RSS 1.0Personality Disorders
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Unified protocol vs mentalization-based therapy for adolescents with borderline personality disorder: A randomized controlled trialBACKGROUND: Despite several treatments, e.g., mentalization-based therapy (MBT) and Unified Protocol (UP), being adapted to treat adolescents with borderline personality disorder (BPD), there exists a dearth of literature regarding their relative efficacy. In this study modified forms of MBT and UP - MBT-A and UP-A respectively-were compared in their ability to reduce borderline symptoms in a sample of 91 Iranian adolescents (two-thirds female) with a BPD diagnosis. METHODS: Individuals randomly allocated to one of two treatment groups, MBT-A (N = 45) or UP-A (N = 46) were followed up across 36 months following treatment. A MIXED ANCOVA was applied to compare the effectiveness of these interventions in reducing severity of borderline symptoms (the primary outcome), impulsivity, self-harm, emotion dysregulation and anger (secondary outcomes). The trial was retrospectively registered at IRCT20231106059970N1. RESULTS: Both primary outcomes and secondary outcomes decreased significantly following both MBT-A and UP-A. In comparison with MBT-A, UP-A was more effective in reducing emotional dysregulation, but levels of remission declined progressively up to 36 months of follow-up following both treatments. CONCLUSIONS: UP-A appears to be more effective than MBT-A in reducing emotional dysregulation in adolescents with BPD, despite being a shorter and less intensive treatment. An important caveat is that the treatment induced changes were largely limited to the emotion dysregulation aspect of BPD; other aspects (interpersonal and identity disturbances) were largely unchanged by either treatment.
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Mentalisation-based treatment for antisocial personality disorder in males convicted of an offence on community probation in England and Wales (Mentalization for Offending Adult Males, MOAM): A multicentre, assessor-blinded, randomised controlled trialBACKGROUND: Antisocial personality disorder is a major health and social problem, but scepticism about its treatability has restricted development of the evidence base for psychological treatments. Mentalisation-based treatment (MBT) tailored for antisocial personality disorder (MBT-ASPD) can address problematic behaviours by improving the ability to understand and regulate the negative effects of thoughts and feelings. This study aimed to evaluate the clinical and cost-effectiveness of MBT-ASPD compared with probation as usual in reducing aggressive behaviours from baseline to 12 months of follow-up. METHODS: The Mentaliziation for Offending Adult Males (MOAM) trial was a multicentre, two-group, pragmatic, assessor-masked, randomised controlled superiority trial in England and Wales. Eligible participants were male, aged 21 years or older, convicted of an offence and under National Probation Service supervision at one of 13 sites, identified through the Community Personality Disorder Pathways Service, met DSM-5 criteria for antisocial personality disorder, and scored at least 15 on the Overt Aggression Scale-Modified (OAS-M). After a three-stage screening process, consenting participants were randomly allocated (1:1), stratified by site, age, probation order type, and remaining probation duration, to either MBT-ASPD plus probation as usual, or probation as usual alone. Participants in the MBT-ASPD group were offered 12 months of weekly 75-min group therapy sessions and monthly 50 min individual sessions. Probation as usual lasted up to 12 months, after which participants continued under National Probation Service supervision for the remainder of their term. Investigators and data collectors were masked to treatment allocation. The primary outcome was aggression measured by the OAS-M at 12 months after random allocation. Data were collected by a hybrid team of traditional researchers and researchers with lived experience of the criminal justice system. The primary analysis was conducted in the intention-to-treat population using a linear mixed-effects model, adjusted for baseline at each follow-up timepoint (months 3, 6, 9, 12, 15, 18, 21, and 24). This trial is registered with ISRCTN (ISRCTN 32309003), and all pre-planned follow-ups are complete. FINDINGS: Between Jan 2, 2016, and Aug 31, 2018, 1946 individuals were referred to the study; after the screening process, 313 participants were randomly allocated (156 [50%] to probation as usual and 157 [50%] to MBT-ASPD plus probation as usual). Participants had a mean age of 34·2 years (SD 9·3); the majority of participants (247 [79%]) identified as White British, Irish, or White Other; followed by Black British (Caribbean, African, or Other; 30 [10%]) or Mixed (29 [9%]). At 12 months after random allocation, mean OAS-M scores were significantly higher in the probation as usual group (mean score 186 [SD 153]) than in the MBT-ASPD group (90 [126]), with an adjusted mean difference between groups of -73·5 (95% CI -113·7 to -33·2); p<0·0001, with a medium-to-large effect size of 0·74. During the trial, seven participants died, and one presumed death occurred, all in the probation as usual group after random allocation, with none of the deaths deemed related to trial procedures. INTERPRETATION: MBT-ASPD holds promise as an effective intervention for individuals with antisocial personality disorder within a forensic population. Future research should explore these findings' generalisability and the sustainability of treatment gains. FUNDING: National Institute for Health Research Health Technology Assessment programme.
