Recent Submissions

  • Impaired striatal glutamate/GABA regulation in violent offenders with antisocial personality disorder and psychopathy

    Tully, John (2024)
    Men 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.
  • Effects of two treatments on interpersonal, affective, and lifestyle features of psychopathy and emotion dysregulation

    Howard, Richard C. (2023)
    This 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.
  • Pharmacological interventions for people with borderline personality disorder

    Sales, Christian P. (2022)
    BACKGROUND 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.
  • "Self" and "other": A conceptual bridge linking normal with pathological personality

    Howard, Richard C. (2022)
    The 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."
  • The clinical effectiveness and cost effectiveness of clozapine for inpatients with severe borderline personality disorder (CALMED study): a randomised placebo-controlled trial

    Cheshire, Jack; Gibbon, Simon D. (2022)
    BackgroundData 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.
  • Psychotherapies for borderline personality disorder: a focused systematic review and meta-analysis

    Sales, Christian P. (2022)
    BACKGROUNDA 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.
  • Galenic syndromes: combinations of mental state and personality disorders too closely entwined to be separated

    Duggan, Conor (2022)
    Many 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.
  • The Mental Health Act 1983 (as amended in 2007) reform – How proposed changes potentially impact personality disorder services

    Mudholkar, Santosh (2021)
    Abstract: 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.
  • The factor structure of the Zanarini Rating Scale for Borderline Personality Disorder: Exploratory structural equation modelling and measurement invariance over time

    Guo, Boliang; Morriss, Richard K. (2021)
    Objectives 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)
  • 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 probation

    McMurran, Mary (2020)
    BACKGROUNDAntisocial 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.
  • Pharmacological interventions for antisocial personality disorder

