1 Guidance

March 2013: recommendations 1.2.3.1–1.2.3.2, 1.2.4.1–1.2.4.2, 1.2.4.4–1.2.4.5, 1.2.5.1–1.2.5.3, 1.2.6.1–1.2.6.2, 1.2.7.1–1.2.7.7 and 1.2.8.1–1.2.8.4 have been deleted and replaced by Antisocial behaviour and conduct disorders in children and young people (NICE clinical guideline 158).

The following guidance is based on the best available evidence. The full guideline gives details of the methods and the evidence used to develop the guidance.

1.1 General principles for working with people with antisocial personality disorder

People with antisocial personality disorder have tended to be excluded from services, and policy implementation guidance from the Department of Health, 'Personality disorder: no longer a diagnosis of exclusion' (2003)[1], aims to address this. To change the current position, staff need to work actively to engage people with antisocial personality disorder in treatment. Evidence from both clinical trials and scientific studies of antisocial personality disorder shows that positive and reinforcing approaches to the treatment of antisocial personality disorder are more likely to be successful than those that are negative or punitive.

1.1.1 Access and assessment

1.1.1.1 People with antisocial personality disorder should not be excluded from any health or social care service because of their diagnosis or history of antisocial or offending behaviour.

1.1.1.2 Seek to minimise any disruption to therapeutic interventions for people with antisocial personality disorder by:

  • ensuring that in the initial planning and delivery of treatment, transfers from institutional to community settings take into account the need to continue treatment

  • avoiding unnecessary transfer of care between institutions whenever possible during an intervention, to prevent disruption to the agreed treatment plan. This should be considered at initial planning of treatment.

1.1.1.3 Ensure that people with antisocial personality disorder from black and minority ethnic groups have equal access to culturally appropriate services based on clinical need.

1.1.1.4 When language or literacy is a barrier to accessing or engaging with services for people with antisocial personality disorder, provide:

  • information in their preferred language and in an accessible format

  • psychological or other interventions in their preferred language

  • independent interpreters.

1.1.1.5 When a diagnosis of antisocial personality disorder is made, discuss the implications of it with the person, the family or carers where appropriate, and relevant staff, and:

  • acknowledge the issues around stigma and exclusion that have characterised care for people with antisocial personality disorder

  • emphasise that the diagnosis does not limit access to a range of appropriate treatments for comorbid mental health disorders

  • provide information on and clarify the respective roles of the healthcare, social care and criminal justice services.

1.1.1.6 When working with women with antisocial personality disorder take into account the higher incidences of common comorbid mental health problems and other personality disorders in such women, and:

  • adapt interventions in light of this (for example, extend their duration)

  • ensure that in inpatient and residential settings the increased vulnerability of these women is taken into account.

1.1.1.7 Staff, in particular key workers, working with people with antisocial personality disorder should establish regular one-to-one meetings to review progress, even when the primary mode of treatment is group based.

1.1.2 People with disabilities and acquired cognitive impairments

1.1.2.1 When a person with learning or physical disabilities or acquired cognitive impairments presents with symptoms and behaviour that suggest antisocial personality disorder, staff involved in assessment and diagnosis should consider consulting with a relevant specialist.

1.1.2.2 Staff providing interventions for people with antisocial personality disorder with learning or physical disabilities or acquired cognitive impairments should, where possible, provide the same interventions as for other people with antisocial personality disorder. Staff might need to adjust the method of delivery or duration of the intervention to take account of the disability or impairment.

1.1.3 Autonomy and choice

1.1.3.1 Work in partnership with people with antisocial personality disorder to develop their autonomy and promote choice by:

  • ensuring that they remain actively involved in finding solutions to their problems, including during crises

  • encouraging them to consider the different treatment options and life choices available to them, and the consequences of the choices they make.

1.1.4 Developing an optimistic and trusting relationship

1.1.4.1 Staff working with people with antisocial personality disorder should recognise that a positive and rewarding approach is more likely to be successful than a punitive approach 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.

1.1.5 Engagement and motivation

1.1.5.1 When providing interventions for people with antisocial personality disorder, particularly in residential and institutional settings, pay attention to motivating them to attend and engage with treatment. This should happen at initial assessment and be an integral and continuing part of any intervention, as people with antisocial personality disorder are vulnerable to premature withdrawal from treatment and supportive interventions.

1.1.6 Involving families and carers

1.1.6.1 Ask directly whether the person with antisocial personality disorder wants their family or carers to be involved in their care, and, subject to the person's consent and rights to confidentiality:

  • encourage families or carers to be involved

  • ensure that the involvement of families or carers does not lead to a withdrawal of, or lack of access to, services

  • inform families or carers about local support groups for families or carers.

