ANALYTIC FRAMEWORK AND CLINICAL QUESTIONS

National Collaborating Centre for Mental Health (UK)

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National Collaborating Centre for Mental Health (UK). Antisocial Personality Disorder: Treatment, Management and Prevention. Leicester (UK): British Psychological Society; 2010. (NICE Clinical Guidelines, No. 77.)

See 2013 Partial Update

March 2013: Some recommendations in sections 5.3.9, 5.4.9, 5.4.14, 5.4.19, 5.4.24 and 8.2 have been removed from this guideline by NICE. August 2018: Some recommendations have been updated to link to NICE topic pages.

March 2013: Some recommendations in sections 5.3.9, 5.4.9, 5.4.14, 5.4.19, 5.4.24 and 8.2 have been removed from this guideline by NICE. August 2018: Some recommendations have been updated to link to NICE topic pages.

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Antisocial Personality Disorder: Treatment, Management and Prevention.

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APPENDIX 7ANALYTIC FRAMEWORK AND CLINICAL QUESTIONS

	Topic area	Key question(s)
1	Assessment and referral	1a. What is the threshold for intervening to treat problems associated with antisocial personality disorder? 1b. What is the threshold for intervening to treat symptoms associated with antisocial personality disorder? 1c. What is the threshold for intervening to treat antisocial personality disorder? 1d. What is the threshold at which other treatment and care should be modified because of antisocial personality disorder? 1e. What is the threshold for referral to another service or setting? 1f. When is a formal diagnosis of antisocial personality disorder needed/when does a diagnosis of antisocial personality disorder improve outcomes? 1g. What are the harms of diagnosis? 1h. What is the threshold for risk assessment?
2	Interventions for adults with antisocial personality disorder	2. What interventions for people with antisocial personality disorder improve outcomes?
3	Treatment of comorbid disorders	3. For people with antisocial personality disorder with comorbid disorders, does treatment of comorbid disorders improve outcomes?
4	Interventions for offending behaviour	4. For people with antisocial personality disorder, do interventions for offending behaviour improve outcomes?
5	Structures for the delivery of care and management of people with antisocial personality disorder	5a. What service structures for the management of ongoing long-term care and the delivery of interventions for people with antisocial personality disorder deliver the best outcomes?
		5b. What organisational structures and processes to support professionals and staff caring for and managing people with antisocial personality disorder deliver the best outcomes?
6	Risk assessment and management for adults with antisocial personality disorder	6. For people with antisocial personality disorder, does formal risk assessment and management improve outcomes and reduce harm to others?
7	Early intervention in children and adolescents to prevent antisocial personality disorder	7a. Are there early interventions for young at-risk children that are effective at preventing antisocial personality disorder?
		7b. Are interventions with children and adolescents with conduct disorder effective at preventing antisocial personality disorder?

CLINICAL QUESTIONS

1.1. Assessment and referral

1.1.1.: What is the threshold for intervening to treat problems associated with antisocial personality disorder?
1.1.2.: What is the threshold for intervening to treat symptoms associated with antisocial personality disorder?
1.1.3.: What is the threshold for intervening to treat antisocial personality disorder?
1.1.4.: What is the threshold at which other treatment and care should be modified because of antisocial personality disorder?
1.1.5.: What is the threshold for referral to another service or setting?
1.1.6.: When is a formal diagnosis of antisocial personality disorder needed/when does a diagnosis of antisocial personality disorder improve outcomes?
1.1.7.: What are the harms of diagnosis?
1.1.8.: What is the threshold for risk assessment?

2. What interventions for people with antisocial personality disorder improve outcomes?

2.1. Interventions in primary care for problems associated with antisocial personality disorder

2.1.1.: What identifies people who have the potential to benefit from, and meet the threshold for, primary care interventions for antisocial personality disorder related problems?
2.1.2.: What interventions to address problems and behaviour associated with antisocial personality disorder, or to promote harm avoidance, improve outcomes?
2.1.3.: For each of these interventions, what factors favour and contraindicate referral?
2.1.4.: What harms are associated with interventions to address problems and behaviour associated with antisocial personality disorder?
2.1.5.: Where people with antisocial personality disorder have problems that are primarily social, are there non-healthcare services that improve outcomes?
2.1.6.: What harms to people with antisocial personality disorder are associated with their use of non-healthcare services?

2.2. Secondary care mental health interventions to treat ‘symptoms’ of antisocial personality disorder

2.2.1.: What identifies people who have the potential to benefit from, and meet the threshold for, interventions to treat antisocial personality disorder symptoms?
2.2.2.: What interventions are effective at treating symptoms of antisocial personality disorder?
2.2.3.: For each of these interventions, what factors favour and contraindicate referral?
2.2.4.: What are the harms of interventions to treat symptoms of antisocial personality disorder?

