useful if we
are to advance our understanding of patients behind bars and their
needs.

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