Professor Conor Duggan summarises the duties of primary care in relation to the NICE guideline on the prevention and management of antisocial personality disorder

Antisocial personality disorder (ASPD) is a common condition, with a prevalence rate in the general population of around 1%,1,2 which means that it is as prevalent as other major psychiatric conditions, such as schizophrenia and bipolar disorder.3 It is also associated with a high rate of co-morbid conditions (including other personality disorders, depression, anxiety, and, in particular, drug and alcohol misuse), and is very costly, not only for the person with ASPD and their family, but also for society as a whole. The crucial point to note is that ASPD is a preventable condition as there is continuity between conduct disorder (CD) in children and ASPD in adults.1,2

Patients with ASPD are, perhaps, unique in that their diagnosis often provides justification for not offering treatment—a reversal of most medical practices. To counteract this deficiency, NICE has produced a guideline, Antisocial personality disorder: Treatment, management and prevention.1,2 This article examines the need for this guideline and how the recommendations will affect primary care. The emphasis on prevention radically repositions the management of ASPD from specialised secure facilities in prisons or high-security hospitals, to more general mental healthcare services and primary care.

Need for the guideline

To put the NICE guideline on ASPD into context, it is worth outlining why healthcare professionals have been reluctant to intervene in this condition and why it is necessary for them to take action. Many healthcare professionals believe that the management of ASPD is the responsibility of the criminal justice system because it often manifests behaviourally as persistent rule-breaking, thus strongly overlapping with criminality. Although many patients with ASPD do have a criminal history, it is important to recognise that the relationship between ASPD and criminality is partial: less than 50% of those in prison have ASPD and only 47% of those with ASPD in the community have significant arrest records.1,2 Moreover, antisocial personality traits (such as a desire to be in control, suspicion of the motives of others, and achieving one’s ends through whatever means possible, including by force) also influence healthcare professionals because this group of patients can be a particularly challenging group to work with.

Patients with ASPD are also ‘treatment rejecting’ rather than ‘treatment seeking’;4 that is, they typically present for the treatment of a co-morbid condition, or when legally mandated to do so, and it is consequently difficult to engage and to maintain them in the treatment process. Finally, another factor is the weakness of the evidence base for effective pharmacological or psychological interventions for ASPD.5,6

Prevention of ASPD

As the evidence for successful interventions in adults is so poor, it is logical to take action at an early age to prevent ASPD, which is preceded by CD, but only 50% of children with CD go on to develop ASPD. This can be achieved either by interventions in preschool children to prevent the development of CD, or by management of children with CD to prevent progression to ASPD.

The guideline development group (GDG) found good evidence for the effectiveness of preschool programmes focusing on parental education and support, with home visiting and access to preschool nurseries in children under the age of 5 years. However, for these measures to be cost effective they needed to be targeted towards high-risk families.2 Once CD has developed, effective treatments include parent training, and for children aged 8 years and over, cognitive problem-solving programmes (ideally combined with parent training). As parental influence decreases when the child is older, these programmes might need to be augmented by more systemic programmes, such as multisystemic family therapy and functional family therapy.1,2 As the Government has invested heavily in training therapists in this preventative role, it is practical to implement these recommendations.

Indirect interventions for the treatment of ASPD

Co-morbid conditions
Mindful that there was little evidence to support direct interventions to treat ASPD in adults, the GDG also looked at the treatment of co-morbid conditions. It found no evidence to support the exclusion of patients with ASPD from conventional treatments for frequently co-morbid conditions, such as depression and substance-misuse disorders. It should be noted that as it is likely that ASPD will have a negative influence on the impact of these treatments, therapy may need to be intensive, and perhaps of longer duration if it is to be effective. The GDG recognised that patients ‘dropping out’ of treatment was a particular problem in this group and that healthcare professionals would have to be attentive to this.2

Criminogenic factors
Although ASPD and criminality are not synonymous, there is an important overlap. There are effective programmes that address criminogenic factors (e.g. impulsivity, aggression, and substance misuse), which are largely, though not exclusively, delivered in prison. Therefore, the NICE guideline recommends that these programmes, most of which are group-based cognitive and behavioural interventions (such as one called ‘reasoning and rehabilitation’), should be more widely available in the community for patients with ASPD.1,2

Integrated care

In addition to healthcare services, people with ASPD typically come into contact with several agencies (including the criminal justice system, housing agencies, and social services).2 Therefore, there is a need to establish care pathways and improve inter-agency working through the development of managed care networks. These networks would specify standards, regulate movement between different agencies, and monitor activity to ensure that people with ASPD do not continue to be excluded from services that might benefit them. The GP could also play a crucial role as a broker within a larger managed care network because they are often the one common factor linking these agencies.

There is a need to train and support front-line staff (such as accident and emergency staff, practice receptionists, and housing officers); and the Department of Health, in association with the Open University, is funding a suite of training initiatives to address this requirement (for more information contact: info@pdinstitute.org.uk).

Impact of the guideline on primary care

Patients with ASPD are already frequent users of primary healthcare for co-morbid conditions that may not be responding as expected because of the presence of (often unrecognised) ASPD. A quick but systematic method to detect ASPD is, therefore, needed. While a full personality disorder examination would not be expected in this setting, the practitioner might consider certain indicators; for example:1

  • criminal history—even though around half of patients with a criminal history will fail to meet the criteria for ASPD, it is, nonetheless, an important pointer
  • antisocial behaviour in childhood—educational problems (such as school exclusion and truanting) and aggressive behaviour
  • domestic violence
  • neglect of children
  • frequent loss of employment because of aggression or difficulty getting on with co-workers.