    Gibbon, Simon D.; Cheung, Natalie; McCarthy, Lucy (2020)
    Background: Antisocial personality disorder (AsPD) is associated with rule‐breaking, criminality, substance use, unemployment, relationship difficulties, and premature death. Certain types of medication (drugs) may help people with AsPD. This review updates a previous Cochrane review, published in 2010. Objectives: To assess the benefits and adverse effects of pharmacological interventions for adults with AsPD. Search methods: We searched CENTRAL, MEDLINE, Embase, 13 other databases and two trials registers up to 5 September 2019. We also checked reference lists and contacted study authors to identify studies. Selection criteria: Randomised controlled trials in which adults (age 18 years and over) with a diagnosis of AsPD or dissocial personality disorder were allocated to a pharmacological intervention or placebo control condition. Data collection and analysis: Four authors independently selected studies and extracted data. We assessed risk of bias and created 'Summary of findings tables' and assessed the certainty of the evidence using the GRADE framework. The primary outcomes were: aggression; reconviction; global state/global functioning; social functioning; and adverse events. Main results: We included 11 studies (three new to this update), involving 416 participants with AsPD. Most studies (10/11) were conducted in North America. Seven studies were conducted exclusively in an outpatient setting, one in an inpatient setting, and one in prison; two studies used multiple settings. The average age of participants ranged from 28.6 years to 45.1 years (overall mean age 39.6 years). Participants were predominantly (90%) male. Study duration ranged from 6 to 24 weeks, with no follow‐up period. Data were available from only four studies involving 274 participants with AsPD. All the available data came from unreplicated, single reports, and did not allow independent statistical analysis to be conducted. Many review findings were limited to descriptive summaries based on analyses carried out and reported by the trial investigators. No study set out to recruit participants on the basis of having AsPD; many participants presented primarily with substance abuse problems. The studies reported on four primary outcomes and six secondary outcomes. Primary outcomes were aggression (six studies) global/state functioning (three studies), social functioning (one study), and adverse events (seven studies). Secondary outcomes were leaving the study early (eight studies), substance misuse (five studies), employment status (one study), impulsivity (one study), anger (three studies), and mental state (three studies). No study reported data on the primary outcome of reconviction or the secondary outcomes of quality of life, engagement with services, satisfaction with treatment, housing/accommodation status, economic outcomes or prison/service outcomes. Eleven different drugs were compared with placebo, but data for AsPD participants were only available for five comparisons. Three classes of drug were represented: antiepileptic; antidepressant; and dopamine agonist (anti‐Parkinsonian) drugs. We considered selection bias to be unclear in 8/11 studies, attrition bias to be high in 7/11 studies, and performance bias to be low in 7/11 studies. Using GRADE, we rated the certainty of evidence for each outcome in this review as very low, meaning that we have very little confidence in the effect estimates reported. Phenytoin (antiepileptic) versus placebo: One study (60 participants) reported very low‐certainty evidence that phenytoin (300 mg/day), compared to placebo, may reduce the mean frequency of aggressive acts per week (phenytoin mean = 0.33, no standard deviation (SD) reported; placebo mean = 0.51, no SD reported) in male prisoners with aggression (skewed data) at endpoint (six weeks). The same study (60 participants) reported no evidence of difference between phenytoin and placebo in the number of participants reporting the adverse event of nausea during week one (odds ratio (OR) 1.00, 95% confidence interval (CI) 0.06 to 16.76; very low‐certainty evidence). The study authors also reported that no important side effects were detectable via blood cell counts or liver enzyme tests (very low‐certainty evidence). The study did not measure reconviction, global/state functioning or social functioning. Desipramine (antidepressant) versus placebo: One study (29 participants) reported no evidence of a difference between desipramine (250 to 300 mg/day) and placebo on mean social functioning scores (desipramine = 0.19; placebo = 0.21), assessed with the family‐social domain of the Addiction Severity Index (scores range from zero to one, with higher values indicating worse social functioning), at endpoint (12 weeks) (very low‐certainty evidence). Neither of the studies included in this comparison measured the other primary outcomes: aggression; reconviction; global/state functioning; or adverse events. Nortriptyline (antidepressant) versus placebo: One study (20 participants) reported no evidence of a difference between nortriptyline (25 to 75 mg/day) and placebo on mean global state/functioning scores (nortriptyline = 0.3; placebo = 0.7), assessed with the Symptom Check List‐90 (SCL‐90) Global Severity Index (GSI; mean of subscale scores, ranging from zero to four, with higher scores indicating greater severity of symptoms), at endpoint (six months) in men with alcohol dependency (very low‐certainty evidence). The study measured side effects but did not report data on adverse events for the AsPD subgroup. The study did not measure aggression, reconviction or social functioning. Bromocriptine (dopamine agonist) versus placebo: One study (18 participants) reported no evidence of difference between bromocriptine (15 mg/day) and placebo on mean global state/functioning scores (bromocriptine = 0.4; placebo = 0.7), measured with the GSI of the SCL‐90 at endpoint (six months) (very low‐certainty evidence). The study did not provide data on adverse effects, but reported that 12 patients randomised to the bromocriptine group experienced severe side effects, five of whom dropped out of the study in the first two days due to nausea and severe flu‐like symptoms (very low‐certainty evidence). The study did not measure aggression, reconviction and social functioning. Amantadine (dopamine agonist) versus placebo: The study in this comparison did not measure any of the primary outcomes. Authors' conclusions: The evidence summarised in this review is insufficient to draw any conclusion about the use of pharmacological interventions in the treatment of antisocial personality disorder. The evidence comes from single, unreplicated studies of mostly older medications. The studies also have methodological issues that severely limit the confidence we can draw from their results. Future studies should recruit participants on the basis of having AsPD, and use relevant outcome measures, including reconviction.
  • Psychological interventions for antisocial personality disorder

