Forensic Psychiatry and Forensic Psychology: Personality Disorder

R Nathan, Mersey Care NHS Trust, Merseyside, UK; University of Liverpool, Liverpool, UK; University of Chester, Chester, UK; and
Scott Clinic, Merseyside, UK
H Wood, Waterloo Manor Hospital, Leeds, UK and The Grange, Cleckheaton, UK
r 2016 Elsevier Ltd. All rights reserved.
This article is a revision of the previous edition article by J. Frazer, K.J.B. Rix, volume 2, pp 424–434, r 2005, Elsevier Ltd.

Abstract

Personality disorder is a broad concept that covers a wide range of enduring psychological dysfunctions
that tend to emerge in childhood and persist through the life-course. In this chapter, the prominent
conceptual models of personality disorder and etiolgical processes are described. Drawing on their
experience of assessing and treating patients with personality disorder in forensic and non-forensic settings,
the authors present common approaches to assessment and treatment.

Introduction lengthy standardized clinician-administered interviews

(Widiger, 2012). Many assessment approaches have
Personality disorder is a clinical concept that is used to emerged from the clinical tradition, whereas others have
describe extremes of personality functioning that has been developed from the extensive literature on ‘normal’
significant negative correlates such as intense distress or personality. These different approaches are not mutually
gross impairment in performance in work or social do- exclusive and in clinical practice they may be compli-
mains. Despite controversies, the concept of personality mentary. Most assessment techniques draw on internal
disorder has not become redundant, and it remains experiences and behaviors on which the patient and
useful to clinicians working with individuals identified as others are able to readily report. Experienced clinicians
having a personality disorder since they are able to relate are often able to additionally uncover potential psycho-
their clinical practice to an expanding scientific litera- logical mechanisms that account for the disturbed pattern
ture. The problem with the term arises when it is used in of experience and behavior, but standardized approaches
a way that the evidence base does not support. Whereas to this type of assessment are less well developed.
diagnostic practice in physical healthcare has developed
so that the diagnostic label has become more closely
linked with specific underlying pathology, a categorical
Models of Understanding Personality Disorder
diagnosis of personality disorder (in common with other
mental disorder diagnoses) has a more superficial func-
Personality disorders are at the extreme of continua with
tion as a description of associated symptoms or traits.
‘normal’ personality. The term personality is used to
In the recent past the personality disorder label was
describe the characteristic way in which an individual
often associated with therapeutic nihilism and an in-
thinks, feels, relates to others, and behaves. Although an
creased likelihood of rejection from mental health ser-
individual may think, feel, relate to others, and behave
vices. More recently, significant strides have been made
in different ways in different circumstances, there is a
in the study of interventions in this field which has
general consistency of experience and behavior over
generated convincing evidence for the effectiveness of
time and across situations. The consistent pattern is the
particular therapies for certain types of personality dis-
foundation both of our unique sense of self and of how
order. It should be recognized that there is less evidence
we are seen by others. Our pattern of personality func-
to support the benefits of interventions for some per-
tioning emerges in early life and becomes more generally
sonality disorder types, although this may be a reflection
well defined from adolescence.
of the more limited research in this area. Although there
In line with the paradigm of personality disorders
has been an increased level of clinical expertize in the
lying on continua with non-disordered personality, the
area of personality disorder, patients with this diagnosis
use of approaches developed from studies of nonclinical/
may still be disadvantaged in comparison to patients
non-forensic groups has been extended to the clinical
diagnosed with a mental illness. The reality, however, is
arena. Most notable, in terms of empirical support
that in many cases personality disorder and mental ill-
and widespread use, is the five-factor model (Costa and
ness coexist and there is some reason to question the
Widiger, 1994). This model posits five overarching
validity of the previously supposed distinction between
personality trait factors:
personality disorder and mental illness.
There are different methods of personality disorder 1. Neuroticism, contrasting with emotional stability
assessment ranging from brief self-report measures to 2. Extraversion, contrasting with introversion

662 Encyclopedia of Forensic and Legal Medicine, Volume 2 doi:10.1016/B978-0-12-800034-2.00192-0

 Forensic Psychiatry and Forensic Psychology: Personality Disorder
3. Openness to experience, contrasting with discomfort
with novel experiences
4. Agreeableness, contrasting with antagonism
5. Conscientiousness, contrasting with undependability.
This structure, which is found to exist cross-
culturally, appears to have a genetic basis, to be rela-
tively stable over the life-course, and to predict health
outcomes. Each factor comprises six lower order facets
(e.g., neuroticism facets: anxiousness, anger hostility,
depressiveness, self-consciousness, impulsivity, and vul-
nerability). Five-factor personality functioning can be
assessed by means of self-report inventories or stand-
ardized interview.
