Harrison, Antonia C.
(2015)
Personality disorder: complex cases or difficult cases?: a question of placement in forensic services.
DForenPsy thesis, University of Nottingham.
Abstract
This thesis explored whether patients in high security hospitals are more ‘Complex Cases’ or more ‘Difficult Cases’ than their counterparts in lower security settings. Herein, case complexity is associated with co-morbid diagnoses or clinical needs, whilst case difficulty refers to challenging, violent and aggressive behaviour.
A systematic literature review examined institutional violence and aggression in different security settings within healthcare and prison environments. No clear differences were found in frequency of incidents between the security levels, and a suggestion that the severity of incidents were greatest in lower security had limited generalisability. The results were confounded by data incompatibility, meaning that it could not be concluded that higher security sites house the more ‘Difficult Cases’.
An empirical research study examined differences in clinical complexity between personality disordered (PD) patients living in high and medium security units (MSUs). Statistical differences were found on several clinical and forensic variables between settings, including age at first conviction, and difficulties with affective instability, paranoia and depression (assessed with the Personality Assessment Inventory; PAI). This led to the development of a Model of a Complex Case of PD. The results suggested that higher security sites do treat a greater number of ‘Complex Cases’ of PD. Interestingly, they were also found to house a greater number of physically violent patients than the MSUs, ie. more ‘Difficult Cases’.
A case study examined a high security PD patient, ‘Andrew’. His assessment, formulation and violence relapse prevention treatment were presented and discussed. It was identified that on admission Andrew was a match to the Model of a Complex Case of PD, and that a lowering of his PAI score profile over time reflected his treatment gains and lessening of his clinical difficulties. When preparing to transition to an MSU, Andrew could no longer be classified as complex, according to the Model.
Finally a critique of the PAI psychometric was presented. The tool was assessed for reliability and validity as a measure of clinical psychopathologies, interaction styles and treatment needs, and was praised for its utility with PD patients.
The findings from the thesis chapters were reviewed, and the application of the Model of a Complex Case of PD was also discussed. It was concluded that the high security hospital currently provides treatment services to more ‘Complex Cases’ of PD and more ‘Difficult Cases’ than the investigated medium security counterparts.
Please note that Chapter 3, which details a confidential patient case study, has been redacted.
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