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How does stigma impact acts of compassion among people with borderline personality disorderBorderline personality disorder (BPD) is a highly stigmatised mental disorder. A variety of research exists highlighting the stigma experienced by individuals with BPD and the impacts of such prejudices on their lives. Similarly, much research exists on the benefits of engaging in compassionate acts, including improved mental health recovery. However, there is a notable gap in understanding how stigma experienced by people with BPD acts as a barrier to compassion and by extension recovery. This paper synthesises these perspectives, examining common barriers to compassionate acts, the impact of stigma on people with BPD, and how these barriers are exacerbated for individuals with BPD due to the stigma they face. The synthesis of perspectives in the article highlights the critical role of compassion in supporting the recovery of individuals with BPD, while also revealing the significant barriers posed by stigma. Addressing these challenges requires a comprehensive understanding of the intersection between compassion and stigma, informing the development of targeted interventions to promote well-being and recovery for individuals with BPD.
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The impact of age and sex on the expression and severity of borderline symptoms in individuals with borderline personality disorder: An Iranian studyReports of sex and age differences in the presentation of borderline symptoms have been limited to the Western literature and have not systematically compared adolescents with emerging and older adults with borderline personality disorder (BPD). This study aimed to examine the impact of age and sex on the expression of borderline symptoms in adolescents, young adults, and older adults with BPD. A sample of 493 Iranian individuals with a confirmed diagnosis of BPD was segregated into 2 age groups: 134 young people aged 12-25 (mean = 17.60), and 142 adults aged 26 and older (mean = 31.69). Young people were divided into: 241 adolescents (mean = 15.59) and 100 young adults (mean = 22.45). Older groups compared with their younger counterparts showed significantly greater severity of borderline symptoms and greater difficulties with emotion regulation, but younger groups showed greater emotional and behavioral dysregulation. Sex differences generally mirrored those reported in the Western literature. Despite being limited by its cross-sectional design, this study suggests that adolescents, young adults, and older adults differ significantly in the way their borderline symptoms are expressed. The development of gender identity in adolescents with BPD and a disturbed sense of self is a neglected but potentially fruitful area of future research.
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Pharmacological interventions for co-occurring psychopathology in people with borderline personality disorder: Secondary analysis of the Cochrane systematic review with meta-analysesBACKGROUND: Medications are commonly used to treat co-occurring psychopathology in persons with borderline personality disorder (BPD). AIMS: To systematically review and integrate the evidence of medications for treatment of co-occurring psychopathology in people with BPD, and explore the role of comorbidities. METHOD: Building on the current Cochrane review of medications in BPD, an update literature search was done in March 2024. We followed the methods of this Cochrane review, but scrutinised all identified placebo-controlled trials post hoc for reporting of non BPD-specific ('co-occurring') psychopathology, and explored treatment effects in subgroups of samples with and without defined co-occurring disorders. GRADE ratings were done to assess the evidence certainty. RESULTS: Twenty-two trials were available for quantitative analyses. For antipsychotics, we found very-low-certainty evidence (VLCE) of an effect on depressive symptoms (standardised mean difference (SMD) -0.22, P = 0.04), and low-certainty evidence (LCE) of an effect on psychotic-dissociative symptoms (SMD -0.28, P = 0.007). There was evidence of effects of anticonvulsants on depressive (SMD -0.44, P = 0.02; LCE) and anxious symptoms (SMD -1.11, P < 0.00001; VLCE). For antidepressants, no significant findings were observed (VLCE). Exploratory subgroup analyses indicated a greater effect of antipsychotics in samples including participants with co-occurring substance use disorders on psychotic-dissociative symptoms (P = 0.001). CONCLUSIONS: Our findings, based on VLCE and LCE only, do not support the use of pharmacological interventions in people with BPD to target co-occurring psychopathology. Overall, the current evidence does not support differential treatment effects in persons with versus without defined comorbidities. Medications should be used cautiously to target co-occurring psychopathology.
