Dangerous People With Severe Personality Disorders

To the Editor: We read Dr. Appelbaum's April column (1) and wondered how most psychiatrists in the United States would propose to handle "dangerous people with severe personality disorders" (DSPD). The term was coined by government officials after a public outrage over the case of Michael Stone, who in 1996, after he was refused treatment because of a diagnosis of personality disorder, carried out his threat and bludgeoned to death Lin Russel and her six-year-old daughter Megan in Kent (2). Our guess is that most psychiatrists in the United States would not have ignored this psychopath on the basis of his nontreatability. The U.K. government was responding to a loophole that led to these murders by proposing the DSPD category and the broadened criteria for commitment of persons in this category. This controversial concept is analogous to the concept in the United States of sexually violent predators, a form of antisocial personality disorder. At least 17 states provide for commitment of these individuals after their imprisonment (3), a decision that has been repeatedly backed by the U.S. Supreme Court.

Dr. Appelbaum and others have questioned the rationale behind such a diagnostic category. We would like to reiterate that psychiatric diagnoses have evolved on the basis of emerging science and societal metamorphosis. Also, grading of diagnoses on the basis of severity is not unique to personality disorder. Mood disorders and mental retardation readily come to mind. Consequently, we do not believe that the U.K. government overreacted by proposing DSPD as an extreme form of antisocial personality disorder.

Another point raised by Dr. Appelbaum is the issue of treatability. Before the U.K. proposal, psychiatrists could reject requests to treat people with personality disorder—no matter how dangerous they may be to others—on the basis of the treatability criterion. This is indeed puzzling, because we do not use treatability to determine whether to provide services for people with other psychiatric diagnoses. In the United States we do not discharge to the community patients with borderline personality disorder who are in crisis, because the disorder is not readily treatable. Mental retardation is a DSM-IV-TR diagnostic entity for which we strive to do our best in terms of providing services, even though the disorder itself is untreatable. When psychopathy coexists with another mental disorder, how does one determine treatability, and when does one decide to stop treatment?

Unlike Dr. Appelbaum, we agree with the "holistic" framework of treatment that includes nursing care and habilitation. Some habilitative programs proposed for dangerous people with severe personality disorders have been used for people with mental retardation and borderline personality disorder. Such programs may help patients respond to daily stressful situations adaptively rather than in maladaptive overemotional and aggressive ways.