Of all the personality disorders, people with ASPD are probably the easiest to recognise as they externalise their difficulties. Treatments for ASPD, as stated above, are group-based cognitive and behavioural interventions, and will typically be provided by community and mental health services or in institutional care.1,2 This will not affect primary care directly, but it is important for primary care practitioners to know about the availability of such programmes.

The emphasis on preventing the disorder in children offers a unique opportunity for primary care practitioners to intervene and break the downward spiral. Primary care practitioners are in an excellent position to identify vulnerable parents and their children, because ASPD is a condition that tends to persist from one generation to the next,7 and because of their familiarity with the family. They can then offer these patients the interventions that are recommended in the guideline

Economical impact of ASPD

Implementing the guideline will not only improve the long-term outcomes of children with CD and people with ASPD, but will also benefit the wider society. While some NICE recommendations may benefit the individual at a cost to society, this does not apply to the guideline for ASPD because this is already a very expensive condition for the individual and their family, and for society as a whole. For example, it has been calculated that the difference in costs (and these are mostly costs of incarceration) for a person aged 28 years who had CD as a child, compared with a person without the condition, is approximately £63,000.8

Conclusion

As with any medical condition, an effective intervention will change the natural course of ASPD for the better. The evidence for the natural course of ASPD is that while offending generally diminishes with age, the other features of the disorder persist.9 Personality disorders are increasingly seen as chronic, slowly remitting conditions that, nonetheless, wax and wane, with remissions and exacerbations. To survive and cope with these difficulties rather than expect a ‘cure’ is perhaps the most realistic option. This is best summed up by Joel Paris: ‘The best outcomes do not consist of untroubled lives, but of a way around troubles. …While patients obtained some benefit from treatment, they continued to demonstrate clinically significant fragility and difficulties over time.10 Who better than a primary care physician to manage such chronic difficulties?

Acknowledgement

The author is grateful for the assistance of Clare Taylor at the National Collaborating Centre for Mental Health, who has contributed to the writing of this article.

NICE implementation tools

NICE has developed the following tools to support implementation of its guideline on Antisocial personality disorder: Treatment, management and prevention. They are now available to download from the NICE website:
www.nice.org.uk

Costing tools

National cost reports and local cost templates for the guideline have been produced:

  • costing reports are estimates of the national cost impact arising from implementation based on assumptions about current practice, and predictions of how it might change following implementation of the guideline
  • costing templates are spreadsheets that allow individual NHS organisations and local health economies to estimate the costs of implementation, taking into account local variation from the national estimates; they quickly assess the impact the guideline may have on local budgets.

Slide set

The slides are aimed at supporting organisations to raise awareness of the guideline and resulting implementation issues at a local level, and can be edited to cater for local audiences. This information does not supersede or replace the guidance itself.

  • ASPD causes much expense to society but often falls outside the immediate healthcare budget
  • The conditions are best prevented through effective interventions for conduct disorder in children
  • Effective interventions in adulthood are group-based cognitive and behavioral therapies
  • Joint working and care pathway design with other agencies (e.g. criminal justice and education) will be essential in providing care for patients with ASPD
  • Co-funding of these services with other agencies will be worth exploring
  • Mental health services as yet fall outside of the PbR budget, but this does not prevent PBC groups specifying and commissioning services in partnership with their PCT
  1. National Institute for Health and Care Excellence. Antisocial personality disorder: treatment, management and prevention. Clinical Guideline 77. London: NICE, 2009. Available at: www.nice.org.uk/guidance/CG77
  2. National Collaborating Centre for Mental Health. Antisocial personality disorder: treatment, management and prevention. Clinical Guideline 77. London: NICE, 2009. Available at: www.nice.org.uk/guidance/CG77
  3. Gelder G, Lopez-Ibor J, Andreasen N. New Oxford textbook of psychiatry, 2nd edn. Oxford: Oxford University Press, 2009.
  4. Tyrer P, Mitchard S, Methuen C, Ranger M. Treatment rejecting and treatment seeking personality disorders: type R and type S. J Pers Disord 2003; 17 (3): 268–270.
  5. Duggan C, Huband N, Smailagic N et al. The use of psychological treatments for people with personality disorder: A systematic review of randomized controlled trials. Personality and Mental Health 2007; 1 (2): 95–125.
  6. Duggan C, Huband N, Smailagic N et al. The use of pharmacological treatments for people with personality disorder: A systematic review of randomized controlled trials. Personality and Mental Health 2008; 2 (3): 119–170.
  7. Viding E, Frick P, Plomin R. Aetiology of the relationship between callous-unemotional traits and conduct problems in childhood. Br J Psychiatry suppl 2007; 49: s33–38.
  8. Scott S, Knapp M, Henderson J et al. Financial cost of social exclusion: follow-up of antisocial children into adulthood. BMJ 2001; 323 (7306): 191–194.
  9. Black D, Baumgard C, Bell S. A 16- to  45-year follow-up of 71 men with antisocial personality disorder. Compr Psychiatry 1995; 36 (2):130–140.
  10. Paris J. Personality disorders over time: precursors, course and outcome. J Pers Disord 2003; 17 (6) 479–488.G