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A Randomized controlled trial comparing mentalization-based therapy with the unified protocol in the treatment of psychopathy and comorbid borderline + antisocial personality disordersBACKGROUND: Those with cooccurring antisocial personality disorder (ASPD) and borderline personality disorder (BPD) are reported to be highly psychopathic and to represent a severe challenge to treatment efforts. In a sample of such individuals, the effects of two treatments, mentalization-based therapy (MBT) and the unified protocol (UP), were investigated on three outcomes: (i) the psychopathy trait domains of meanness, boldness and disinhibition proposed by the triarchic psychopathy model (TPM); (ii) antisocial and borderline symptom severity; and (iii) the severity of their common features including impulsivity, anger expression and self-harm. METHODS: Of 163 individuals with BPD + ASPD screened for eligibility, 55 were randomized to MBT treatment and 53 to UP treatment. Outcomes of treatment were assessed at 6-month intervals to 36 months. RESULTS: Short-term reductions were seen following both treatments in traits of psychopathy, antisocial and borderline personality symptom severity, anger dysregulation, impulsivity and self-harm, but both treatment groups showed almost complete relapse of symptoms at the 36-month follow-up. UP had more durable effects than MBT. CONCLUSIONS: Despite being a considerably shorter treatment, UP was at least as effective as MBT and in some respects superior. Remission of symptoms was not achieved by either treatment in the long term. Psychopathy and borderline/antisocial comorbidity with which it is associated are to some extent remediable through psychotherapy, but only in the short term. CLINICAL IMPLICATIONS: Patients with high levels of impulsivity and disinhibition are likely to relapse following psychotherapy and should be closely monitored after treatment.
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A Randomized controlled trial comparing mentalization-based therapy with the unified protocol in the treatment of psychopathy and comorbid borderline + antisocial personality disordersBACKGROUND: Those with cooccurring antisocial personality disorder (ASPD) and borderline personality disorder (BPD) are reported to be highly psychopathic and to represent a severe challenge to treatment efforts. In a sample of such individuals, the effects of two treatments, mentalization-based therapy (MBT) and the unified protocol (UP), were investigated on three outcomes: (i) the psychopathy trait domains of meanness, boldness and disinhibition proposed by the triarchic psychopathy model (TPM); (ii) antisocial and borderline symptom severity; and (iii) the severity of their common features including impulsivity, anger expression and self-harm. METHODS: Of 163 individuals with BPD + ASPD screened for eligibility, 55 were randomized to MBT treatment and 53 to UP treatment. Outcomes of treatment were assessed at 6-month intervals to 36 months. RESULTS: Short-term reductions were seen following both treatments in traits of psychopathy, antisocial and borderline personality symptom severity, anger dysregulation, impulsivity and self-harm, but both treatment groups showed almost complete relapse of symptoms at the 36-month follow-up. UP had more durable effects than MBT. CONCLUSIONS: Despite being a considerably shorter treatment, UP was at least as effective as MBT and in some respects superior. Remission of symptoms was not achieved by either treatment in the long term. Psychopathy and borderline/antisocial comorbidity with which it is associated are to some extent remediable through psychotherapy, but only in the short term. CLINICAL IMPLICATIONS: Patients with high levels of impulsivity and disinhibition are likely to relapse following psychotherapy and should be closely monitored after treatment.