2.3. Interventions to treat antisocial personality disorder in tertiary care/specialist services

2.3.1.: What identifies people who have the potential to benefit from, and meet the threshold for, interventions to treat antisocial personality disorder?
2.3.2.: What interventions are effective at treating antisocial personality disorder?
2.3.3.: For each of these interventions, what factors favour and contraindicate referral?
2.3.4.: What are the harms of interventions to treat antisocial personality disorder?

2.4. The therapeutic environment

2.4.1.: For people with antisocial personality disorder, what features of the environment in which interventions are delivered improve outcomes?
2.4.1.: For people with antisocial personality disorder, what features of the environment in which interventions are delivered cause harm?

3. For people with antisocial personality disorder with comorbid disorders, does treatment of comorbid disorders improve outcomes?

3.1. Assessment for people with antisocial personality disorder and comorbid disorders

3.1.1.: Where people with antisocial personality disorder have multiple comorbidities, what disorders/problems should be treated first?
3.1.2.: Should people with antisocial personality disorder who have been treated for comorbid disorders be referred for assessment and treatment of antisocial personality disorder or antisocial personality disorder symptoms?

3.2. Interventions for people with antisocial personality disorder who have comorbid alcohol problems or dependence

3.2.1.: What identifies people with antisocial personality disorder who have the potential to benefit from, and meet the threshold for, interventions for alcohol problems or dependence?
3.2.2.: What interventions are effective at treating alcohol problems or dependence in people with antisocial personality disorder?
3.2.2a.: Are interventions for alcohol problems or dependence less effective for people with antisocial personality disorder?
3.2.2b.: How should interventions for alcohol problems or dependence be adapted for people with antisocial personality disorder?
3.2.3.: For people with antisocial personality disorder, what are the harms of treating alcohol problems or dependence?

3.3. Interventions for people with antisocial personality disorder who have comorbid drug misuse or dependence

3.3.1.: What identifies people with antisocial personality disorder who have the potential to benefit from, and meet the threshold for, interventions for drug misuse or dependence?
3.3.2.: What interventions are effective at treating drug misuse or dependence in people with antisocial personality disorder?
3.3.2a.: Are interventions for drug misuse or dependence less effective for people with antisocial personality disorder?
3.3.2b.: How should interventions for drug misuse or dependence be adapted for people with antisocial personality disorder?
3.3.3.: For people with antisocial personality disorder, what are the harms of treating drug misuse or dependence?

3.4. Interventions for people with antisocial personality disorder who have comorbid depression or anxiety

3.4.1.: What identifies people with antisocial personality disorder who have the potential to benefit from, and meet the threshold for, interventions for depression or anxiety?
3.4.2.: What interventions are effective at treating depression or anxiety in people with antisocial personality disorder?
3.4.3.: For people with antisocial personality disorder, what are the harms of treating depression or anxiety?

3.5. Interventions for people with antisocial personality disorder who have comorbid personality disorders

3.5.1.: What identifies people with antisocial personality disorder who have the potential to benefit from, and meet the threshold for, interventions for comorbid personality disorders?
3.5.2.: What interventions are effective at treating comorbid personality disorders in people with antisocial personality disorder?
3.5.3.: For people with antisocial personality disorder, what are the harms of treating comorbid personality disorders?

4. For people with antisocial personality disorder, do interventions for offending behaviour improve outcomes?

4.1. Could any interventions for offending behaviour be used as interventions to treat people with antisocial personality disorder in a healthcare setting?

4.1.1.: What interventions are effective at reducing re-offending in the general offender population?
4.1.2.: What harms to offenders are associated with interventions to reduce offending behaviour?
4.1.3.: In offender populations, what factors can be used as proxy indicators of antisocial personality disorder and validate extrapolation to people with antisocial personality disorder?
4.1.4.: What identifies people with antisocial personality disorder who have the potential to benefit from, and meet the threshold for, interventions for offending behaviour?
4.1.5.: What interventions for offenders improve outcomes for people with antisocial personality disorder or offenders with proxy indicators of antisocial personality disorder?
4.1.5a.: For each of these interventions, does the effectiveness differ for offenders with antisocial personality disorder compared with the general offender population?
4.1.5b.: For each of these interventions, what factors favour and contraindicate referral?
4.1.6.: What harms to people with antisocial personality disorder are associated with interventions to reduce offending behaviour?

5a. What service structures for the management of ongoing long-term care and the delivery of interventions for people with antisocial personality disorder deliver the best outcomes?