    Gibbon, Simon D.; Cheung, Natalie; McCarthy, Lucy (2020)
    Background: Antisocial personality disorder (AsPD) is associated with poor mental health, criminality, substance use and relationship difficulties. This review updates Gibbon 2010 (previous version of the review). Objectives: To evaluate the potential benefits and adverse effects of psychological interventions for adults with AsPD. Search methods: We searched CENTRAL, MEDLINE, Embase, 13 other databases and two trials registers up to 5 September 2019. We also searched reference lists and contacted study authors to identify studies. Selection criteria: Randomised controlled trials of adults, where participants with an AsPD or dissocial personality disorder diagnosis comprised at least 75% of the sample randomly allocated to receive a psychological intervention, treatment‐as‐usual (TAU), waiting list or no treatment. The primary outcomes were aggression, reconviction, global state/functioning, social functioning and adverse events. Data collection and analysis: We used standard methodological procedures expected by Cochrane. Main results: This review includes 19 studies (eight new to this update), comparing a psychological intervention against TAU (also called 'standard Maintenance'(SM) in some studies). Eight of the 18 psychological interventions reported data on our primary outcomes. Four studies focussed exclusively on participants with AsPD, and 15 on subgroups of participants with AsPD. Data were available from only 10 studies involving 605 participants. Eight studies were conducted in the UK and North America, and one each in Iran, Denmark and the Netherlands. Study duration ranged from 4 to 156 weeks (median = 26 weeks). Most participants (75%) were male; the mean age was 35.5 years. Eleven studies (58%) were funded by research councils. Risk of bias was high for 13% of criteria, unclear for 54% and low for 33%. Cognitive behaviour therapy (CBT) + TAUversus TAU: One study (52 participants) found no evidence of a difference between CBT + TAU and TAU for physical aggression (odds ratio (OR) 0.92, 95% CI 0.28 to 3.07; low‐certainty evidence) for outpatients at 12 months post‐intervention. One study (39 participants) found no evidence of a difference between CBT + TAU and TAU for social functioning (mean difference (MD) −1.60 points, 95% CI −5.21 to 2.01; very low‐certainty evidence), measured by the Social Functioning Questionnaire (SFQ; range = 0‐24), for outpatients at 12 months post‐intervention. Impulsive lifestyle counselling (ILC) + TAU versus TAU: One study (118 participants) found no evidence of a difference between ILC + TAU and TAU for trait aggression (assessed with Buss‐Perry Aggression Questionnaire‐Short Form) for outpatients at nine months (MD 0.07, CI −0.35 to 0.49; very low‐certainty evidence). One study (142 participants) found no evidence of a difference between ILC + TAU and TAU alone for the adverse event of death (OR 0.40, 95% CI 0.04 to 4.54; very low‐certainty evidence) or incarceration (OR 0.70, 95% CI 0.27 to 1.86; very low‐certainty evidence) for outpatients between three and nine months follow‐up. Contingency management (CM) + SM versus SM: One study (83 participants) found evidence that, compared to SM alone, CM + SM may improve social functioning measured by family/social scores on the Addiction Severity Index (ASI; range = 0 (no problems) to 1 (severe problems); MD −0.08, 95% CI −0.14 to −0.02; low‐certainty evidence) for outpatients at six months. ‘Driving whilst intoxicated' programme (DWI) + incarcerationversus incarceration: One study (52 participants) found no evidence of a difference between DWI + incarceration and incarceration alone on reconviction rates (hazard ratio 0.56, CI −0.19 to 1.31; very low‐certainty evidence) for prisoner participants at 24 months. Schema therapy (ST) versus TAU: One study (30 participants in a secure psychiatric hospital, 87% had AsPD diagnosis) found no evidence of a difference between ST and TAU for the number of participants who were reconvicted (OR 2.81, 95% CI 0.11 to 74.56, P = 0.54) at three years. The same study found that ST may be more likely to improve social functioning (assessed by the mean number of days until patients gain unsupervised leave (MD −137.33, 95% CI −271.31 to −3.35) compared to TAU, and no evidence of a difference between the groups for overall adverse events, classified as the number of people experiencing a global negative outcome over a three‐year period (OR 0.42, 95% CI 0.08 to 2.19). The certainty of the evidence for all outcomes was very low. Social problem‐solving (SPS) + psychoeducation (PE) versus TAU: One study (17 participants) found no evidence of a difference between SPS + PE and TAU for participants’ level of social functioning (MD −1.60 points, 95% CI −5.43 to 2.23; very low‐certainty evidence) assessed with the SFQ at six months post‐intervention. Dialectical behaviour therapy versus TAU: One study (skewed data, 14 participants) provided very low‐certainty, narrative evidence that DBT may reduce the number of self‐harm days for outpatients at two months post‐intervention compared to TAU. Psychosocial risk management (PSRM; 'Resettle') versus TAU: One study (skewed data, 35 participants) found no evidence of a difference between PSRM and TAU for a number of officially recorded offences at one year after release from prison. It also found no evidence of difference between the PSRM and TAU for the adverse event of death during the study period (OR 0.89, 95% CI 0.05 to 14.83, P = 0.94, 72 participants (90% had AsPD), 1 study, very low‐certainty evidence). Authors' conclusions: There is very limited evidence available on psychological interventions for adults with AsPD. Few interventions addressed the primary outcomes of this review and, of the eight that did, only three (CM + SM, ST and DBT) showed evidence that the intervention may be more effective than the control condition. No intervention reported compelling evidence of change in antisocial behaviour. Overall, the certainty of the evidence was low or very low, meaning that we have little confidence in the effect estimates reported. The conclusions of this update have not changed from those of the original review, despite the addition of eight new studies. This highlights the ongoing need for further methodologically rigorous studies to yield further data to guide the development and application of psychological interventions for AsPD and may suggest that a new approach is required.
  • Substance use disorders and criminal justice contact among those with co-occurring antisocial and borderline personality disorders: Findings from a nationally representative sample