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Developing models and a framework for multi‐professional clinical supervisionThe UK government proposals for services for individuals considered to be dangerous with a severe personality disorder (DSPD) are developing. The complex task of balancing safety and therapeutic change in DSPD services will rest largely upon the skills, knowledge and practice of the staff group. As a result, one challenge for DSPD services is to provide sufficient training and support to staff, in order to ensure that adequate resources are available to assist them in processing their emotional reactions to their work. As part of this, clinical supervision systems need to be developed to offer professional support and learning, enabling individual practitioners to develop knowledge and competence and assume responsibility for their own practice (DoH, 1993). Among the service developments at Rampton Hospital an innovative multi‐professional supervision strategy has been introduced for all staff working in the unit. This paper describes the evolving supervision framework, including a new tool, the ‘Supervision Matrix’, and implementation guidelines, and describes how this supervision framework will be evaluated.
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Exploring the effects of early trauma in a forensic high secure population: evaluating associations between adverse childhood experiences (ACEs) and diagnosis of antisocial personality disorder (ASPD)Aims. To examine links between Adverse Childhood Experiences (ACE) categories and diagnosis of antisocial personality disorder (ASPD) in this population; it is predicted that there will be a positive association between number of ACEs and ASPD. The effectiveness of high secure hospital admission and treatment in reducing number of risk incidents was also examined. ACEs are known to impact significantly on the development of the personality and future psychiatric risk. Currently, research into links between distinct ACE categories and the diagnosis of ASPD in the high-secure inpatient population is limited. Methods. Data were collected from a sample (n = 221) including all patients in the Mental Health, Personality Disorder and Women's Services at a high-secure hospital. Records were examined for evidence of abuse/neglect during childhood, and a number of markers of household dysfunction. The statistical relationship between each ACE category and subsequent diagnosis of ASPD was examined through paired t-tests. Frequency of incident reports (IR1s) involving violence was compared in the first, third and fifth years post-admission. Results. Significant associations with adult diagnosis of ASPD were seen in categories of childhood physical abuse, sexual abuse, divorced/separated parents, Looked After Child (LAC) status and parental substance misuse, and total number of ACE categories present overall. Significant reductions in frequency of IR1s were seen in all services between first- and fifth- year post admission. Conclusion. A significant association between ACEs in specific domains and ASPD in adulthood was found. The importance of detailed exploration of childhood circumstances in this group is highlighted, as well as the need for further investigation of the psychological and social mechanisms underlying.
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Impaired striatal glutamate/GABA regulation in violent offenders with antisocial personality disorder and psychopathyMen with antisocial personality disorder (ASPD) with or without psychopathy (+/−P) are responsible for most violent crime in society. Development of effective treatments is hindered by poor understanding of the neurochemical underpinnings of the condition. Men with ASPD with and without psychopathy demonstrate impulsive decision-making, associated with striatal abnormalities in functional neuroimaging studies. However, to date, no study has directly examined the potential neurochemical underpinnings of such abnormalities. We therefore investigated striatal glutamate: GABA ratio using Magnetic Resonance Spectroscopy in 30 violent offenders (16 ASPD-P, 14 ASPD + P) and 21 healthy non-offenders. Men with ASPD +/− P had a significant reduction in striatal glutamate : GABA ratio compared to non-offenders. We report, for the first time, striatal Glutamate/GABA dysregulation in ASPD +/− P, and discuss how this may be related to core behavioral abnormalities in the disorders.
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Effects of two treatments on interpersonal, affective, and lifestyle features of psychopathy and emotion dysregulationThis study investigated the relative efficacy of Mentalization-based therapy (MBT) and United Protocol (UP) in reducing symptoms of psychopathy and emotion dysregulation in a sample of Iranian community residents with concurrent diagnoses of antisocial and borderline personality disorders (PDs). Interpersonal, affective, and lifestyle features of psychopathy were measured post-treatment and at 6-, 12-, 18-, 24-, and 36-months follow-up using the 13-item version of the Psychopathy Revised-Checklist (PCL-R), which excluded, by design, criminal history features. Emotion dysregulation was measured using the Deficits in Emotion Regulation Scale (DERS) developed by Gratz and Roemer (2004). After treatment, both UP- and MBT-treated individuals showed significantly fewer features of psychopathy and significantly less emotion dysregulation. Compared with those treated with MBT, UP-treated individuals showed significantly less emotion dysregulation in all DERS subscales and a greater reduction in psychopathy features, particularly affective features. It is suggested that this likely reflected the particular emphasis placed by UP on improving emotional self-regulation and facilitating the therapeutic alliance. These results suggest that, despite the traditional pessimism that surrounds psychopathic individuals' treatability, they can be successfully treated.