5.1.1.: What identifies people with antisocial personality disorder who need long- term care and support through and beyond treatment interventions?
5.1.2.: What service structures for delivering interventions and providing ongoing long-term care and support for people with antisocial personality disorder improve outcomes?
5.1.3.: What harms are associated with structures for providing care for people with antisocial personality disorder?
5.1.4.: What are the support needs of carers/people (including children) who live with people with antisocial personality disorder?
5.1.5.: How can services meet the support needs of carers/people (including children) who live with people with antisocial personality disorder?
5.1.6.: Does the delivery of care and interventions for the person with antisocial personality disorder cause harms to carers/the people (including children) who live with them?
5.1.7.: Do the support needs of carers/people (including children) who live with people with antisocial personality disorder conflict with the needs of the person with antisocial personality disorder?

5b. What organisational structures and processes to support professionals and staff caring for and managing people with antisocial personality disorder deliver the best outcomes?

5.2.1.: What are the potential harms to professionals and staff from working with people with antisocial personality disorder?
5.2.1a.: Do harms to professionals and staff lead to harms to the people with antisocial personality disorder they care for (for example by undermining treatment)?
5.2.2.: How can services address the challenges of providing care for people with antisocial personality disorder?
5.2.2a.: What support for staff including training, consultation/liaison, supervision, peer support, team-based and collective working is associated with improved outcomes?
5.2.2b.: What leadership and management interventions (including clarity of roles and purpose, taking responsibility, case loads) are associated with improved outcomes?
5.2.3.: What are the harms of measures to address the challenges of providing care for people with antisocial personality disorder?
5.2.4.: Is there a conflict between what delivers better outcomes for people with antisocial personality disorder and what delivers better outcomes for professionals and staff?
5.2.5.: Is there evidence on what ethos adopted by a service is most likely to deliver better outcomes?

6. For people with antisocial personality disorder, does formal risk assessment and management improve outcomes and reduce harm to others?

6.1. Risk assessment

6.1.1.: What is the threshold for formal risk assessment?
6.1.2.: What instruments and tools predict risk in people with antisocial personality disorder?
6.1.2a.: What features of a risk assessment process make it more effective at predicting/improving outcomes?
6.1.3.: What are the harms of risk assessment?

6.2. Risk management

6.2.1.: What is the threshold for structured risk management?
6.2.2.: Does structured risk management improve outcomes?
6.2.2a.: What are the essential features of an effective risk management plan?
6.2.3.: What are the harms of structured risk management?
6.2.4.: What is the threshold for limiting an individual’s freedom because of risk?
6.2.5.: Does limiting an individual’s freedom improve outcomes?
6.2.6.: What are the harms of limiting an individual’s freedom?

7a. Are there early interventions for young at risk children that are effective at preventing antisocial personality disorder?

7.1. Early interventions for young children at risk of developing antisocial personality disorder prior to the development of behavioural symptoms

7.1.1.: What identifies children at risk of developing antisocial personality disorder before they develop behavioural disorders (with particular reference to developmental, psychosocial and family factors)?
7.1.1a.: What are key modifiable risk factors that can be targeted by interventions?
7.1.1b.: How can children who would benefit from interventions be identified?
7.1.2.: For children who do not have behavioural disorders, what are the harms of early identification of risks for antisocial personality disorder (with particular consideration of harm from stigma/labelling)?
7.1.3.: What proportion of young children with risk factors for antisocial personality disorder will go on to develop conduct disorder?
7.1.3a.: Where children have risk factors for antisocial personality disorder, what is the likelihood that they will go on to develop antisocial personality disorder?
7.1.4.: What early interventions improve intermediate outcomes?
7.1.4a.: Following early intervention, what proportion of young children with risk factors for antisocial personality disorder will go on to develop conduct disorder and meet criteria for interventions for conduct disorder?
7.1.4b.: What early interventions prevent antisocial personality disorder?
7.1.5.: What are the harms of early interventions (with particular consideration of harm from stigma/labelling)?
7.1.6.: For children with risk factors for antisocial personality disorder who develop conduct disorder following early intervention, does early intervention make them more susceptible to interventions for conduct disorder?

7b. Are interventions with children and adolescents with conduct disorder effective at preventing antisocial personality disorder?

7.2. Interventions for children and young people with conduct disorder

7.2.1.: What identifies young people who could benefit from interventions for conduct disorder?
7.2.2.: What are the harms of identification of conduct disorder (with particular consideration of harm from stigma/labelling)?
7.2.3.: What is the likelihood that a young person with conduct disorder will convert to antisocial personality disorder?
7.2.3a.: What other factors are most predictive of conversion to antisocial personality disorder?
7.2.4.: What interventions for conduct disorder improve intermediate outcomes?
7.2.4a.: What interventions for conduct disorder prevent antisocial personality disorder?
7.2.5.: What are the harms of treatment for conduct disorder?
7.2.6.: For young people in contact with services because of conduct disorder, how should the transition to adult services be managed to maintain consistency of care and interventions, promote beneficial treatment outcomes and minimise harms?