Assessment and management of dangerous and severe personality disorders

To review recent literature on the assessment and management of individuals with severe personality disorders who present as a risk to others.

The literature shows an expansion of services for individuals with personality disorders, including offenders. This appears to be partly due to increased concerns about public safety and relevant changes in legal frameworks. In England and Wales, services for individuals with 'dangerous and severe personality disorders' have been established. The evidence for the effectiveness of interventions for personality disorders remains limited and the extent to which they lead to a reduction in offending and improvements in long-term outcomes remains uncertain. Group-based interventions using cognitive-behavioural approaches have the best evidence base. Preliminary evidence suggests that pharmacological interventions using mood stabilizers and atypical antipsychotics may be effective for some symptoms of personality disorders. A number of authors have emphasized the importance of readiness for treatment and the use of motivational strategies to reduce drop-out.

Evidence for the effectiveness of any interventions for dangerous and severe personality disorders is limited. This poses particular ethical challenges for forensic psychiatrists who are increasingly expected to become involved in the management of individuals who pose a risk to others.