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Pharmacological interventions for people with borderline personality disorderBACKGROUND Among people with a diagnosis of borderline personality disorder (BPD) who are engaged in clinical care, prescription rates of psychotropic medications are high, despite the fact that medication use is off‐label as a treatment for BPD. Nevertheless, people with BPD often receive several psychotropic drugs at a time for sustained periods. OBJECTIVES to assess the effects of pharmacological treatment for people with BPD. SEARCH METHODS For this update, we searched CENTRAL, MEDLINE, Embase, 14 other databases and four trials registers up to February 2022. We contacted researchers working in the field to ask for additional data from published and unpublished trials, and hand searched relevant journals. We did not restrict the search by year of publication, language or type of publication. SELECTION CRITERIA Randomised controlled trials comparing pharmacological treatment to placebo, other pharmacologic treatments or a combination of pharmacologic treatments in people of all ages with a formal diagnosis of BPD. The primary outcomes were BPD symptom severity, self‐harm, suicide‐related outcomes, and psychosocial functioning. Secondary outcomes were individual BPD symptoms, depression, attrition and adverse events. DATA COLLECTION AND ANALYSIS At least two review authors independently selected trials, extracted data, assessed risk of bias using Cochrane's risk of bias tool and assessed the certainty of the evidence using the GRADE approach. We performed data analysis using Review Manager 5 and quantified the statistical reliability of the data using Trial Sequential Analysis. MAIN RESULTS We included 46 randomised controlled trials (2769 participants) in this review, 45 of which were eligible for quantitative analysis and comprised 2752 participants with BPD in total. This is 18 more trials than the 2010 review on this topic. Participants were predominantly female except for one trial that included men only. The mean age ranged from 16.2 to 39.7 years across the included trials. Twenty‐nine different types of medications compared to placebo or other medications were included in the analyses. Seventeen trials were funded or partially funded by the pharmaceutical industry, 10 were funded by universities or research foundations, eight received no funding, and 11 had unclear funding. For all reported effect sizes, negative effect estimates indicate beneficial effects by active medication. Compared with placebo, no difference in effects were observed on any of the primary outcomes at the end of treatment for any medication. Compared with placebo, medication may have little to no effect on BPD symptom severity, although the evidence is of very low certainty (antipsychotics: SMD ‐0.18, 95% confidence interval (CI) ‐0.45 to 0.08; 8 trials, 951 participants; antidepressants: SMD −0.27, 95% CI −0.65 to 1.18; 2 trials, 87 participants; mood stabilisers: SMD −0.07, 95% CI −0.43 to 0.57; 4 trials, 265 participants). The evidence is very uncertain about the effect of medication compared with placebo on self‐harm, indicating little to no effect (antipsychotics: RR 0.66, 95% CI 0.15 to 2.84; 2 trials, 76 participants; antidepressants: MD 0.45 points on the Overt Aggression Scale‐Modified‐Self‐Injury item (0‐5 points), 95% CI −10.55 to 11.45; 1 trial, 20 participants; mood stabilisers: RR 1.08, 95% CI 0.79 to 1.48; 1 trial, 276 participants). The evidence is also very uncertain about the effect of medication compared with placebo on suicide‐related outcomes, with little to no effect (antipsychotics: SMD 0.05, 95 % CI −0.18 to 0.29; 7 trials, 