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Dangerous people with severe personality

disorder
Paul E Mullen
BMJ 1999;319;1146-1147

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References

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Editorials

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work to translate the principle of revalidation into a
process that stimulates the continuing professional
development of doctors but does not become an
empty chore that diverts clinicians time and energy
from caring for patients.

the profession be able to withstand legal challenge? For

example, how will the many non-principals working in
general practice show their continuing competence?
The GMC has so far set its face against formal examinations, but for some groups this would be a sensible
option.
In fulfilling its primary responsibility to protect
patients the GMC will add revalidation to its existing
regulatory powers. It will require intelligence and hard

Scottish Council for Postgraduate Medical and Dental Education,

Edinburgh EH2 1EL

2
3

Southgate L, Pringle M. revalidation in the United Kingdom: general

principles based on experience in general practice. BMJ
1999;319:1180-3.
Norcini JJ. Recertification in the United States. BMJ 1999;319:1183-5.
Newble D, Paget N, McLaren B. Revalidation in Australia and New
Zealand: approach of Royal Australasian College of Physicians. BMJ
1999;319:1185-8.
Dauphinee WD. Revalidation of doctors in Canada. BMJ 1999;319:
1188-90.

Graham Buckley executive director

7
8

Swinkels JA. Reregistration of medical specialists in the Netherlands. BMJ

1999;319:1191-2.
United Kingdom Central Council for Nursing, Midwifery, and Health
Visiting. Standards for post-registration education and practice. London:
UKCCN, 1995.
General Dental Council. Reaccreditation and recertification for the dental profession. London: GDC, 1997.
Lord Cohen Lecture. www.educ.unimaas.nl/lord-cohen-lecture.htm
(accessed 25 October 1999).

Dangerous people with severe personality disorder

British proposals for managing them are glaringly wrongand unethical

his summer the British Department of Health

and the Home Office jointly issued a paper on
Managing Dangerous People with Severe Personality Disorder.1 The paper was apparently based on the
results of extensive informal discussions and sets out
the governments policy objectives in dealing with what
the paper calls the dangerous severely personality disordered. The paper avoids descending into the apparently unending debate over what is, or is not, a
personality disorder and to what extent personality
disorders are treatable and attempts to cut through the
gordian knot with what presumably are intended as
straightforward and practical proposals for action. If
only it were that simple.
This government framework for the future
proposes legal powers for detaining indefinitely people
with dangerous severe personality disorder. Specialists,
including psychiatrists, are to be employed both to better identify people with dangerous severe personality
disorder and to develop approaches to detention and
management. Finally a comprehensive programme of
research is to be established to support development of
policy and practice. The proposals make a point of
insisting that indeterminate detention will be authorised only on the basis of evidence from an intensive
specialist assessment (my italics).
There are people whose antisocial and self
damaging behaviours are at least in part a product of
abiding character traits such as impulsivity and
suspiciousness combined with abnormalities of mental
state, including instability of mood and dissociative
symptoms. Such distressed and disturbed individuals
currently attract little interest from mental health
professionals and even less from those who fund
services. Clinical experience suggests, however, that such
disorders can be improved, if not cured, even if research
has failed to pinpoint the best therapeutic approaches.
Severely personality disordered individuals are overrepresented among recidivist offenders, though such
disorders do not inevitably lead to serious offending; nor
are serious offenders drawn exclusively from their ranks.
1146

Crime and violence are major political issues. Surveys indicate growing public support for more
punitive approaches to offenders,2 and populist
governments around the world, be they left, right, or
third way leaning, fall over themselves to respond to
law and order agendas. In England and Wales section
2 of the Crimes (Sentencing) Act already provides for
discretionary life sentences for those convicted a
second time for serious violence or a sexual offence.
The courts have, however, shown a signal lack of
enthusiasm for imposing such sentences, frustrating
the governments carceral enthusiasms. The proposals
set out in this document openly acknowledge the
hope that the judicial reluctance to sentence on the
basis of predicted future behaviour will be reduced if
courts are provided with medical evidence that
offenders have dangerous severe personality disorder.
What is wrong then with proposals that promise far
greater resources for a relatively ignored group of
mentally disordered people and at the same time hold
out the prospect of increased community safety? If
dangerousness was really a characteristic of some personality disordered individuals rather than a characteristic of some acts by some of them; if the proposed
special centres, with their multidisciplinary teams
armed with batteries of standardised procedures,
could reliably recognise dangerous severe personality
disorder; if these proposals were really about providing
care and treatment for the personality disordered; and
if health professionals were really judges and jailers
charged with maintaining public order, then perhaps
these proposals would be worth taking seriously. But
none of these assumptions holds true.
Enthusiastic advocates exist for actuarial methods
of predicting future criminality, and some place
considerable theoretical emphasis on the contribution
of personality.3 4 In practice, however, the probability of
future offending is predicted most effectively by past
offending.5 Variables such as being a substance abuser
or having a history of being abused as a child, have significant, if less consistent, associations with increased
BMJ VOLUME 319

