Abstract
Aims and methodThere is evidence that changing diagnoses may be an important factor preceding homicide, but there is little literature on diagnostic antecedents to admission to specialist secure units after violent behaviour. Our aim was to establish the frequency of a history of changing diagnoses in patients in a UK specialist unit, and to explore the characteristics of these patients.ResultsIn total, 38 of 42 study participants had prior contact with psychiatric services. Just over 40% (16 of the 38) had had their diagnosis changed three or more times. All those who had major changes in their diagnosis had received a diagnosis of a psychotic illness at some point prior to the secure unit admission, but then had it withdrawn, only to be restored after prolonged assessment in the secure unit. Personality disorder and substance misuse comorbidity was common in this group; however, non-psychotic diagnoses were seen as more important than psychotic diagnoses by general services.Clinical implicationsChanges in diagnosis between first presentation to psychiatric services and admission to a medium-security unit were more common than would be expected from reports in the general literature. They are a testimony to the difficulties experienced by service providers in delivering a consistent service. This needs to be studied further.
Highlights
The demographic composition of our study sample is comparable with that of patients in other studies of medium secure units, but none of these looked at changes in diagnoses.[8,9]
Following assessment at Caswell Clinic, 88.1% received a diagnosis of a psychotic disorder (78.6% paranoid schizophrenia) compared with 93% in the Lelliott et al (2001) survey[8] and 86% in the Mckenna (1996) survey.[9]
Our main findings were that over 40% of patients in this cohort had been subject to changing diagnoses, with an earlier period of recognition of functional psychosis, followed by a period in which substance misuse and/or personality disorder diagnoses prevailed, and under conditions of prolonged, multidisciplinary assessment in the absence of substances, a diagnosis of a functional psychosis was restored, with or without comorbid diagnoses
Summary
A total of 42 patients had been resident in Caswell Clinic at some time between 1 February 2006 and 31 January 2008. The one thing all three individuals in these examples had in common was that a diagnosis of some form of psychosis had been given at some point during the course of their illness prior to the medium secure unit admission, and rejected at some point before its restoration after an offence and prolonged assessment during detention in mediumsecurity hospital conditions. Not statistically significant: w2 = 0.025, P = 0.878 Another common factor among patients with multiple diagnoses was their receiving the diagnosis of personality disorder at some point during their contact with psychiatric services. Of the two remaining patients, one had received a primary diagnosis of personality disorder and the other had not previously been in contact with mental health services. Available records did not clearly identify how these diagnoses were made and no evidence of use of any personality disorder questionnaires was found
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