1.1.6.2 Consider the needs of families and carers of people with antisocial personality disorder and pay particular attention to the:

  • impact of antisocial and offending behaviours on the family

  • consequences of significant drug or alcohol misuse

  • needs of and risks to any children in the family and the safeguarding of their interests.

1.2 Prevention of antisocial personality disorder – working with children and young people and their families

The evidence for the treatment of antisocial personality disorder in adult life is limited and the outcomes of interventions are modest. The evidence for working with children and young people who are at risk, and their families, points to the potential value of preventative measures. There are definitions of the psychological interventions referred to in the recommendations in section 8.

1.2.1 General principles

1.2.1.1 Child and adolescent mental health service (CAMHS) professionals working with young people should:

  • balance the developing autonomy and capacity of the young person with the responsibilities of parents and carers

  • be familiar with the legal framework that applies to young people, including the Mental Capacity Act, the Children Acts and the Mental Health Act.

1.2.2 Identifying children at risk of developing conduct problems

1.2.2.1 Services should establish robust methods to identify children at risk of developing conduct problems, integrated when possible with the established local assessment system. These should focus on identifying vulnerable parents, where appropriate antenatally, including:

  • parents with other mental health problems, or with significant drug or alcohol problems.

  • mothers younger than 18 years, particularly those with a history of maltreatment in childhood

  • parents with a history of residential care

  • parents with significant previous or current contact with the criminal justice system.

1.2.2.2 When identifying vulnerable parents, take care not to intensify any stigma associated with the intervention or increase the child's problems by labelling them as antisocial or problematic.

1.2.3 Early interventions for preschool children at risk of developing conduct problems and potentially subsequent antisocial personality disorder

1.2.3.1 This recommendation has been deleted

1.2.3.2 This recommendation has been deleted.

1.2.4 Interventions for children with conduct problems younger than 12 years and their families

1.2.4.1 This recommendation has been deleted.

1.2.4.2 This recommendation has been deleted.

1.2.4.3 Additional interventions targeted specifically at the parents of children with conduct problems (such as interventions for parental, marital or interpersonal problems) should not be provided routinely alongside parent-training programmes, as they are unlikely to have an impact on the child's conduct problems.

1.2.4.4 This recommendation has been deleted.

1.2.4.5 This recommendation has been deleted.

1.2.5 How to deliver interventions for children with conduct problems aged younger than 12 years and their families

1.2.5.1 This recommendation has been deleted.

1.2.5.2 This recommendation has been deleted.

1.2.5.3 This recommendation has been deleted.

1.2.6 Cognitive behavioural interventions for children aged 8 years and older with conduct problems

1.2.6.1 This recommendation has been deleted.

1.2.6.2 This recommendation has been deleted.

1.2.7 How to deliver interventions for children aged 8 years and older with conduct problems

1.2.7.1 This recommendation has been deleted.

1.2.7.2 This recommendation has been deleted.

1.2.7.3 This recommendation has been deleted.

1.2.7.4 This recommendation has been deleted.

1.2.7.5 This recommendation has been deleted.

1.2.7.6 This recommendation has been deleted.

1.2.7.7 This recommendation has been deleted.

1.2.8 How to deliver interventions for young people with conduct problems aged between 12 and 17 years and their families

1.2.8.1 This recommendation has been deleted.

1.2.8.2 This recommendation has been deleted.

1.2.8.3 This recommendation has been deleted.

1.2.8.4 This recommendation has been deleted.

1.2.9 Transition from child and adolescent services to adult services

1.2.9.1 Health and social care services should consider referring vulnerable young people with a history of conduct disorder or contact with youth offending schemes, or those who have been receiving interventions for conduct and related disorders, to appropriate adult services for continuing assessment and/or treatment.

1.3 Assessment and risk management of antisocial personality disorder

In primary and secondary care services, antisocial personality disorder is under-recognised. When it is identified, significant comorbid disorders such as treatable depression or anxiety are often not detected. In secondary and forensic services there are important concerns about assessing risk of violence and risk of harm to self and others.

1.3.1 Assessment

1.3.1.1 When assessing a person with possible antisocial personality disorder, healthcare professionals in secondary and forensic mental health services should conduct a full assessment of:

  • antisocial behaviours

  • personality functioning, coping strategies, strengths and vulnerabilities

  • comorbid mental disorders (including depression and anxiety, drug or alcohol misuse, post-traumatic stress disorder and other personality disorders)

  • the need for psychological treatment, social care and support, and occupational rehabilitation or development

  • domestic violence and abuse.

