Table Of ContentAntisocial
Personality
Disorder
THE NICE GUIDELINE ON TREATMENT,
MANAGEMENT AND PREVENTION
ANTISOCIAL
PERSONALITY
DISORDER:
TREATMENT,
MANAGEMENT AND
PREVENTION
National Clinical Practice Guideline Number 77
National Collaborating Centre for Mental Health
commissioned by the
National Institute for Health
& Clinical Excellence
published by
The British Psychological Society and The Royal College of
Psychiatrists
© The British Psychological Society
& The Royal College of Psychiatrists, 2010
The views presented in this book do not necessarily reflect those of the British
Psychological Society, and the publishers are not responsible for any error of
omission or fact. The British Psychological Society is a registered charity
(no. 229642).
All rights reserved. No part of this book may be reprinted or reproduced or
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Psychological Society.
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the British Library.
ISBN-: 978-1-85433-478-7
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Contents
CONTENTS
GUIDELINE DEVELOPMENT GROUP MEMBERS 6
1. PREFACE 9
1.1 National guidelines 9
1.2 The national antisocial personality disorder guideline 12
2 ANTISOCIAL PERSONALITY DISORDER 14
2.1 Introduction 14
2.2 The disorder 17
2.3 Aetiology 22
2.4 Presentation in healthcare and other settings 24
2.5 Use of health service resources and other costs 25
2.6 Treatment and management in the NHS 27
2.7 The Dangerous and Severe Personality Disorder initiative 29
2.8 The organisation and coordination of treatment and care 30
2.9 Assessment 31
2.10 Ethical considerations in antisocial personality disorder 32
3 METHODS USED TO DEVELOP THIS GUIDELINE 39
3.1 Overview 39
3.2 The scope 39
3.3 The Guideline Development Group 40
3.4 Clinical questions 42
3.5 Systematic clinical literature review 43
3.6 Health economics methods 53
3.7 Stakeholder contributions 55
3.8 Validation of the guideline 56
4 ORGANISATION AND EXPERIENCE OF CARE 57
4.1 Introduction 57
4.2 Organisation and delivery of care 57
4.3 Training, supervision and support 67
4.4 Service user experience of care and services 74
4.5 Carer experience 85
4.6 Overall summary 87
5 INTERVENTIONS IN CHILDREN AND ADOLESCENTS
FOR THE PREVENTION OF ANTISOCIAL PERSONALITY
DISORDER 89
5.1 Introduction 89
5.2 Risk factors 90
3
Contents
5.3 Early interventions 93
5.4 Interventions for children with conduct problems 107
5.5 Coordination of care 140
6 RISK ASSESSMENT AND MANAGEMENT 143
6.1 Introduction 143
6.2 Assessment of violence risk 143
6.3 Risk management 163
7 INTERVENTIONS FOR PEOPLE WITH ANTISOCIAL
PERSONALITY DISORDER AND ASSOCIATED
SYMPTOMS AND BEHAVIOURS 169
7.1 Introduction 169
7.2 Psychological interventions for antisocial personality disorder 170
7.3 Treatment of comorbid disorders in people with
antisocial personality disorder 196
7.4 Therapeutic community interventions for people
with antisocial personality disorder and associated
symptoms and behaviours 202
7.5 Pharmacological interventions for antisocial personality disorder 208
7.6 Research recommendations 217
8 SUMMARY OF RECOMMENDATIONS 220
8.1 General principles for working with people with
antisocial personality disorder 220
8.2 Prevention of antisocial personality disorder – working
with children and young people and their families 222
8.3 Assessment and risk management of antisocial
personality disorder 227
8.4 Treatment and management of antisocial personality
disorder and related and comorbid disorders 230
8.5 Psychopathy and dangerous and severe personality disorder 231
8.6 Organisation and planning of services 232
8.7 Severity as a potential moderator of effect in group-based
cognitive and behavioural interventions 234
8.8 Group-based cognitive and behavioural interventions
for populations outside criminal justice settings 235
8.9 Effectiveness of multisystemic therapy versus functional
family therapy 235
8.10 Interventions for infants at high risk of developing
conduct disorders 236
8.11 Treatment of comorbid anxiety disorders in
antisocial personality disorder 237
8.12 Using selective serotonin reuptake inhibitors to increase
cooperative behaviour in people with antisocial
personality disorder in a prison setting 237
4
Contents
8.13 A therapeutic community approach for antisocial
personality disorder in a prison setting 238
9. APPENDICES 239
10.REFERENCES 322
11.ABBREVIATIONS 356
5
Guideline development group members
GUIDELINE DEVELOPMENT GROUP MEMBERS
Professor Conor Duggan (Chair, Guideline Development Group)
Professor of Forensic Mental Health, The University of Nottingham;
Honorary Consultant Psychiatrist, Nottinghamshire Healthcare Trust
Dr Stephen Pilling (Facilitator, Guideline Development Group)
Joint Director, The National Collaborating Centre for Mental Health;
Director, Centre for Outcomes Research and Effectiveness, University College
London
Dr Gwen Adshead
Consultant Forensic Psychotherapist, Broadmoor Hospital, West London Mental
Health NHS Trust
Ms Amy Brown