    Howard, Richard C. (2020)
    One variant of borderline personality disorder (BPD), frequently encountered in forensic and correctional samples, is the 'dissocial' subtype that combines borderline and antisocial traits. We tested the hypothesis that this subtype, defined by the co-occurrence of antisocial personality disorder (ASPD) and BPD (ASPD + BPD), would be associated with high rates of substance use disorder and contact with the criminal justice (CJ) system in a large nationally representative sample of North American adults (N = 36 309). Results suggested that the dissocial variant of BPD was associated with a high risk for substance use disorders and CJ contact. The odds of these outcomes were significantly raised about fivefold in ASPD + BPD individuals in comparison with those who lacked either an ASPD or BPD diagnosis. ASPD + BPD, compared with BPD alone, was also associated with significantly (p < 0.0001) greater severity of borderline symptoms. Although CJ contact appears to be strongly driven by ASPD, substance use, primarily driven by severity of borderline symptoms, added to the risk of CJ contact. It is suggested that, in the 11th Revision of the International Classification of Diseases terms, the dissocial borderline variant is a severe form of personality disorder characterized by high levels of traits within domains of negative emotionality and dissociality. Further studies will be required to verify this suggestion. (c) 2020 The Authors Personality and Mental Health Published by John Wiley & Sons Ltd.
  • Priorities for service improvement in personality disorder in Australia: Perspectives of consumers, carers and clinicians

    Ng, Fiona (2020)
    BACKGROUNDImprovements to service provision for personality disorder has been predominately explored through the perspectives of clinicians, with limited understanding of the views of consumers and carers. The aim of the present study was to understand the priorities for service improvement through multiple perspectives.METHODTwelve roundtables, with a total of 53 consumers, clinicians and carers, discussed how organizations could improve service provision for people with personality disorder and completed a questionnaire on current and optimal service provision. Inductive thematic analysis was used to identify the priorities for service improvement, and we aimed to identify differences between what participants currently receive and what they believe to be optimal.RESULTSFour priorities were identified: (1) increasing consumer, carer and peer involvement in care, (2) re-orienting approaches to service provision, (3) improving access and accessibility of treatment and (4) building the capacity of services. Participants were more likely to receive individual or group treatment alone, yet believed combined individual and group treatment to be optimal. Significantly, more participants believed that long-term treatment was optimal.CONCLUSIONA shift in focus from establishing a consistent approach to servicing, to focusing on holistic care that involves consumers and carers in care, is required. © 2020 The Authors Personality and Mental Health Published by John Wiley & Sons Ltd.
  • An intervention for parents with severe personality difficulties whose children have mental health problems: a feasibility RCT