854 participants; antidepressants: SMD −0.26, 95% CI −1.62 to 1.09; 2 trials, 45 participants; mood stabilisers: SMD −0.36, 95% CI −1.96 to 1.25; 2 trials, 44 participants). Very low‐certainty evidence shows little to no difference between medication and placebo on psychosocial functioning (antipsychotics: SMD −0.16, 95% CI −0.33 to 0.00; 7 trials, 904 participants; antidepressants: SMD −0.25, 95% CI ‐0.57 to 0.06; 4 trials, 161 participants; mood stabilisers: SMD −0.01, 95% CI ‐0.28 to 0.26; 2 trials, 214 participants). Low‐certainty evidence suggests that antipsychotics may slightly reduce interpersonal problems (SMD −0.21, 95% CI −0.34 to ‐0.08; 8 trials, 907 participants), and that mood stabilisers may result in a reduction in this outcome (SMD −0.58, 95% CI ‐1.14 to ‐0.02; 4 trials, 300 participants). Antidepressants may have little to no effect on interpersonal problems, but the corresponding evidence is very uncertain (SMD −0.07, 95% CI ‐0.69 to 0.55; 2 trials, 119 participants). The evidence is very uncertain about dropout rates compared with placebo by antipsychotics (RR 1.11, 95% CI 0.89 to 1.38; 13 trials, 1216 participants). Low‐certainty evidence suggests there may be no difference in dropout rates between antidepressants (RR 1.07, 95% CI 0.65 to 1.76; 6 trials, 289 participants) and mood stabilisers (RR 0.89, 95% CI 0.69 to 1.15; 9 trials, 530 participants), compared to placebo. Reporting on adverse events was poor and mostly non‐standardised. The available evidence on non‐serious adverse events was of very low certainty for antipsychotics (RR 1.07, 95% CI 0.90 to 1.29; 5 trials, 814 participants) and mood stabilisers (RR 0.84, 95% CI 0.70 to 1.01; 1 trial, 276 participants). For antidepressants, no data on adverse events were identified. AUTHOR’S CONCLUSIONS This review included 18 more trials than the 2010 version, so larger meta‐analyses with more statistical power were feasible. We found mostly very low‐certainty evidence that medication may result in no difference in any primary outcome. The rest of the secondary outcomes were inconclusive. Very limited data were available for serious adverse events. The review supports the continued understanding that no pharmacological therapy seems effective in specifically treating BPD pathology. More research is needed to understand the underlying pathophysiologic mechanisms of BPD better. Also, more trials including comorbidities such as trauma‐related disorders, major depression, substance use disorders, or eating disorders are needed. Additionally, more focus should be put on male and adolescent samples.
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"Self" and "other": A conceptual bridge linking normal with pathological personalityThe goal of this paper is to try and close the gap between the ways in which pathological and normal personality, including their development, are conceptualized. To this end, attention is drawn to parallels that exist between the ways self-function is conceptualized in contemporary personality psychology and in recent iterations of the major psychiatric nosologies, particularly ICD-11. Conceptualizations in both normal and abnormal personality see a fundamental dichotomy between self as identity and self as socially interdependent (vs autonomous). Evidence is reviewed supporting a basic dichotomy between two categories of personality pathology that can be subsumed under the labels "Acting Out" and "Anxious-Inhibited." It is suggested that fundamental to the personality pathology subsumed under "Acting Out" is a deficient interdependent self, while a defective self-identity is proposed to underlie the personality pathology subsumed under "Anxious-Inhibited."
