July 2003. At a workshop held during an American Psychiatric Association (APA) meeting, the practice guideline for the treatment of patients with borderline personality disorder (BPD) was being discussed. After a generally enthusiastic audience response, one participant expressed the opinion that, if anything, the development of this practice guideline was long overdue, and that guidelines should also be developed for other personality disorders. I took a straw poll of the audience, and there was a pretty strong consensus agreeing with this suggestion. To my surprise, however, the personality disorder overwhelmingly recommended for the next guideline was antisocial personality disorder (ASPD). I suggested at the time that the need for help and guidance to treat patients with ASPD was clear, since it is a long-term, highly disabling disorder that has been estimated to cost society more than schizophrenia. However, the development of an evidence-based practice guideline depends upon the presence of a fairly well-established evidence base, preferably with some randomized controlled treatment trials demonstrating the efficacy of specific treatment approaches. Ten years prior to the development of the BPD practice guideline, in a conference that launched the APA practice guideline development process, it was concluded that the controlled trial treatment literature was insufficient to justify developing a BPD guideline at the time, even though clinicians were clamoring for help in their work with these patients. When, 10 years later, we revisited the possibility of developing a BPD guideline, a number of randomized controlled treatment trials demonstrating selected efficacy had been published, an evidence base that, although not robust, contributed importantly to the final product. Yet even with respect to the BPD guideline, there are patients with this diagnosis who are severely disabled (e.g., in forensic institutional settings), and it is not clear whether the treatment recommendations in the BPD guideline, which are aimed at the “prototypic” patient at the center of the bell-shaped curve, will be useful for those on the far end of the curve.
In this issue of the journal, Rutter and Tyrer remind us of a treatment modality not as commonly seen in the United States but still in substantial use in the United Kingdom, the voluntary therapeutic community (TC). They clarify the indications for such a treatment model, since it is generally not viewed as appropriate for violent or antisocial patients, and it needs to be differentiated from forensic or prison-based TCs. Rutter and Tyrer argue persuasively that randomized controlled trials of this treatment are feasible and needed. If such studies established the usefulness of this treatment model for patients with various personality disorders, support for their availability in this country would be greatly strengthened. Also in this issue, Stone presents a selection of clinical treatment cases that demonstrate a spectrum of treatment outcome ranging from moderate success to outright failure. Among the characteristics of patients Stone would categorize as beyond the border of treatability are those with extensive antisocial features. In turn, Hoptman reviews neuroimaging studies of violent behavior in psychiatric patient populations, with a particular focus on antisocial behavior. These types of studies, combined with other new neurobiological and psychosocial findings, promise to shed light on our still tentative path toward understanding how to develop effective treatments for these patients. However, in spite of understandable requests from practicing clinicians, in my opinion a practice guideline for ASPD is not yet ready for prime time.
On a separate note, in this issue we are pleased to present the second place winner in our resident paper competition, in an article focusing on psychiatric advance directives. This thoughtful paper reviews the important issue of how patients with severe and disabling psychiatric disorders can participate in their own treatment, even when the illnesses themselves, at times, may interfere with insight, judgment, and decision-making capacity.