Another established typology identified three in-
dependent temperamental dimensions that were pur-
ported to be strongly genetically influenced and to
have a neurobiological basis, i.e., novelty-seeking, harm
avoidance, and reward dependence (Cloninger et al.,
1993). Although in comparison to the five-factor model
this typology has received mixed support from the
empirical evidence base, it has clinical utility since it en-
courages a focus on personality styles relevant to clinical
assessment and decision making particularly within a
forensic settings. Novelty-seeking describes a propensity
to approach novel stimuli and an active avoidance of
monotony. Harm avoidance involves strong behavioral
inhibition in response to aversive stimuli. Reward de-
pendence involves a particular tendency to respond to
rewarding responses. Different personality types may be
described according to the profile of scores across these
three dimensions, for example, offenders are more prone
to display a profile of high novelty-seeking, low harm
avoidance, and reward dependence. The original three-
factor model was subsequently extended to include
another dimension of temperament (i.e., persistence)
and three dimensions of character (i.e., self-directness,
cooperativeness, and self-transcendence).
The most widely used assessment approaches that
have been developed from work with clinical groups are
described in the International Classification of Diseases,
10th edition (ICD-10; World Health Organisation,
1993) and the Diagnostic and Statistical Manual, 5th
edition (DSM-5; American Psychiatric Association,
2014). Within these manuals a categorical approach is
adopted, in which different distinct personality disorder
types are identified on the basis of the presence of a
predefined number of traits from a longer list which is
mostly, but not exclusively, specific to each personality
disorder type. There are two stages to the diagnostic
process. Firstly, the general diagnostic criteria for per-
sonality disorder need to be satisfied. In both ICD-10
and DSM-5, the general criteria require evidence of a
pattern of disordered thinking, feeling, relating, and
behaving, that is present persistently over time (stretch-
ing back to adolescence or early adulthood) and across
situations, and that is not better accounted for by
663
another mental disorder, medical disorder, or the effects
of substances. These general criteria are important to
ensure that personality disorder is not used to describe
more time-limited changes in psychological functioning
even if the manifestations of the psychological dys-
function resemble personality disorder traits. Proper
application of the general diagnostic criteria also re-
quires that the clinician explores for the possibility
that there may be another diagnostic explanation for
the history. The experienced clinician is vigilant to this
possibility and draws on their familiarity with the rec-
ognized potential overlaps between specific personality
disorder categories and other diagnoses. For example, it
is necessary to specifically examine for the possibility
that the patient with apparent paranoid personality
disorder traits is laboring under delusional ideas arising
from a psychotic mental illness. Reports of apparent
schizotypal traits also require an assessment for symp-
toms of a psychotic mental illness. The identification of
schizoid personality disorder traits should stimulate the
clinician to consider whether the history can be better
accounted for by autism spectrum disorder. The absence
of a similar criterion for mental illnesses requiring the
clinician to consider whether mental illness symptoms
are better explained by personality disorder establishes
a hierarchy of diagnoses. However, it should not be
forgotten that the categories in DSM-5 and ICD-10 are
not empirically derived and as such the validity of
the diagnostic output should not be overstated. Thus,
the co-occurrence of apparent paranoid or schizotypal
personality disorder traits and paranoid psychosis in
the same patient is more likely to be reflective of com-
mon underlying processes rather than the unfortunate
coincidental occurrence of two ‘paranoid conditions.’
A debate over whether a clinical history of preference for
being alone, interpersonal detachment, and restricted
interests is a consequence of autism spectrum disorder or
schizoid personality disorder is based on an assumption
that the diagnosis identifies the cause of the problems,
whereas in fact it describes the problems. DSM and ICD
are atheoretical pragmatic tools that are thought by
many, but not all, clinicians to have sufficient utility to
support their continued use. However, the burgeoning
neuroscientific research into the core psychological
mechanism disturbances driving symptoms and traits is
unlikely to support the carving of mental disorders at the
current DSM and ICD joints.
