Mental Disorder and Trauma in Female Personality Disordered Offenders Sarah McCrory & Annette McKeown Forensic Psychologists Primrose Service Tees Esk & Wear Valleys NHS Foundation Trust

Aims & Objectives Inform understanding of prevalence mental disorder and trauma in female personality disordered offenders. Present research findings on a prison-based study exploring prevalence of mental disorder in female prisoners in a specialist personality disorder service. Present case studies of female prisoners response to trauma treatment within prison setting. Consider practical implications of findings to guide treatment provision. Will present offence types, personality disorder profiles and existing comparisons.

Mental Disorder Literature I Corston Report (2007) emphasised role of mental health difficulties in women’s pathway into the criminal justice system. Mental health as a key consideration in understanding the violence risk of women (Espinosa, Sorensen, & Lopez, 2013). Importance of adequately treating mental health difficulties to help reduce violence risk in this domain (Bartlett et al., 2015). Psychiatric comorbidity found at higher levels in female offenders than male offenders (Butler, Allnutt, Cain, Owens, & Muller, 2005). Understanding findings in the literature on prevalence of Axis I mental disorder in female prisoners can be complicated by literature that combines Axis I mental disorders and Axis II personality disorders under the umbrella term of “mental disorder” (e.g., Tye & Mullen, 2006). In the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychological Association, 1994), the Axis I diagnostic category includes all mental disorders with the exception of personality disorders and developmental disorders. The Axis II diagnostic category includes personality disorders and developmental disorders. When attempting to interpret findings it is important to examine what mental disorders are included in the prevalence rates within particular studies. For example, it has been emphasized that the high prevalence of substance use disorders can artificially inflate statistics on the prevalence of Axis I mental disorder in forensic populations (e.g., Teesson & Proudfoot, 2003). There is also often disparity between different types of measures used to identify mental disorders that can vary between clinical judgment, psychometric measures and more structured clinical diagnostic tools (Naidoo & Mkize, 2012). All these factors warrant consideration when examining prevalence rates presented.

Mental Disorder Literature II In general terms, men have been found to present a higher likelihood of violence than women across different psychiatric diagnoses (Cross & Campbell, 2011). Gender difference in violence reduces in women presenting with psychosis and/or antisocial personality disorder (Coid et al., 2006). High prevalence of psychosis and depression has been found in mothers who have killed their children (Friedman, Horwitz & Resnick, 2005) Prevalence rates of violence becoming more comparable

Mental Disorder Literature III Interpreting research is complicated by definitions, time periods and assessment measures. Mental disorders are more frequently found in prison populations in comparison to community samples (e.g., Prins, 2014). Mental disorders are also more prevalent in female prisoners in comparison to male prisoners (Andreoli et al., 2014). In women prisoners, lifetime prevalence rates of 68%, and current mental disorder prevalence rates of 59% were found (Parsons, Walker, & Grubin, 2001) “ Parsons study, these prevalence rates were found when substance use disorders were excluded from analysis. In contrast, in male remand prisoners, lifetime prevalence rates of 30% were identified within this population. Current prevalence rates of 26% were found when personality disorder diagnoses were included but substance use disorders were excluded (Birmingham, Mason, & Grubin, 1996).

Mental Disorder Literature IV Prevalence rates of mental disorder in female offenders are approximately double that of male offenders (e.g., Brooke, Taylor, Gunn, & Maden, 1996; Steedman et al., 2009). Higher prevalence in remand populations in comparison to sentenced forensic populations (Singleton et al., 1998). Meta-analysis including over 30,000 prisoners (Fazel & Seewald, 2012). Females marginally higher rates of psychosis (3.9% vs. 3.6%) Females higher rates of depression (14.1% vs. 10.2%) Some evidence has suggested higher rates of psychotic disorders in male offenders in comparison to female offenders (Andreoli et al., 2014). In the UK, male offenders have presented with higher rates of psychosis than female offenders (Singleton et al., 1998).

Post-Traumatic Stress Disorder (PTSD) High prevalence rates of post-traumatic stress disorder (PTSD) have been found in female prisoner populations (e.g., Lynch et al., 2014). Prevalence rates of PTSD have ranged from 4% to 40% with female prisoners more likely to suffer from this mental health condition than male prisoners (Goff, Rose, Rose, & Purves, 2007; Findings have identified trauma as a significant predictor of mental health and personality difficulties in female offenders (e.g., Gunter, Chibnall, Antoniak, McCormick, & Black, 2012). Some evidence has suggested higher rates of psychotic disorders in male offenders in comparison to female offenders (Andreoli et al., 2014). In the UK, male offenders have presented with higher rates of psychosis than female offenders (Singleton et al., 1998).