BMJ 1999;319:11467

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rates of future violence.4 6 Mental health variables contribute little to such predictive characteristics. A
diagnosis of psychopathy, or antisocial personality disorder, often does little more than recycle the history of
prior offending behaviours in a different form, producing a potentially spurious association between personality disorder and offending. In practice, therefore, we
would be identifying people with dangerous severe
personality disorder not on mental health, or even personality, variables but on their past offending, their past
history of victimisation, and their current drug and
alcohol habits. Except for substance abuse, none of
these predictive factors is open to change.
The governments proposals masquerade as extensions to mental health services. They are in fact
proposals for preventive detention, not too far
removed from the dangerous offender and sexual
predator laws in North America.5 They aim to make
judges more amenable to imposing discretionary life
sentences. They are intended, as Eastman observed in
these pages,7 to circumvent the European Convention
on Human Rights, which prohibits preventive detention except in those of unsound mind. With their
promises of new money and research funding, they
hope to bribe doctors into complicity in the indefinite
detention of certain selected offenders. Discussion of
the ethical dilemmas that these proposals present for
health professionals is absent, presumably because
they are ethically and professionally indefensible.
There is a crying need for mental health services for
severely personality disordered individuals. Such services would decrease the morbidity and staggering

Editorials

mortality associated with these conditions. In the

process they would contribute to community safety. The
British governments proposals largely ignore this
central issue of developing appropriate treatment
services in favour of creating a system for locking up
men and women who frighten officials. On first reading
this document created both disappointment and
foreboding. On more careful consideration it became
clear that the contradictions were so glaring, the deceptions so open and palpable, and the agenda so obvious,
that these proposals can surely not have any chance of
influencing reality.
Paul E Mullen professor of forensic psychiatry
Monash University and Institute of Forensic Mental Health, Victoria,
3084 Australia

2
3
4

Department of Health, Home Office. Managing dangerous people with

severe personality disorder. London: Home Office, 1999. http://
www.homeoffice.gov.uk/cpd/persdis.htm
Kury H, Ferdinand T. Public opinion and punitivity. Int J Law Psych
1999;22:373-92.
Hare RD. The Hare PCL-R: some issues concerning its use and misuse.
Legal Criminol Psychol 1998;3:99-112.
Quinsey VL, Harris GT, Rice ME, Cormier CA. Violent offenders: appraising
and managing risk. Washington, DC: American Psychological Association,
1998.
Heilbrun, K, Ogloff JRP, Picarello, K. Dangerous offender statutes in the
United States and Canada: implications for risk assessment. Int J Law
Psych 1999;22:393-415.
Steadman HJ, Mulvey E, Monahan J, Robbins PC, Appelbaum PS, Grisso
T, et al. Violence by people discharged from acute psychiatric inpatient
facilities and by others in the same neighborhoods. Arch Gen Psych
1998;55:393-401.
Eastman N. Public health psychiatry or crime prevention? BMJ 1999;
318:549-51.

Meningococcal disease and healthcare workers

The risks to healthcare workers are very low

BMJ 1999;319:11478

BMJ VOLUME 319

lthough Neisseria meningitidis is a relatively

uncommon cause of overt infection (2580
notifications in 1998),1 the horrors of its clinical presentation have stimulated intense media
interest, particularly after outbreaks. With the disappearance of many infectious competitors in the latter
half of this century, meningococcal disease has become
the leading infectious cause of death in childhood and
is now the third most common cause of death in children outside infancy (after accidents and malignancy).2
The introduction in October 1999 of a serogroup C
protein-polysaccharide conjugate vaccine for children
and young adults has the potential to reduce
significantly the incidence of disease.3 Nevertheless,
most cases are caused by serogroup B meningococci,
for which no vaccine is available, and the disease will
remain prevalent in the United Kingdom. As a result of
the dramatic presentation of cases and the high fatality
rate the perceived risk of meningococcal disease is
high among those who have had contact with a case.
Close contact with nasopharyngeal secretions from
a case is necessary for transmission. Therefore secondary attack rates (increased risk relative to the general
population) are as high as 1200 in household contacts,
160 in secondary schools, 60 in primary schools, and
1.8 in universities in the days after presentation of the
30 OCTOBER 1999

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index case.4 Despite the perceived risk, however, only a

few cases arise from contact with a case and only 0.5%
of all cases are associated with family contacts.5
A few healthcare workers have very close contact
with a patient suffering from meningococcal disease
during assessment, resuscitation, and stabilisation. The
nasopharynx of patients with meningococcal disease
often contains viable organisms at presentation, even
after antibiotic therapy in the community with
penicillin.6 Although the fears of healthcare workers
might seem justified, few published reports exist of
healthcare workers7 8 or laboratory staff9 10 developing
invasive meningococcal disease. However, a recent
report from France again highlights this issue: a paediatrician developed meningococcaemia a week after she
intubated a comatose child with meningococcal
disease.11
Doctors, nurses, and paramedics who are directly
exposed to nasopharyngeal secretions or pulmonary
oedema from such patients, mainly during airway
management (mouth to mouth resuscitation, intubation, and airway toilet), may therefore be at some
increased risk of meningococcal disease. Current
guidelines in the United Kingdom advise offering antibiotic chemoprophylaxis only to those undertaking
mouth to mouth resuscitation.12 In the United States
1147