The second stage of the categorical diagnostic
assessment process within DSM-5 and ICD-10 is the
identification of a predefined number of personality
traits from a longer list of traits for each personality
disorder diagnosis. There are strong similarities between
the DSM-5 and ICD-10 personality disorder types, but
also some notable differences. DSM personality disorder
types have been grouped into three clusters.
Cluster A, which has been described as the ‘odd
or eccentric’ group includes paranoid, schizoid, and
664 Forensic Psychiatry and Forensic Psychology: Personality Disorder
schizotypal personality disorders. ICD has paranoid and
schizoid personality disorders, but schizotypal disorder
is categorized within the schizophrenia, schizotypal,
and delusional disorder section. Patients with paranoid
personality disorder display pervasive distrust and sus-
piciousness as evidenced by unfounded suspicions that
others are harming or deceiving them and are likely to be
disloyal and untrustworthy. These patients tend to avoid
disclosing personal information, misattribute threat or
criticism to the actions of others, display oversensitivity
to perceived slights, bear grudges, and maintain con-
spiratorial explanations of events. Schizoid personality
disorder is characterized by significant interpersonal
detachment and limited capacity for the expression of
emotions and for pleasure from activities. A patient with
these traits may appear cold and indifferent to others.
There has been relatively limited research into this per-
sonality disorder category despite the significant associ-
ated impaired functioning. Schizotypal personality
disorder, the third Cluster A personality disorder, is a
multifactor construct comprising cognitive–perceptual
traits (e.g., unusual beliefs, perceptual disturbances,
ideas of reference, and paranoia) disorganized/oddness
traits (odd thinking, speech, and behavior) and inter-
personal traits (lack of friends and social anxiety).
However, there is some overlap with other personality
disorders in that the paranoia has been found to be more
linked to paranoid personality disorder and the inter-
personal traits are correlated with several personality
disorders. This illustrates that blurred inter-diagnostic
boundaries not only exist between personality disorder
and other mental disorder diagnoses, but also between
different personality disorder diagnoses.
DSM Cluster B, the so-called ‘dramatic, emotional
or eccentric’ group, includes antisocial personality dis-
order, borderline personality disorder, histrionic per-
sonality disorder, and narcissistic personality disorder.
In ICD-10, the antisocial category is dissocial person-
ality disorder (which differs more than just in name),
the equivalent to borderline personality disorder is
emotionally unstable personality disorder and a distinct
narcissistic construct does not appear. Within DSM-5, a
diagnosis of antisocial personality disorder is supported
by a history of involvement in antisocial behavior,
deceitfulness, impulsivity, aggression, irresponsibility,
recklessness, and lack of remorse. It is the only person-
ality disorder diagnosis that also requires the endorse-
ment of specific childhood criteria (i.e., conduct
problems, such as stealing, fighting, truanting, and
running away from home). This diagnosis has been
criticized as being so broad-brush that it is merely cap-
turing those with a history of committing criminal
acts rather than describing a more coherent pattern of
psychological functioning associated with antisocial be-
havior. This criticism is supported by the high preva-
lence of this diagnosis within offender groups. To make
a diagnosis of ICD-10 dissocial personality disorder, the
clinician has to explore beneath the behavior to identify
disordered psychological functioning. The listed traits
refer to interpersonal emotional impairments (in relation
to concern for the feelings of others and the capacity
to experience guilt), cognitive distortions (involving
blaming others and other rationalizations for antisocial
behavior), problems managing frustration (with a
readiness to aggressive responding), and attachment
problems (difficulty maintaining but not establishing
enduring relationships). Thus the terms antisocial and
dissocial as applied to personality disorders are not
interchangeable. Although there may be some indi-
viduals who meet the criteria for both, dissocial per-
sonality disorder is a narrower construct that has
more in common with the even narrower notion of
psychopathy.
Borderline personality disorder traits describe in-
stability across a number of domains including inter-
personal (avoidance of abandonment and unstable/
intense relationships), identity (resulting in a lack of
clear sense of self), impulsivity (in areas such as spend-
ing, sex, and substance use), and emotional (manifest in
unregulated and intense emotions on the one hand, and
an emotional void experienced as emptiness on the
other). Suicidal behavior, which is another trait of bor-
derline personality disorder, often occurs at crisis points
when the above instabilities are activated. Under
particular stress there can be a transient reduction in
reality testing in the form of paranoia or dissociation.