Provision for Women with Personality Disorder and Comorbid Mental Disorder I Prior to 1999, mental health services within custody were the responsibility of the prison service to identify, manage and implement In 1999, new directions including “The Future Organisation of Prison Healthcare” formalised collaboration between the prison service and the National Health Service (NHS) In 2006, commissioning and the provision of prison healthcare services were officially transferred to the NHS. Some evidence has suggested higher rates of psychotic disorders in male offenders in comparison to female offenders (Andreoli et al., 2014). In the UK, male offenders have presented with higher rates of psychosis than female offenders (Singleton et al., 1998).

Provision for Women with Personality Disorder and Comorbid Mental Disorder II It was noted the primary reason over half of the women were located in specialist healthcare settings in prison related to self-harm (Hales, Somers, Reeves, & Bartlett, 2015). For women located in secure hospital settings, research identified for 1 in 20 women self-harm was the primary reason for detention in this setting (Bartlett et al., 2014). For return transfers from secure hospital back to prison, higher prevalence of personality disorder and lower levels of motivation (Doyle et al., 2014). Some evidence has suggested higher rates of psychotic disorders in male offenders in comparison to female offenders (Andreoli et al., 2014). In the UK, male offenders have presented with higher rates of psychosis than female offenders (Singleton et al., 1998).

Provision for Women with Personality Disorder and Comorbid Mental Disorder II Few studies comparing female offenders on hospital orders to female prisoners in the main prison population. Logan and Blackburn (2009) Similar patterns of mental health conditions in both populations of violent women. Women in prison, higher levels of affective disorder, substance use disorder an generealized anxiety disorder. Higher prevalence of NPD, APD and OCPD. Women in hospital, higher levels of psychosis, PTSD, panic disorder and OCD. Research on secure female patients has identified psychotic disorder (43%), followed by personality disorder (38%) were the most common diagnosis within this population (Bartlett, Somers, Fiander, & Harty, 2014).

Current Study

Current Study I Notable lack of research in specialist forensic settings in the UK comparing prevalence of mental disorder to other settings. The current cross-sectional study presents descriptive statistics on Axis I mental disorders with female personality disordered prisoners assessed by the Primrose Service. Prevalence of transfers to secure hospital settings will be presented and compared to existing findings with male offenders, Characteristics of women transferred to secure hospital settings will be presented.

Current Study II Population: All women assessed by the service between 2006 and 2015 (N = 45) were invited to participate in the research study. Overall 30 women (66%) consented to engage in the broader research project. Of this sample, twenty eight women were assessed for mental disorder using SCID-I and were included in the current study. Offence Types: 93% incarcerated for violent offence (n = 26) 7% incarcerated for sexual offences (n = 2) The STOP intervention is recommended to run over a 12-month period and includes assertiveness training, understanding anger and increasing understanding of empathy. undertaken by a charity in Leeds.

Current Study III Measures: Demographic Information Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I; First et al., 1997) i Psychopathy Checklist - Revised (Hare, 2003) International Personality Disorder Examination (IPDE; Loranger, 1999) The STOP intervention is recommended to run over a 12-month period and includes assertiveness training, understanding anger and increasing understanding of empathy. undertaken by a charity in Leeds.

Current Study III Table 1 Prevalence of Current and Lifetime Disorder in Primrose sample   Current Mental Disorder n (%) Lifetime Mental Disorder Psychotic Disorder 2 (7.1%) 3 (10.7%) Mood Disorder 5 (17.8%) 17 (60.7%) Substance Use Disorder 21 (75%) PTSD 9 (32.1%) Panic Disorder 6 (21.4%) OCD 1 (3.6%) Generalised Anxiety Disorder 4 (14.2%) Twenty eight Primrose Service women were assessed using the SCID-I assessment of mental disorder. Of women assessed, 42.9% (n = 12) of women presented with current mental disorder and 57.1% (n = 16) of women presented with no current mental disorder. Mood disorder was the most commonly diagnosed current and lifetime mental disorder diagnosed within this sample. This was then followed in broad terms by post-traumatic stress disorder (PTSD), panic disorder, generalized anxiety disorder, psychotic disorder and obsessive-compulsive disorder (OCD). At the time of assessment, six women (21.4%) met criteria for diagnosis of two current mental health disorders. None of the women in the sample met criteria for more than two current mental disorders. Eighty-nine per cent of women (n = 25) met criteria for lifetime diagnosis of one or more mental disorders. As outlined in Table 9, substance use disorder was the most prevalent mental disorder diagnosed across the lifetime in this sample.   There were consistent patterns of lower prevalence of current diagnosis of mental disorder in comparison to lifetime diagnosis. Substance use disorder was found to be the mental disorder with the largest difference between lifetime and current diagnosis. The percentage of the sample with a current diagnosis was ten times lower than those with a lifetime diagnosis. The prevalence of current diagnoses of mood disorder, PTSD, panic disorder and OCD diagnosis was approximately three times lower than lifetime diagnoses. The prevalence of lifetime diagnosis of generalised anxiety disorder was approximately four times lower than levels of current diagnosis. Psychotic disorder demonstrated the highest rate of consistency with two thirds of the sample with a lifetime diagnosis continuing to meet current criteria for diagnosis (