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The clinical effectiveness and cost effectiveness of clozapine for inpatients with severe borderline personality disorder (CALMED study): a randomised placebo-controlled trialBackgroundData from case series suggest that clozapine may benefit inpatients with borderline personality disorder (BPD), but randomised trials have not been conducted.MethodsMulticentre, double-blind, placebo-controlled trial. We aimed to recruit 222 inpatients with severe BPD aged 18 or over, who had failed to respond to other antipsychotic medications. We randomly allocated participants on a 1:1 ratio to receive up to 400 mg of clozapine per day or an inert placebo using a remote web-based randomisation service. The primary outcome was total score on the Zanarini Rating scale for Borderline Personality Disorder (ZAN-BPD) at 6 months. Secondary outcomes included self-harm, aggression, resource use and costs, side effects and adverse events. We used a modified intention to treat analysis (mITT) restricted to those who took one or more dose of trial medication, using a general linear model fitted at 6 months adjusted for baseline score, allocation group and site.ResultsThe study closed early due to poor recruitment and the impact of the COVID-19 pandemic. Of 29 study participants, 24 (83%) were followed up at 6 months, of whom 21 (72%) were included in the mITT analysis. At 6 months, 11 (73%) participants assigned to clozapine and 6 (43%) of those assigned to placebo were still taking trial medication. Adjusted difference in mean total ZAN-BPD score at 6 months was -3.86 (95% Confidence Intervals = -10.04 to 2.32). There were 14 serious adverse events; 6 in the clozapine arm and 8 in the placebo arm of the trial. There was little difference in the cost of care between groups.InterpretationWe recruited insufficient participants to test the primary hypothesis. The study findings highlight problems in conducting placebo-controlled trials of clozapine and in using clozapine for people with BPD, outside specialist inpatient mental health units.Trial registrationISRCTN18352058. https://doi.org/10.1186/ISRCTN18352058.
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Psychotherapies for borderline personality disorder: a focused systematic review and meta-analysisBACKGROUNDA recently updated Cochrane review supports the efficacy of psychotherapy for borderline personality disorder (BPD).AIMSTo evaluate the effects of standalone and add-on psychotherapeutic treatments more concisely.METHODWe applied the same methods as the 2020 Cochrane review, but focused on adult samples and comparisons of active treatments and unspecific control conditions. Standalone treatments (i.e. necessarily including individual psychotherapy as either the sole or one of several treatment components) and add-on interventions (i.e. complementing any ongoing individual BPD treatment) were analysed separately. Primary outcomes were BPD severity, self-harm, suicide-related outcomes and psychosocial functioning. Secondary outcomes were remaining BPD diagnostic criteria, depression and attrition.RESULTSThirty-one randomised controlled trials totalling 1870 participants were identified. Among standalone treatments, statistically significant effects of low overall certainty were observed for dialectical behaviour therapy (self-harm: standardised mean difference (SMD) -0.54, P = 0.006; psychosocial functioning: SMD -0.51, P = 0.01) and mentalisation-based treatment (self-harm: risk ratio 0.51, P < 0.0007; suicide-related outcomes: risk ratio 0.10, P < 0.0001). For adjunctive interventions, moderate-quality evidence of beneficial effects was observed for DBT skills training (BPD severity: SMD -0.66, P = 0.002; psychosocial functioning: SMD -0.45, P = 0.002), and statistically significant low-certainty evidence was observed for the emotion regulation group (BPD severity: mean difference -8.49, P < 0.00001), manual-assisted cognitive therapy (self-harm: mean difference -3.03, P = 0.03; suicide-related outcomes: SMD -0.96, P = 0.005) and the systems training for emotional predictability and problem-solving (BPD severity: SMD -0.48, P = 0.002).CONCLUSIONSThere is reasonable evidence to conclude that psychotherapeutic interventions are helpful for individuals with BPD. Replication studies are needed to enhance the certainty of findings.
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Galenic syndromes: combinations of mental state and personality disorders too closely entwined to be separatedMany mental disorders are linked to personality, but this is rarely recognised in clinical practice. It is suggested here that when the links are very close, the two can be joined. Galenic syndromes are so named because Galen was the first physician to recognise the links between personality and disease.
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The Mental Health Act 1983 (as amended in 2007) reform – How proposed changes potentially impact personality disorder servicesAbstract: At the beginning of this year, the UK government released a White Paper on Reforms of the 1983 Mental Health Act (MHA) aiming to achieve higher quality, accessible mental health care, as well as empowering people detained under MHA during the process and continuation of detention. In this piece, we focus on the potential impact of the proposal around appropriate care, management and detention of people with Personality Disorder (PD) within the criminal justice system (CJS), psychiatric service provision and community routes. We briefly review the historical context of reforms of PD services in the UK and discuss the proposed changes and issues in relation to the criteria of least restriction, detention and therapeutic benefit. We highlight the complexity around referral routes and logistics barriers for secure PD services that might hamper speeded referral routes and raise concerns around responsibility for authorisation of transfers in the context of risk of serious harm to the public. We emphasise the complex treatment needs of individuals with PDs and how these are potentially not met. We also discuss the shift of focus from reactive care to preventative measures and early intervention in the community for individuals with mild-to-moderate levels of PD. We highlight the need for appropriate integrative services in the community to facilitate assessment across services, identification of complex needs and support options including earlier routine screening and potential digital interventions to optimise specialised care for PD.