1.3.1.2 Staff involved in the assessment of antisocial personality disorder in secondary and specialist services should use structured assessment methods whenever possible to increase the validity of the assessment. For forensic services, the use of measures such as PCL-R or PCL-SV to assess the severity of antisocial personality disorder should be part of the routine assessment process.

1.3.1.3 Staff working in primary and secondary care services (for example, drug and alcohol services) and community services (for example, the probation service) that include a high proportion of people with antisocial personality disorder should be alert to the possibility of antisocial personality disorder in service users. Where antisocial personality disorder is suspected and the person is seeking help, consider offering a referral to an appropriate forensic mental health service depending on the nature of the presenting complaint. For example, for depression and anxiety this may be to general mental health services; for problems directly relating to the personality disorder it may be to a specialist personality disorder or forensic service.

1.3.2 Risk assessment and management

Risk assessment is part of the overall approach to assessment and care planning as defined in the framework of the Care Programme Approach, and the following recommendations should be regarded in that context.

Primary care services

1.3.2.1 Assessing risk of violence is not routine in primary care, but if such assessment is required consider:

  • current or previous violence, including severity, circumstances, precipitants and victims

  • the presence of comorbid mental disorders and/or substance misuse

  • current life stressors, relationships and life events

  • additional information from written records or families and carers (subject to the person's consent and right to confidentiality), because the person with antisocial personality disorder might not always be a reliable source of information.

1.3.2.2 Healthcare professionals in primary care should consider contact with and/or referral to secondary or forensic services where there is current violence or threats that suggest significant risk and/or a history of serious violence, including predatory offending or targeting of children or other vulnerable people.

Secondary care services

1.3.2.3 When assessing the risk of violence in secondary care mental health services, take a detailed history of violence and consider and record:

  • current or previous violence, including severity, circumstances, precipitants and victims

  • contact with the criminal justice system, including convictions and periods of imprisonment

  • the presence of comorbid mental disorder and/or substance misuse

  • current life stressors, relationships and life events

  • additional information from written records or families and carers (subject to the person's consent and right to confidentiality), as the person with antisocial personality disorder might not always be a reliable source of information.

1.3.2.4 The initial risk management should be directed at crisis resolution and ameliorating any acute aggravating factors. The history of previous violence should be an important guide in the development of any future violence risk management plan.

1.3.2.5 Staff in secondary care mental health services should consider a referral to forensic services where there is:

  • current violence or threat that suggests immediate risk or disruption to the operation of the service

  • a history of serious violence, including predatory offending or targeting of children or other vulnerable people.

Specialist personality disorder or forensic services

1.3.2.6 When assessing the risk of violence in forensic, specialist personality disorder or tertiary mental health services, take a detailed history of violence, and consider and record:

  • current and previous violence, including severity, circumstances, precipitants and victims

  • contact with the criminal justice system, including convictions and periods of imprisonment

  • the presence of comorbid mental disorder and/or substance misuse

  • current life stressors, relationships and life events

  • additional information from written records or families and carers (subject to the person's consent and right to confidentiality), as the person with antisocial personality disorder might not always be a reliable source of information.

1.3.2.7 Healthcare professionals in forensic or specialist personality disorder services should consider, as part of a structured clinical assessment, routinely using:

  • a standardised measure of the severity of antisocial personality disorder (for example, PCL-R or PCL-SV)

  • a formal assessment tool such as HCR-20 to develop a risk management strategy.

1.3.3 Risk management

1.3.3.1 Services should develop a comprehensive risk management plan for people with antisocial personality disorder who are considered to be of high risk. The plan should involve other agencies in health and social care services and the criminal justice system. Probation services should take the lead role when the person is on a community sentence or is on licence from prison with mental health and social care services providing support and liaison. Such cases should routinely be referred to the local Multi-Agency Public Protection Panel.

1.4 Treatment and management of antisocial personality disorder and related and comorbid disorders

The evidence base for the treatment of antisocial personality disorder is limited. In the development of the recommendations set out below these limitations were addressed by drawing on four related sources of evidence, namely, evidence for: (1) interventions targeted specifically at antisocial personality disorder; (2) the treatment and management of the symptoms and behaviours associated with antisocial personality disorder, such as impulsivity and aggression; (3) the treatment of comorbid disorders such as depression and drug misuse; and (4) the management of offending behaviour. Although the focus of several interventions is offending behaviour, the interventions have the potential to help people with antisocial personality disorder address a wider range of antisocial behaviours with consequent benefits for themselves and others.