    McMurran, Mary (2020)
    BACKGROUND: The children of parents with severe personality difficulties have greater risk of significant mental health problems. Existing care is poorly co-ordinated, with limited effectiveness. A specialised parenting intervention may improve child and parenting outcomes, reduce family morbidity and lower the service costs. OBJECTIVES: To develop a specialised parenting intervention for parents affected by severe personality difficulties who have children with mental health problems and to conduct a feasibility trial. DESIGN: A pragmatic, mixed-methods design to develop and pilot a specialised parenting intervention, Helping Families Programme-Modified, and to conduct a randomised feasibility trial with process evaluation. Initial cost-effectiveness was assessed using UK NHS/Personal Social Services and societal perspectives, generating quality-adjusted life-years. Researchers collecting quantitative data were masked to participant allocation. SETTING: Two NHS mental health trusts and concomitant children's social care services. PARTICIPANTS: Parents who met the following criteria: (1) the primary caregiver of the index child, (2) aged 18-65 years, (3) have severe personality difficulties, (4) proficient in English and (5) capable of providing informed consent. Index children who met the following criteria: (1) aged 3-11 years, (2) living with index parent and (3) have significant emotional/behavioural difficulties. Exclusion criteria were (1) having coexisting psychosis, (2) participating in another parenting intervention, (3) receiving inpatient care, (4) having insufficient language/cognitive abilities, (5) having child developmental disorder, (6) care proceedings and (7) index child not residing with index parent. INTERVENTION: The Helping Families Programme-Modified - a 16-session intervention using structured, goal-orientated strategies and collaborative therapeutic methods to improve parenting, and child and parent functioning. Usual care - standard care augmented by a single psychoeducational session. MAIN OUTCOME MEASURES: Trial feasibility - rates of recruitment, eligibility, allocation, retention, data completion and experience. Intervention acceptability - rates of acceptance, completion, alliance (Working Alliance Inventory-Short Revised) and experience. Outcomes - child (assessed via Concerns About My Child, Eyberg Child Behaviour Inventory, Child Behaviour Checklist-Internalising Scale), parenting (assessed via the Arnold-O'Leary Parenting Scale, Kansas Parental Satisfaction Scale), parent (assessed via the Symptom Checklist-27), and health economics (assessed via the Client Service Receipt Inventory, EuroQol-5 Dimensions). RESULTS: The findings broadly supported trial feasibility using non-diagnostic screening criteria. Parents were mainly referred from one site (75.0%). Site and participant factors delayed recruitment. An estimate of eligible parents was not obtained. Of the 86 parents referred, 60 (69.7%) completed screening and 48 of these (80.0%) were recruited. Participants experienced significant disadvantage and multiple morbidity. The Helping Families Programme-Modified uptake (87.5%) was higher than usual-care uptake (62.5%). Trial retention (66.7%, 95% confidence interval 51.6% to 79.6%) exceeded the a priori rate. Process findings highlighted the impact of random allocation and the negative effects on retention. The Helping Families Programme-Modified was acceptable, with duration of delivery longer than planned, whereas the usual-care condition was less acceptable. At initial follow-up, effects on child and parenting outcomes were detected across both arms, with a potential outcome advantage for the Helping Families Programme-Modified (effect size range 0.0-1.3). For parental quality-adjusted life-years, the Helping Families Programme-Modified dominated usual care, and child quality-adjusted life-years resulted in higher costs and more quality-adjusted life-years. At second follow-up, the Helping Families Programme-Modified was associated with higher costs and more quality-adjusted lif -years than usual care. For child quality-adjusted life-years, when controlled for baseline EuroQol-5 Dimensions, three-level version, usual care dominated the Helping Families Programme-Modified. No serious adverse events were reported. CONCLUSION: The Helping Families Programme-Modified is an acceptable specialised parenting intervention. Trial methods using non-diagnostic criteria were largely supported. For future work, a definitive efficacy trial should consider site selection, recruitment methods, intervention efficiency and revised comparator condition. TRIAL REGISTRATION: Current Controlled Trials ISRCTN14573230. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 14. See the NIHR Journals Library website for further project information. Parents affected by personality difficulties experience strong, overwhelming emotions and struggle in their personal and social relationships. These difficulties can interfere with their ability to provide stable, safe and warm parenting, which increases the risk of their children developing mental health problems. This research developed the Helping Families Programme-Modified, a new parenting intervention designed to help parents with severe personality difficulties who have children with mental health problems. Parents received 16 home-based appointments to learn new parenting skills and improve their children’s difficulties. The research assessed how the Helping Families Programme-Modified worked in practice and the viability of evaluation methods. A short questionnaire assessing personality difficulties, rather than a lengthy diagnostic interview, was more effective and acceptable for identifying parents who may benefit from the Helping Families Programme-Modified. Parents taking part had high levels of personal, family and social problems. This slowed the rate at which parents agreed to take part in the evaluation and lengthened the intervention period. The research tested parent agreement to being randomly allocated to receive either the Helping Families Programme-Modified or usual care plus a specially designed parenting appointment. Although this random allocation was feasible, parents were disappointed when they did not receive the Helping Families Programme-Modified. They often felt overwhelmed by family difficulties and lacked other suitable services. These parents were less likely to take up the additional parenting appointment available or to provide subsequent research information, which affected the certainty of the research findings. Parents receiving the Helping Families Programme-Modified or usual care reported improvements, with a potentially greater impact on parents and children, and better acceptability, for the new intervention. Parents generally supported the tailored, home-based approach of the Helping Families Programme-Modified, and they valued its content, therapist skills and persistence. It was uncertain whether the new intervention increased or reduced service costs. These results will be used to plan the most suitable methods for a large-scale evaluation of the Helping Families Programme-Modified.
  • Psychological therapies for people with borderline personality disorder