The term ‘borderline’ appears in ICD-10 to describe
a similar profile of personality traits, but it is one of the
two variants of the broader category of emotionally
unstable personality disorder. The other variant (im-
pulsive type) emphasizes lack of impulse control and
proneness to outbursts of threatening or aggressive
behavior.
At the core of the histrionic personality disorder
diagnosis, in both ICD-10 and DSM-5, is attention
seeking (e.g., being uncomfortable if not the center of
attention, use of physical appearance to draw attention,
self-dramatization, and theatricality) and excessive
emotionality (e.g., rapidly changing shallow expression
of emotions and exaggerated expression of emotions).
Additional diagnostic characteristics include suggest-
ibility, impressionistic style of speech, and a tendency to
consider relationships more intimate than they are. The
DSM narcissistic personality disorder diagnostic criteria
include grandiosity in fantasy (about great success,
power, and being special) and behavior (haughtiness and
expectations of being recognized as superior, of associ-
ation with other special people, of excessive admiration,
and of entitlement). Patients with this disorder are con-
sidered to have difficulty recognizing the feelings of
others and to exploit others. They often have strong
feelings of envy either in the form of envy of others or of
beliefs that others are envious of him or her. Although
the DSM diagnosis is based largely on manifestations of
 Forensic Psychiatry and Forensic Psychology: Personality Disorder
the ‘grandiose’ dimension of pathological narcissism, the
‘vulnerable’ dimension is not reflected in the diagnostic
criteria. An understanding of Cluster B personality dis-
orders is particularly important in the forensic field.
Antisocial personality disorder by definition is associ-
ated with offending. However, identification of specific
Cluster B personality disorder traits (such as impulsivity
and anger dyscontrol in borderline personality disorder;
or empathy deficits and exploitative behaviour in nar-
cissistic personality disorder) can inform the assessment
and management of the risk of reoffending.
The third grouping, Cluster C (also known as the
‘anxious and fearful’ group) is made up of avoidant
personality disorder, dependent personality disorder and
obsessive–compulsive personality disorder. Avoidant
personality disorder as defined within DSM-5 is char-
acterized by social inhibition as a consequence of feel-
ings of inadequacy and sensitivity to negative evaluation
(e.g., criticism, disapproval, or rejection). The diagnostic
traits cover negative self-representations (inept, un-
appealing, or inferior), preoccupations about adverse
responses by others (being criticized or rejected) and
certain types of interpersonal avoidance (of expression
of feelings and confiding within partner relationships, of
unfamiliar social settings and activities, and of work
involving significant contact). The ICD-10 equivalent,
which is titled ‘anxious (avoidant),’ relies on similar
evidence for a diagnosis, but additionally refers to per-
sistent feelings of tension and apprehension. A cursory
behaviorally focused assessment of the interpersonal
functioning of a patient with avoidant personality dis-
order may lead the clinician to conclude that there is
schizoid detachment. However, an assessment of in-
ternal experiences reveals that the interpersonal avoid-
ance in avoidant personality disorder is actively sought
in response to the associated distress, whereas in schiz-
oid personality disorder there is a more passive detach-
ment. At the core of the dependent personality disorder
diagnosis is an intense need to be taken care of associ-
ated with submissiveness, clinging, and fear of separ-
ation. The DSM diagnostic traits describe the typical
psychological experiences (feeling uncomfortable when
alone and preoccupied by fears of being left to care
for himself or herself) and interpersonal consequences
(needing excessive advice or reassurance to make de-
cisions, needing others to assume responsibility for his/
her life, difficulty expressing disagreement due to an-
ticipated loss of approval, difficulty starting projects
alone, going to excessive lengths to obtain nurturance
or support, and urgently seeking another relationship
following the end of a close relationship). There is sig-
nificant overlap with the listed traits for an ICD-10
diagnosis. Obsessive–compulsive personality disorder,
which is distinct from obsessive–compulsive disorder, is
characterized by excessive attempts to maintain control
of (1) events through an undue preoccupation with de-
tails, lists and order, (2) the way tasks are carried out,
665
both by oneself adopting such a high degree of perfec-
tionism that task completion is disrupted, and by others
insisting things are done their way, (3) possessions, re-
sulting in an inability to throw away objects of no value,
(4) finances, resulting in miserliness, and (5) ethics and
values to a degree that may lead to inflexible adherence
to rules. Consequently, the patient with obsessive–
compulsive personality disorder often devotes them-
selves to work at the expense of their own leisure time
and appears to others to be rigid and stubborn. The
equivalent ICD-10 category, anankastic personality
disorder, includes additional items that suggest a link
with obsessive–compulsive disorder (i.e., feelings of ex-
cessive doubt and the intrusion of unwelcome thoughts).