Current Study IV Table 2 Comparison of current/recent diagnosis of mental disorder across Primrose sample, female sentenced and male sentenced sample   Primrose Sample n (%) Female Sentenced %6 Male Sentenced Psychotic Disorder 2 (7.1%) 14% 7% Mood Disorder 5 (17.8%) 15% 8% PTSD 3 (10.7%) 5%** 3%** Panic Disorder 4% 3% OCD 1 (3.6%) Generalised Anxiety Disorder 11% Singleton et al. (1998) sample of 3,563 male and female prisoners (diagnosis in the last year) **PTSD in this sample referred to prisoners who met all PTSD ICD-10 diagnostic criteria. Descriptive findings of the prevalence of current and lifetime diagnosis were compared to existing findings on various populations. Some studies presented either current or lifetime diagnoses and this is outlined below. The prevalence of current diagnoses of mental disorders were compared to the female sentenced and male sentenced offenders included within the large national prison study undertaken by Singleton et al. (1998) (see Table 10). In Singleton et al.’s (1998) study, “current” diagnosis referred to diagnosis within the last year so may have inflated prevalence to some degree. Formal diagnosis of substance use disorder was not undertaken in this study and therefore is not presented for comparison. Similar prevalence of current diagnosis of psychotic disorder was found in the Primrose sample and male sentenced offenders. Prevalence of psychotic disorder was notably less prevalent than general female sentenced offenders. Higher prevalence of current diagnoses of mood disorder, PTSD, panic disorder was noted in the current sample in comparison to female and male sentenced prisoners. It is important to note that mood disorder in Singleton et al.’s (1998) study referred to a single depressive episode that may have reduced the findings in their sample. Higher prevalence of OCD and generalized anxiety disorder were identified in the general female and male sentenced population.

Current Study IV Table 2 Comparison of current/recent diagnosis of mental disorder across Primrose sample, female sentenced and male sentenced sample   Primrose Sample n (%) Female Sentenced %6 Male Sentenced Psychotic Disorder 2 (7.1%) 14% 7% Mood Disorder 5 (17.8%) 15% 8% PTSD 3 (107%) 5%** 3%** Panic Disorder 4% 3% OCD 1 (3.6%) Generalised Anxiety Disorder 11% Singleton et al. (1998) sample of 3,563 male and female prisoners (diagnosis in the last year) **PTSD in this sample referred to prisoners who met all PTSD ICD-10 diagnostic criteria. Descriptive findings of the prevalence of current and lifetime diagnosis were compared to existing findings on various populations. Some studies presented either current or lifetime diagnoses and this is outlined below. The prevalence of current diagnoses of mental disorders were compared to the female sentenced and male sentenced offenders included within the large national prison study undertaken by Singleton et al. (1998) (see Table 10). In Singleton et al.’s (1998) study, “current” diagnosis referred to diagnosis within the last year so may have inflated prevalence to some degree. Formal diagnosis of substance use disorder was not undertaken in this study and therefore is not presented for comparison. Similar prevalence of current diagnosis of psychotic disorder was found in the Primrose sample and male sentenced offenders. Prevalence of psychotic disorder was notably less prevalent than general female sentenced offenders. Higher prevalence of current diagnoses of mood disorder, PTSD, panic disorder was noted in the current sample in comparison to female and male sentenced prisoners. It is important to note that mood disorder in Singleton et al.’s (1998) study referred to a single depressive episode that may have reduced the findings in their sample. Higher prevalence of OCD and generalized anxiety disorder were identified in the general female and male sentenced population.

Current Study V Overall, 17.8% (n = 5) of the sample were transferred to secure hospital settings. The primary reasons for secure hospital transfer included; escalating self-harm (n = 3), psychotic disorder (n = 1) and autism (n = 1). Secure hospital transfers is notably higher than transfers in male specialist personality disorder service based in custody where prevalence figures of 4.3% (n = 8) have been identified (Kirkpatrick et al., 2010). Prevalence rates of violence becoming more comparable

Current Study VI Average PCL-R score of women with a current mental disorder diagnosis was lower than those without a current mental disorder diagnosis. An independent t-test indicated this differences between PCL-R scores in women with (M = 19.91; SD = 5.34, and without a current mental disorder (M = 20.81, SD = 5.73; t (25) = .41, p = .68; d = -.16, 95% CI [-3.60, 5.22]) was not significant. A small effect size was found. Prevalence rates of violence becoming more comparable

Thank You Any questions? Annette.Mckeown01@hmps.gsi.gov.uk Annette.mckeown@nhs.net