    Sales, Christian P. (2020)
    Abstract - Background Over the decades, a variety of psychological interventions for borderline personality disorder (BPD) have been developed. This review updates and replaces an earlier review (Stoffers‐Winterling 2012). Objectives To assess the beneficial and harmful effects of psychological therapies for people with BPD. Search methods In March 2019, we searched CENTRAL, MEDLINE, Embase, 14 other databases and four trials registers. We contacted researchers working in the field to ask for additional data from published and unpublished trials, and handsearched relevant journals. We did not restrict the search by year of publication, language or type of publication. Selection criteria Randomised controlled trials comparing different psychotherapeutic interventions with treatment‐as‐usual (TAU; which included various kinds of psychotherapy), waiting list, no treatment or active treatments in samples of all ages, in any setting, with a formal diagnosis of BPD. The primary outcomes were BPD symptom severity, self‐harm, suicide‐related outcomes, and psychosocial functioning. There were 11 secondary outcomes, including individual BPD symptoms, as well as attrition and adverse effects. 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 75 randomised controlled trials (4507 participants), predominantly involving females with mean ages ranging from 14.8 to 45.7 years. More than 16 different kinds of psychotherapy were included, mostly dialectical behaviour therapy (DBT) and mentalisation‐based treatment (MBT). The comparator interventions included treatment‐as‐usual (TAU), waiting list, and other active treatments. Treatment duration ranged from one to 36 months. Psychotherapy versus TAU Psychotherapy reduced BPD symptom severity, compared to TAU; standardised mean difference (SMD) −0.52, 95% confidence interval (CI) −0.70 to −0.33; 22 trials, 1244 participants; moderate‐quality evidence. This corresponds to a mean difference (MD) of −3.6 (95% CI −4.4 to −2.08) on the Zanarini Rating Scale for BPD (range 0 to 36), a clinically relevant reduction in BPD symptom severity (minimal clinical relevant difference (MIREDIF) on this scale is −3.0 points). Psychotherapy may be more effective at reducing self‐harm compared to TAU (SMD −0.32, 95% CI −0.49 to −0.14; 13 trials, 616 participants; low‐quality evidence), corresponding to a MD of −0.82 (95% CI −1.25 to 0.35) on the Deliberate Self‐Harm Inventory Scale (range 0 to 34). The MIREDIF of −1.25 points was not reached. Suicide‐related outcomes improved compared to TAU (SMD −0.34, 95% CI −0.57 to −0.11; 13 trials, 666 participants; low‐quality evidence), corresponding to a MD of −0.11 (95% CI −0.19 to −0.034) on the Suicidal Attempt Self Injury Interview. The MIREDIF of −0.17 points was not reached. Compared to TAU, psychotherapy may result in an improvement in psychosocial functioning (SMD −0.45, 95% CI −0.68 to −0.22; 22 trials, 1314 participants; low‐quality evidence), corresponding to a MD of −2.8 (95% CI −4.25 to −1.38), on the Global Assessment of Functioning Scale (range 0 to 100). The MIREDIF of −4.0 points was not reached. Our additional Trial Sequential Analysis on all primary outcomes reaching significance found that the required information size was reached in all cases. A subgroup analysis comparing the different types of psychotherapy compared to TAU showed no clear evidence of a difference for BPD severity and psychosocial functioning. Psychotherapy may reduce depressive symptoms compared to TAU but the evidence is very uncertain (SMD −0.39, 95% CI −0.61 to −0.17; 22 trials, 1568 participants; very low‐quality evidence), corresponding to a
  • Randomised feasibility trial of the helping families programme-modified: An intensive parenting intervention for parents affected by severe personality difficulties