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The factor structure of the Zanarini Rating Scale for Borderline Personality Disorder: Exploratory structural equation modelling and measurement invariance over timeObjectives There is a lack of independent longitudinal evidence on the factor structure and validity of the Zanarini Rating Scale for Borderline Personality Disorder (ZAN‐BPD). This study aimed to investigate the dimensionality of ZAN‐BPD and its conceptual consistency over time. Methods Adult BPD participants (n = 276) were recruited for a multicentre, two‐arm randomised clinical trial with ZAN‐BPD measured at baseline and follow up at 12, 24 and 52 weeks. The construct and stability of the ZAN‐BPD across 52 weeks was examined through a measurement equivalence/invariance procedure via Exploratory Structural Equation Modelling. Results Factor analysis results showed that the ZAN‐BPD had a bi‐2 factor structure that was stable over 52 weeks with a general factor and two specific factors. Factor loadings for eight of the nine items were greater for the general factor than the two specific factors. Factor 1 contrasts externalising distress with internalising distress. Factor 2 contrasts depression and self‐destruction with interpersonal anxiety and conflict. Conclusion ZAN‐BPD is a conceptually and empirically valid measure of total BPD symptom severity in BPD patients over time suitable for use in clinical trials. Two factors related to the expression of distress and self‐harm may be utilised as possible predictors of outcome. (PsycInfo Database Record (c) 2021 APA, all rights reserved) (Source: journal abstract)
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Mentalization for Offending Adult Males (MOAM): study protocol for a randomized controlled trial to evaluate mentalization-based treatment for antisocial personality disorder in male offenders on community probationBACKGROUNDAntisocial personality disorder (ASPD), although associated with very significant health and social burden, is an under-researched mental disorder for which clinically effective and cost-effective treatment methods are urgently needed. No intervention has been established for prevention or as the treatment of choice for this disorder. Mentalization-based treatment (MBT) is a psychotherapeutic treatment that has shown some promising preliminary results for reducing personality disorder symptomatology by specifically targeting the ability to recognize and understand the mental states of oneself and others, an ability that is compromised in people with ASPD. This paper describes the protocol of a multi-site RCT designed to test the effectiveness and cost-effectiveness of MBT for reducing aggression and alleviating the wider symptoms of ASPD in male offenders subject to probation supervision who fulfil diagnostic criteria for ASPD.METHODSThree hundred and two participants recruited from a pool of offenders subject to statutory supervision by the National Probation Service at 13 sites across the UK will be randomized on a 1:1 basis to 12 months of probation plus MBT or standard probation as usual, with follow-up to 24 months post-randomization. The primary outcome is frequency of aggressive antisocial behaviour as assessed by the Overt Aggression Scale - Modified. Secondary outcomes include violence, offending rates, alcohol use, drug use, mental health status, quality of life, and total service use costs. Data will be gathered from police and criminal justice databases, NHS record linkage, and interviews and self-report measures administered to participants. Primary analysis will be on an intent-to-treat basis; per-protocol analysis will be undertaken as secondary analysis. The primary outcome will be analysed using hierarchical mixed-effects linear regression. Secondary outcomes will be analysed using mixed-effects linear regression, mixed-effects logistic regression, and mixed-effects Poisson models for secondary outcomes depending on whether the outcome is continuous, binary, or count data. A cost-effectiveness and cost-utility analysis will be undertaken.DISCUSSIONThis definitive, national, multi-site trial is of sufficient size to evaluate MBT to inform policymakers, service commissioners, clinicians, and service users about its potential to treat offenders with ASPD and the likely impact on the population at risk.TRIAL REGISTRATIONISRCTN 32309003 . Registered on 8 April 2016.