In recognition of the shortcomings of the categorical
approach to personality disorder assessment, the most
recent version of the DSM-5 has introduced an alter-
native dimensional approach. However, to avoid major
disruption to clinical practice, the categorical approach is
also retained within DSM-5. The dimensional model re-
lies on both an assessment of the level of personality
dysfunction (Criterion A) and an assessment of the
pathological personality traits (Criterion B). Dysfunction
is assessed on continua of self functioning (subdivided
into identity and self-direction) and of interpersonal
functioning (subdivided into empathy and intimacy).
According to this alternative dimensional model, the
pathological personality traits are grouped into five do-
mains (negative affectivity, detachment, antagonism,
disinhibition, and psychoticism) each of which has a
number of trait facets (25 in total, such as emotional
lability, anxiousness, separation insecurity which are
facets of the negative affectivity domain). Similarities can
be observed between this framework of pathological
personality traits and the five-factor model of personality.
The dimensional approach retains the requirements set
out in the general diagnostic criteria for the categorical
approaches for the disturbance: (1) to be present across
situations and over time (pervasiveness and stability, re-
spectively) and (2) not to be better explained by another
mental disorder, a medical condition, or a substance.
Although it does not appear as a standalone diagnostic
entity within DSM-5 or ICD-10, psychopathy is an im-
portant concept in forensic clinical practice, not least be-
cause it has been shown to be a predictor of the risk of
violence (Patrick, 2006). In his influential book, the Mask
of Sanity, Cleckley (1941) reported a series of case studies
to illustrate the characteristics of a ‘psychopath.’ Cleck-
ley’s analysis informed the development of Hare’s Psych-
opathy Checklist which identifies two broad subsets of
traits, i.e., ‘interpersonal-affective’ and ‘antisocial lifestyle.’
Assessment/Measurement of Personality Disorders
Personality disorder assessment can be supported by the
use of standardized assessment tools, which mostly take
666 Forensic Psychiatry and Forensic Psychology: Personality Disorder
the form of clinician-administered interviews and
self-report questionnaires. Some measures involve the
simultaneous assessment of the full range of personality
disorders. One of the most commonly used is the Inter-
national Personality Disorder Examination (IPDE), which
is a semi-structured clinician-administered interview.
For each personality disorder type, the IPDE produces a
categorical output (definite, probable, and absent) and a
dimensional output (sum of the rating for each item) for
each personality disorder category. Other structured
interviews include the Structured Clinical Interview for
DSM-IV Axis II personality disorders (SCID II) and the
Diagnostic Interview for DSM-IV Personality Disorders
(DIPD-IV). Self-report questionnaires with comprehen-
sive coverage include the Millon Clinical Multiaxial
Inventory-III (MCMI-III) and Minnesota Multiphasic
Personality Inventory-2 (MMPI-2). Self-report measures
have the advantages that they require less clinician time to
administer, they are not subject to inter-administrator
variation and scales may be included to index the pa-
tient’s response style. However, these measures are more
dependent on the patient being able to recognize their
styles of psychological functioning and over-endorsement
can be a problem. There are also tools designed to assess
specific personality disorder types, using self-report
and clinician interview methodology (e.g., Narcissistic
Personality Inventory and Revised Diagnostic Interview
for Borderlines, respectively).
Etiology of Personality Disorders
Familial/Genetic Factors
Personality disorders are moderately heritable. The
etiology of some personality disorders has received
more attention than others. The familial aggregation of
paranoid, schizotypal, and (to a lesser extent) schizoid
personality disorders with schizophrenia supports the
positioning of these personality disorders on the
schizophrenia-spectrum. There is also some evidence of
a specific link between paranoid personality disorder
and delusional disorder. There is strong evidence for the
role of genetic factors in the development of antisocial
and borderline personality disorder. Genes appear to
have a more pronounced influence in the early-onset
life-course persistent variant of antisocial personality
disorder. Current research into the etiology of borderline
personality disorder suggests that genetic processes
influence the development of underlying processes (such
as emotional sensitivity and impulsivity) that confer an
increased risk of specific personality disorder traits in the
context of particular environmental experiences.