    McMurran, Mary (2020)
    BACKGROUNDSpecialist parenting intervention could improve coexistent parenting and child mental health difficulties of parents affected by severe personality difficulties.OBJECTIVEConduct a feasibility trial of Helping Families Programme-Modified (HFP-M), a specialist parenting intervention.DESIGNPragmatic, mixed-methods trial, 1:1 random allocation, assessing feasibility, intervention acceptability and outcome estimates.SETTINGSTwo National Health Service health trusts and local authority children's social care.PARTICIPANTSParents: (i) primary caregiver, (ii) 18 to 65 years, (iii) severe personality difficulties, (iv) proficient English and (v) capacity for consent. Child: (i) 3 to 11 years, (ii) living with index parent and (iii) significant emotional/behavioural difficulties.INTERVENTIONHFP-M: 16-session home-based intervention using parenting and therapeutic engagement strategies. Usual care: standard care augmented by single psychoeducational parenting session.OUTCOMESPrimary feasibility outcome: participant retention rate.SECONDARY OUTCOMES(i) rates of recruitment, eligibility and data completion, and (ii) rates of intervention acceptance, completion and alliance (Working Alliance Inventory-Short Revised). Primary clinical outcome: child behaviour (Eyberg Child Behaviour Inventory).SECONDARY OUTCOMESchild mental health (Concerns About My Child, Child Behaviour Checklist-Internalising Scale), parenting (Arnold-O'Leary Parenting Scale, Kansas Parental Satisfaction Scale) and parent mental health (Symptom-Checklist-27). Quantitative data were collected blind to allocation.RESULTSFindings broadly supported non-diagnostic selection criterion. Of 48 participants recruited, 32 completed post-intervention measures at mean 42 weeks later. Participant retention exceeded a priori rate (HFP-M=18; Usual care=14; 66.7%, 95% CI 51.6% to 79.6%). HFP-M was acceptable, with delivery longer than planned. Usual care had lower alliance rating. Child and parenting outcome effects detected across trial arms with potential HFP-M advantage (effect size range: 0.0 to 1.3).CONCLUSIONHFP-M is an acceptable and potentially effective specialist parenting intervention. A definitive trial is feasible, subject to consideration of recruitment and retention methods, intervention efficiency and comparator condition. Caution is required in interpretation of results due to reduced sample size. No serious adverse events reported.TRIAL REGISTRATION NUMBERISRCTN14573230.
  • Case formulation in cognitive and behavioural therapy