1.4.1 General principles

1.4.1.1 People with antisocial personality disorder should be offered treatment for any comorbid disorders in line with recommendations in the relevant NICE clinical guideline, where available (see section 6). This should happen regardless of whether the person is receiving treatment for antisocial personality disorder.

1.4.1.2 When providing psychological or pharmacological interventions for antisocial personality disorder, offending behaviour or comorbid disorders to people with antisocial personality disorder, be aware of the potential for and possible impact of:

  • poor concordance

  • high attrition

  • misuse of prescribed medication

  • drug interactions (including with alcohol and illicit drugs).

1.4.1.3 When providing psychological interventions for comorbid disorders to people with antisocial personality disorder, consider lengthening their duration or increasing their intensity.

1.4.2 The role of psychological interventions

1.4.2.1 For people with antisocial personality disorder, including those with substance misuse problems, in community and mental health services, consider offering group-based cognitive and behavioural interventions, in order to address problems such as impulsivity, interpersonal difficulties and antisocial behaviour.

1.4.2.2 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 (for example, programmes such as 'reasoning and rehabilitation') focused on reducing offending and other antisocial behaviour.

1.4.2.3 For young offenders aged 17 years or younger with a history of offending behaviour who are in institutional care, offer group-based cognitive and behavioural interventions aimed at young offenders and that are focused on reducing offending and other antisocial behaviour.

1.4.2.4 When providing cognitive and behavioural interventions:

  • assess the level of risk and adjust the duration and intensity of the programme accordingly (participants at all levels of risk may benefit from these interventions)

  • provide support and encouragement to help participants to attend and complete programmes, including people who are legally mandated to do so.

1.4.3 The role of pharmacological interventions

1.4.3.1 Pharmacological interventions should not be routinely used for the treatment of antisocial personality disorder or associated behaviours of aggression, anger and impulsivity.

1.4.3.2 Pharmacological interventions for comorbid mental disorders, in particular depression and anxiety, should be in line with recommendations in the relevant NICE clinical guideline (see section 6). When starting and reviewing medication for comorbid mental disorders, pay particular attention to issues of adherence and the risks of misuse or overdose.

1.4.4 Drug and alcohol misuse

Drug and alcohol misuse occurs commonly alongside antisocial personality disorder, and is likely to aggravate risk of harm to self and others and behavioural disturbances in people with antisocial personality disorder.

1.4.4.1 For people with antisocial personality disorder who misuse drugs, in particular opioids or stimulants, offer psychological interventions (in particular, contingency management programmes) in line with recommendations in the relevant NICE clinical guideline (see section 6).

1.4.4.2 For people with antisocial personality disorder who misuse or are dependent on alcohol, offer psychological and pharmacological interventions in line with existing national guidance for the treatment and management of alcohol disorders.

1.4.4.3 For people with antisocial personality disorder who are in institutional care and who misuse or are dependent on drugs or alcohol, consider referral to a specialist therapeutic community focused on the treatment of drug and alcohol problems.

1.5 Psychopathy and dangerous and severe personality disorder

People with psychopathy and people who meet criteria for dangerous and severe personality disorder (DSPD) represent a small proportion of people with antisocial personality disorder. However, they present a very high risk of harm to others and consume a significant proportion of the services for people with antisocial personality disorder. In the absence of any high-quality evidence for the treatment of DSPD, the Guideline Development Group drew on the evidence for the treatment of antisocial personality disorder to arrive at their recommendations. Interventions will often need to be adapted for DSPD (for example, a significant extension of the duration of the intervention). People with DSPD can be seen as having a lifelong disability that requires continued input and support over many years.

1.5.1 Adapting interventions for people who meet criteria for psychopathy or DSPD

1.5.1.1 For people in community and institutional settings who meet criteria for psychopathy or DSPD, consider cognitive and behavioural interventions (for example, programmes such as 'reasoning and rehabilitation') focused on reducing offending and other antisocial behaviour. These interventions should be adapted for this group by extending the nature (for example, concurrent individual and group sessions) and duration of the intervention, and by providing booster sessions, continued follow-up and close monitoring.

1.5.1.2 For people who meet criteria for psychopathy or DSPD, offer treatment for any comorbid disorders in line with existing NICE guidance. This should happen regardless of whether the person is receiving treatment for psychopathy or DSPD because effective treatment of comorbid disorders may reduce the risk associated with psychopathy or DSPD.