Environmental Factors
Adverse environmental experiences are associated with
an increased vulnerability to the development of
psychopathology later in life, including personality dis-
order traits. A range of different adversities (such as
physical, sexual, and emotional abuse and neglect) have
been demonstrated to increase the risk of personality
disorder pathology. It has been proposed that some
types of adversity make a specific contribution to the
vulnerability for specific types of personality disorder.
For example, invalidating responses to the child’s emo-
tions and emotional abuse/neglect have been presented
as key adversities associated with borderline personality
disorder. Harsh and inconsistent discipline has been
linked with antisocial outcomes.
Developmental Pathways
An individual’s personality, whether it is considered
disordered or non-disordered, starts to take shape in
the context of a two-way interaction between genetic
and environmental factors. This is two-way in that on
the one hand temperamental characteristics may have
an influence on the nature of the environment. For ex-
ample, infants vary in the degree to which they are liable
to express emotions and there is a genetic contribution
to this variability. Parents vary in their responses to their
child’s expressions of emotions. In some cases, poor
parenting may be a response to an infant who displays
extremes of emotional expressivity (i.e., over- or under-
expression of emotions). On the other hand, parenting
or care-giving influences the infant’s developing capacity
to reflect on emotions and contain negative emotions.
Thus the experience of poor parenting may be associated
with the impaired understanding of one’s emotions and
a propensity to emotional crises. Interactive influences
apply to a range of psychological processes, in addition
to emotional expression, such emotional empathy,
attributional style, sociability, impulse control, and
risk taking. There is a continued interaction over time
between the developing profile of psychological func-
tioning and the changing environment. The psycho-
logical profile at any one time can be understood as the
combination, on the one hand of the effects of inter-
actions between the environmental and psychological
processes up to that point and on the other the en-
vironmental and psychological demands of the particu-
lar developmental stage. These demands are both
biologically and socially influenced.
Psychological Processes
Studies of psychological mechanisms have generated
clinically useful insights into the etiology of patterns of
behavior that are described by personality disorder
traits. For example, empathy deficits are thought to ac-
count in part for the interpersonal style of patients with
narcissistic personality disorder. Exploring the empathy
construct reveals that there are varied underlying pro-
cesses that may be differentially affected in different
 Forensic Psychiatry and Forensic Psychology: Personality Disorder
conditions. Narcissistic personality disorder is thought
to be associated with impaired emotional empathy (i.e.,
the emotional response to the emotional display of
others), but with relative preservation of cognitive em-
pathy (e.g., understanding the beliefs of others) (Baskin-
Sommers et al., 2014). On the other hand, theory of
mind, which is an example of cognitive empathy, is
found to be impaired in autism spectrum disorder. The
degree of impairment may fluctuate in the same indi-
vidual at different times. Notably, the picture in bor-
derline personality disorder is of marked impaired
emotional empathy (with hyperreactivity to certain cues)
when emotionally aroused.
Socio-emotional capacities develop in the inter-
personal space between the child and his/her care giver
(i.e., the attachment relationship). Attachment theory
provides a useful framework to understand both the
transactional context in which personality facets develop
and how disturbances in early key relationships can in-
fluence the development of vulnerabilities to later psy-
chopathology including personality disorder. A number
of the psychotherapeutic approaches that have been
developed in the treatment of personality disorder, e.g.,
Mentalization Based Therapy, have their theoretical
origin in attachment theory.
Treatment and Management of Personality Disorders
The treatment of personality disorder has received a
great deal of academic and clinical attention in recent
years. Having at one time been an area that was re-
garded with a certain amount of therapeutic disdain, an
increasing number of researchers have invested their
resources in exploring and evaluating intervention
strategies and a number of specialist personality disorder
services have developed within the past 10 years. Central
to the ‘treatment’ of personality disorder is the under-
standing that, although medication might have a role in
managing the symptoms that are associated with some
personality disorder, neuroleptic medication does not
offer a resolution to the underlying disorder. In the UK
no medications are currently licensed by the National
Institute for Health and Care Excellence (NIHCE) for
the treatment of personality disorder. It is generally
accepted that a psychotherapeutic approach is required
to identify and ‘treat’ the underlying issues that drive
personality disorder.
