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This paper focuses on difficulties in the treatment and care of patients with a diagnosis of psychopathic, or anti-social personality disorder as it is usually referred to today. The current psychiatric diagnostic systems (ICD-10 and DSM-IV) are primarily categorical and theoretical. Diagnosis is arrived at by assessing the presence or absence of symptoms and behaviours. These diagnostic systems do not take any account of the individual's development or personality structure and consequently there is no dimension for describing links between different diagnoses. This means that these patients are often thought to be either suffering from paranoid schizophrenia or anti-social personality disorder or a dual diagnosis depending on the phase of their illness. The current diagnostic system does not recognize the underlying personality structures that link the diagnosis and cycles of the illness together. However DSM-V, which is coming out next year, will take a more dimensional approach, and as such will be more compatible with a psychoanalytic understanding of mental disorder.
In this paper the author draws upon literature in this area and suggests that this dichotomy between the psychotic and the anti-social may be too simple and argues that if we can understand that psychotic processes may well also underlie the personality disorders, we may reach a better understanding of what takes place in these settings and how staff are affected by the patients. In order to function effectively, staff need regular, on-going supervision. These arguments will be illustrated with clinical examples taken from supervision groups and consultations in forensic and mental health settings.