Research Assistant (2007), The National Collaborating Centre for Mental Health
Professor Jeremy Coid
Professor of Forensic Psychiatry, Wolfson Institute of Preventive Medicine, Queen
Mary, University of London
Mr Neil Connelly
Representing the interests of service users and carers
Mr Colin Dearden
Deputy Chief Probation Officer, Lancashire Probation Service
Mr Alan Duncan
Systematic Reviewer, The National Collaborating Centre for Mental Health
Mr Matthew Dyer
Health Economist, The National Collaborating Centre for Mental Health
Dr Brian Ferguson
Consultant Psychiatrist and Clinical Director of Specialist Services, Lincolnshire
Partnership NHS Foundation Trust
Ms Esther Flanagan
Project Manager (2008–2009), The National Collaborating Centre for Mental Health
6
Guideline development group members
Professor Peter Fonagy
Freud Memorial Professor of Psychoanalysis, University College London; Head of
Research Department of Clinical, Educational and Health Psychology, University
College London; Chief Executive, Anna Freud Centre, London
Dr Savas Hadjipavlou
Programme Director, The Dangerous People with Severe Personality Disorder
(DSPD) Programme, Ministry of Justice
Professor Eddie Kane
Director, Personality Disorder Institute, The University of Nottingham
Mr Ryan Li
Project Manager (2008), The National Collaborating Centre for Mental Health
Professor Anthony Maden
Professor of Forensic Psychiatry, Imperial College;
Honorary Consultant, West London Mental Health NHS Trust
Dr Ifigeneia Mavranezouli
Senior Health Economist, The National Collaborating Centre for Mental Health
Professor James McGuire
Professor of Forensic Clinical Psychology, University of Liverpool; Honorary
Consultant Clinical Psychologist, Mersey Care NHS Trust
Dr Nicholas Meader
Systematic Reviewer, The National Collaborating Centre for Mental Health
Dr Catherine Pettinari
Centre Manager, The National Collaborating Centre for Mental Health
Ms Peny Retsa
Health Economist (2007–2008), The National Collaborating Centre for Mental
Health
Ms Maria Rizzo
Research Assistant (2007–2008), The National Collaborating Centre for Mental
Health
Ms Carol Rooney
Deputy Director of Nursing, St Andrew’s Healthcare
Ms Sarah Stockton
Information Scientist, The National Collaborating Centre for Mental Health
7
Guideline development group members
Dr Clare Taylor
Editor, The National Collaborating Centre for Mental Health
Dr Nat Wright
Clinical Director for Substance Misuse, HM Prison Service Leeds
8
Preface
1. PREFACE
This guideline has been developed to advise on the treatment and management of
antisocial personality disorder (ASPD). The guideline recommendations have been
developed by a multidisciplinary team of healthcare professionals, a representative
for service users and guideline methodologists after careful consideration of the best
available evidence. It is intended that the guideline will be useful to clinicians and
service commissioners in providing and planning high-quality care for people with
antisocial personality disorder while also emphasising the importance of their expe-
rience of care and that of their carers (see Appendix 1 for more details on the scope
of the guideline).
Although the evidence base is expanding, there are a number of major gaps, and
future revisions of this guideline will incorporate new scientific evidence as it develops.
The guideline makes a number of research recommendations specifically to address
gaps in the evidence base. In the meantime, it is hoped that the guideline will assist
clinicians, people with antisocial personality disorder and their carers by identifying
the merits of particular treatment approaches where the evidence from research and
clinical experience exists.
1.1 NATIONAL GUIDELINES
1.1.1 What are clinical practice guidelines?
Clinical practice guidelines are ‘systematically developed statements that assist
clinicians and patients in making decisions about appropriate treatment for specific
conditions’ (Mann, 1996). They are derived from the best available research evidence,
using predetermined and systematic methods to identify and evaluate the evidence
relating to the specific condition in question. Where evidence is lacking, the guidelines
incorporate statements and recommendations based upon the consensus statements
developed by the Guideline Development Group (GDG).
Clinical guidelines are intended to improve the process and outcomes of healthcare
in a number of different ways. They can:
● provide up-to-date evidence-based recommendations for the management of condi-
tions and disorders by healthcare professionals
● be used as the basis to set standards to assess the practice of healthcare professionals
● form the basis for education and training of healthcare professionals
● assist patients and carers in making informed decisions about their treatment
andcare
● improve communication between healthcare professionals, patients and carers
● help identify priority areas for further research.
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