    McMurran, Mary (2019)
    Personality disorders are complex developmental disorders associated with persistent and pervasive ways of thinking and feeling about oneself and others and behaving that cause distress or impairment in how an individual functions in many aspects of life. The DSM-5 also refers to an emerging model of personality disorders based on levels of impairment in functioning and the personality traits related to impaired functioning. Functioning is assessed in two domains: Self, which includes Identity and Self-Direction, and Interpersonal, which includes Empathy and Intimacy. Case formulation is the abstraction of key features of a clinical case that guide idiographic treatment. It is often rationalized as a reaction to the limits of psychiatric diagnosis whether as an alternative or complementary approach. Personality disorders may be understood on three levels: the diagnostic level summarizes concerns and may be required to access therapeutic services; the basic trait level identifies heritable biological characteristics that influence emotional, behavioural, and interpersonal development; and the process level reveals the psychosocial processes by which heritable traits may interact with the social environment over the lifespan to produce personality disorder. (PsycINFO Database Record (c) 2019 APA, all rights reserved) (Source: chapter)
  • Personality disorders and offending

    Howard, Richard C. (2019)
    Personality disorders are typified by relatively enduring, inflexible, and pervasive disturbances in how individuals experience and interpret themselves, others, and the world around them. The field of personality disorders is currently in a state of flux, with the recent transition from the fourth to the fifth edition of the American Psychiatric Association's (APA's) Diagnostic and Statistical Manual, Fifth Edition (DSM‐5) and the arrival of the 11th edition of the World Health Organization's International Classification of Diseases (ICD‐11). A better understanding of the relationship between personality disorder and crime is clearly required if effective prevention and treatment programs are to be developed. Outcome studies of treatments specifically for personality disorder in offender populations are scarce, and few randomized controlled trials (RCTs) have been conducted. In practice, both mental health and criminal justice psychologists offer treatments that aim to ameliorate the symptoms of personality disorder and reduce the risk of offending.
  • The lived experience of recovery in borderline personality disorder: a qualitative study

    Ng, Fiona (2019)
    Background: The concept of recovery in borderline personality disorder (BPD) is not well defined. Whilst clinical approaches emphasise symptom reduction and functioning, consumers advocate for a holistic approach. The consumer perspective on recovery and comparisons of individuals at varying stages have been minimally explored. Method: Fourteen narratives of a community sample of adult women with a self-reported diagnosis of BPD, were analysed using qualitative interpretative phenomenological analysis to understand recovery experiences. Individuals were at opposite ends of the recovery continuum (seven recovered and seven not recovered). Results: Recovery in BPD occurred across three stages and involved four processes. Stages included; 1) being stuck, 2) diagnosis, and 3) improving experience. Processes included; 1) hope, 2) active engagement in the recovery journey, 3) engagement with treatment services, and 4) engaging in meaningful activities and relationships. Differences between individuals in the recovered and not recovered group were prevalent in the improving experience stage. Conclusion: Recovery in BPD is a non-linear, ongoing process, facilitated by the interaction between stages and processes. Whilst clinical aspects are targets of specialist interventions, greater emphasis on fostering individual motivation, hope, engagement in relationships, activities, and treatment, may be required within clinical practice for a holistic recovery approach.

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