1.5.2 Intensive staff support

1.5.2.1 Staff providing interventions for people who meet criteria for psychopathy or DSPD should receive high levels of support and close supervision, due to increased risk of harm. This may be provided by staff outside the unit.

1.6 Organisation and planning of services

There has been a considerable expansion of services for people with antisocial personality disorder in recent years involving a wider range of agencies in the health and social care sector, the non-statutory sector and the criminal justice system. If the full benefit of these additional services is to be realised, effective care pathways and specialist networks need to be developed.

1.6.1 Multi-agency care

1.6.1.1 Provision of services for people with antisocial personality disorder often involves significant inter-agency working. Therefore, services should ensure that there are clear pathways for people with antisocial personality disorder 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 among clinicians and organisations at all points and provide the means to resolve differences and disagreements.

    Clearly agreed local criteria should also be established to facilitate the transfer of people with antisocial personality disorder between services. As far as is possible, shared objective criteria should be developed relating to comprehensive assessment of need and risk.

1.6.1.2 Services should consider establishing antisocial personality disorder networks, where possible linked to other personality disorder networks. (They may be organised at the level of primary care trusts, local authorities, strategic health authorities or government offices.) These networks should be multi-agency, should actively involve people with antisocial personality disorder and should:

  • take a significant role in training staff, including those in primary care, general, secondary and forensic mental health services, and in the criminal justice system

  • 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.

1.6.2 Inpatient services

1.6.2.1 Healthcare professionals should normally only consider admitting people with antisocial personality disorder to inpatient services for crisis management or for the treatment of comorbid disorders. Admission should be brief, where possible set out in a previously agreed crisis plan and have a defined purpose and end point.

1.6.2.2 Admission to inpatient services solely for the treatment of antisocial personality disorder or its associated risks is likely to be a lengthy process and should:

  • be under the care of forensic/specialist personality disorder services

  • not usually be under a hospital order under a section of the Mental Health Act (in the rare instance that this is done, seek advice from a forensic/specialist personality service).

1.6.3 Staff training, supervision, support

Working in services for people with antisocial personality disorder presents a considerable challenge for staff. Effective training and support is crucial so that staff can adhere to the specified treatment programme and manage any emotional pressures arising from their work.

Staff competencies

1.6.3.1 All staff working with people with antisocial personality disorder should be familiar with the 'Ten essential shared capabilities: a framework for the whole of the mental health practice'[2] and have a knowledge and awareness of antisocial personality disorder that facilitates effective working with service users, families or carers, and colleagues.

1.6.3.2 All staff working with people with antisocial personality disorder should have skills appropriate to the nature and level of contact with service users. These skills include:

  • for all frontline staff, knowledge about antisocial personality disorder and understanding behaviours in context, including awareness of the potential for therapeutic boundary violations (for example, inappropriate relations with service users)

  • for staff with regular and sustained contact with people with antisocial personality disorder, the ability to respond effectively to the needs of service users

  • for staff with direct therapeutic or management roles, competence in the specific treatment interventions and management strategies used in the service.

1.6.3.3 Services should ensure that all staff providing psychosocial or pharmacological interventions for the treatment or prevention of antisocial personality disorder are competent and properly qualified and supervised, and that they adhere closely to the structure and duration of the interventions as set out in the relevant treatment manuals. This should be achieved through:

  • use of competence frameworks based on relevant treatment manuals

  • routine use of sessional outcome measures

  • routine direct monitoring and evaluation of staff adherence, for example through the use of video and audio tapes and external audit and scrutiny where appropriate.

Supervision and support

1.6.3.4 Services should ensure that staff supervision is built into the routine working of the service, is properly resourced within local systems and is monitored. Supervision, which may be provided by staff external to the service, should:

  • make use of direct observation (for example, recordings of sessions) and routine outcome measures

  • support adherence to the specific intervention

  • promote general therapeutic consistency and reliability

  • counter negative attitudes among staff.

1.6.3.5 Forensic services should ensure that systems for all staff working with people with antisocial personality disorder are in place that provide:

  • comprehensive induction programmes in which the purpose of the service is made clear

  • a supportive and open environment that encourages reflective practice and honesty about individual difficulties such as the potential for therapeutic boundary violations (such as inappropriate relations with service users)

  • continuing staff support to review and explore the ethical and clinical challenges involved in working in high-intensity environments, thereby building staff capacity and resilience.

  • National Institute for Health and Care Excellence (NICE)