Personality disorder services stress the need for a
holistic approach to treatment that accommodates all
of the individual’s needs from a biopsychosocial per-
spective. It has been suggested that there are a handful of
key ingredients that must be features of services if they
are to succeed. These are as follows (Livesley, 2003):
• Validation: acknowledging how the individual is feel-
ing and accepting this in a non-judgemental manner,
667
• Collaboration: working with the individual in a
transparent and including them in every aspect of
their treatment,
• Consistency: maintaining a consistent approach that
is understood and shared by all members of the in-
dividual’s team, and
• Motivation: addressing issues relating to changes in
the individual’s motivation for recovery and instilling
a sense of hope for the future.
These key principles are reflected in the guidelines on
antisocial personality disorder and borderline person-
ality disorder published by National Institute for Health
and Care Excellence (2009a,b) which both highlight the
importance of equality in access to services, promoting
autonomy and choice, instilling hope and optimism,
and building trusting therapeutic relationships. The
NIHCE guidelines also stress the importance of clin-
icians working in skilled teams in which professionals
are provided with appropriate training and regular
supervision in support of the work that they do.
A number of specialist services developed in recent
years and services have used Livesley’s model of the
stages of change in personality to develop interventions
that ensure safety while allowing the individual to pro-
gress. The authors of this chapter work on two different
examples of this kind of service. One of the authors
works in a hospital setting which is based on the
Waterloo Integrated Safe and Eclectic (WISE) pathway.
This is a care pathway approach to treatment that rec-
ognizes that individuals’ have different needs as they
proceed in their recovery and that the components of
their care and treatment need to change accordingly.
The other author works in a prison setting in which the
approach to relational security is informed by a psy-
chosocial understanding of personality disorder and of
the specific needs of the inmates.
A number of psychotherapies have either an existing
evidence base or a developing evidence base for the
effective treatment of personality disorder. These are
introduced in the following section.
Psychosocial Treatments: Treatments that Combine
Group Work with Individual Therapy
Dialectical Behaviour Therapy
Dialectical Behaviour Therapy (DBT) is a cognitive be-
havioral approach to therapy developed by Marsha
Linehan in the late 1980s to provide an effective means
of treating individuals with borderline personality
disorder (Linehan, 1993). In its full form it combines
individual therapy sessions with attendance at weekly
skills training groups in which the participants are sup-
ported to learn new skills increasing their ability to
tolerate of distress and to manage their emotions. DBT
includes explicit instruction in the use of mindfulness, a
668 Forensic Psychiatry and Forensic Psychology: Personality Disorder
strategy that has increasingly demonstrated its value in
the treatment of a range of different mental health
problems. Individuals who are engaged in DBT are
supported directly through their involvement in therapy
and in group sessions and receive support outside
of sessions in the form of their access to a 24-hour
telephone, ‘hotline,’ that they are invited to make use
of at times of crisis and in support of their decision
making. A number of randomized controlled trials
have demonstrated that DBT provides an effective
approach to the treatment of borderline personality
disorder. DBT is now often offered as part of the
treatment approach in a number of specialist personality
disorder services and the evidence in support of this in
a number of different types of services, including out-
patients, in-patients and in patients detained in hospital,
is growing.
Mentalization Based Therapy
Mentalization Based Therapy (MBT) was developed by
two psychoanalytic psychotherapists, Peter Fonagy and
Anthony Bateman, to treat people with borderline per-
sonality disorder (Bateman and Fonagy, 2006). MBT is
based on a significant amount of research looking at the
attachment experiences of adults who have developed
personality disorder. The focus is on, ‘mentalization,’ or
the individual’s ability to think about thinking and to
acknowledge and to consider differences between their
own mental world and that of others. Treatment in-
volves a combination of individual therapy sessions and
involvement in group treatment with others with similar
presentations. There is a growing research base for MBT
which indicates that it provides an effective treatment
for personality disorder and that the benefits of this are
maintained over time.
Psychodynamic Psychotherapies
Transference Focused Psychotherapy
Transference Focused Psychotherapy (TFP) was de-
veloped to provide a highly structured psychodynamic
approach to the treatment of personality disorder based
on Otto Kernberg’s object relations model of borderline
personality disorder (Kernberg et al., 2008). The inter-
vention involves individual therapy sessions that follow
a prescribed pathway including the use of an explicit
contract in which both therapist and patient make a
commitment to the therapy, and detailed exploration
of the individual’s sense of self and understanding of
others. The therapy involves a focus upon the process
of sessions and interpretation of transference. The aim is
to help the patient to develop a more integrated sense of
self and others. The efficacy of TFP has been demon-
strated in randomized controlled trials.
Dynamic Deconstructive Psychotherapy
Dynamic Deconstructive Psychotherapy (DDP) was
developed by Professor John Gregory to offer an
approach to the treatment of individuals with borderline
personality disorder who had found it difficult to
engage in alternative approaches to treatment (Gregory
and Remen, 2008). The theory that underpins DDP
combines translational neuroscience, object relations
theory and deconstruction philosophy. Therapy involves
weekly individual sessions which are designed to help
patients to activate the areas of the brain that are
responsible for adaptive and integrative processing. A
12-month randomized controlled trial indicated that this
approach was effective in helping individuals to improve
in a number of areas of functioning. Although the evi-
dence in support of DDP is not yet great in terms of the
number and range of studies, it is recognized that the
evidence that supports this is of the highest caliber and
involves an empirical approach that is robust and valid.
The early indications are that this approach offers an
effective treatment, not least for individuals who have
failed to respond to other approaches.
Integrative Approaches to Psychotherapy
Schema Focused Therapy
Schema Focused Therapy (SFT) was developed by Jeff
Young to provide a form of cognitive therapy that
focuses upon identifying and exploring the underlying
beliefs that influence the individual’s thinking style and
behavior (Young et al., 2003). SFT is informed by cog-
nitive therapy, behavior therapy, object relations psy-
chotherapy, and gestalt therapy. It was developed with
the treatment of personality disorder in mind. Treatment
usually takes place in the form of individual therapy
sessions in which the individual is helped to identify the
maladaptive beliefs that are present and cognitive and
behavioral strategies are introduced to challenge their
validity and relevance. Randomized controlled trials
have demonstrated the efficacy of SFT in the treatment
of personality disorder and the positive effects of this
have been maintained over a period of time.
Cognitive Analytic Therapy
Cognitive Analytic Therapy (CAT) was developed by
Tony Ryle to provide a time-limited relational psycho-
therapy that could be offered to individuals with a wide
range of presentations on the NHS (Ryle, 1995). It was
based on an integration of object relations psycho-
therapy and cognitive therapy, and is informed by social
constructionism. Therapy takes the form of an agreed
number of sessions; often 16- or 24-sessions, which take
place on a weekly basis. There are then between one
and five follow-up sessions. Active collaboration is an
 Forensic Psychiatry and Forensic Psychology: Personality Disorder
essential part of therapy, which uses therapeutic letters
and diagrams to encourage recognition of problematic
patterns of relating to the self and to others. Although
CAT does not yet have as much evidence as some other
interventions there are a handful of randomized con-
trolled trials that indicate that this approach is effective
in the treatment of personality disorder.
Conclusions
Personality disorders are associated with adverse health,
societal and economic outcomes. Although the validity
of the traditional categorical typology of personality
disorder is not supported by the empirical evidence,
many clinicians find this approach has some practical
utility. Dimensional approaches to diagnosis have been
developed although there is not a universally agreed
model for use in clinical settings. The psychological
processes that drive symptoms and behaviors of
personality disorder are shaped during childhood as a
consequence of bidirectional interplay between inherent
and environmental factors. Psychological interventions,
which are the mainstay of treatment, can be delivered
within different conceptual models, but the effectiveness
is likely to relate to some core common therapeutic
ingredients.
See also: Forensic Psychiatry and Forensic Psychology: Autism
Spectrum Disorder. Forensic Psychiatry and Forensic Psychology:
Forensic Psychiatric Assessment. Forensic Psychiatry and Forensic
Psychology: Multiple Personality Disorder. Forensic Psychiatry and
Forensic Psychology: Stalking. Mental Health: Crime and Mental
Health. Suicide: Self-Harm
669
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