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Is there evidence that MBT is effective in the treatment of antisocial personality disorder?
Prof Anthony W Bateman Slagelse November 2017
168 patients screened for eligibility
134 randomized
34 patients excluded: 10 did not attend interview 12 declined participation 5 did not meet inclusion criteria 4 met exclusion criteria 3 were uncontactable
71 patients allocated to MBT-OP
6 attended < 6 months
13 attended 6-12 months
52 completed treatment
71 included in analyses
63 patients allocated to SCM-OP
10 attended < 6 months
6 attended 6-12 months
47 completed treatment
63 included in analyses
Consort Diagram – IOP Study: Patient Recruitment Flow-Chart
Moderators of outcome?
Bateman, A., & Fonagy, P. (2013). Impact of clinical severity on
outcomes of mentalisation-based treatment for borderline personality disorder. British Journal of Psychiatry, 203, 221-227.
Predictive Recovery by Axis II Pathology
-.20
.2.4
.6.8
Line
ar P
redi
ctio
n of
Rec
over
y
Baseline 6 months 12 months 18 monthsAssessment Periods
SCM MBT
One Axis II Diagnosis
-.20
.2.4
.6.8
Line
ar P
redi
ctio
n of
Rec
over
y
Baseline 6 months 12 months 18 monthsAssessment Periods
SCM MBT
Two Axis II Diagnoses
-.20
.2.4
.6.8
Line
ar P
redi
ctio
n of
Rec
over
y
Baseline 6 months 12 months 18 monthsAssessment Periods
SCM MBT
Three Axis II Diagnoses
-.20
.2.4
.6.8
Line
ar P
redi
ctio
n of
Rec
over
y
Baseline 6 months 12 months 18 monthsAssessment Periods
SCM MBT
Four Axis II Diagnoses
Predicted Self-Harm By Axis II Diagnoses
Two programmes of study:
MBT-ASPD – randomised controlled trial (MOAM)
SCM – training and implementation
Antisocial Personality Disorder
Bateman, A., & Fonagy, P. (2011). Antisocial Personality Disorder. In A. Bateman & P.
Fonagy (Eds.), Mentalizing in Mental Health Practice (pp. 357-378). Washington: APPI
Bateman, A., & Fonagy, P. (2016). Mentalization based treatment for personality disorders: a practical guide. Oxford: Oxford University Press
Bateman, A., O'Connell, J., Lorenzini, N., Gardner, T., & Fonagy, P. (2016). A randomised controlled trial of Mentalization-Based Treatment versus Structured
Clinical Management for patients with comorbid borderline personality disorder and antisocial personality disorder. BMC Psychiatry, 304, 304-311.
ASPD characteristics n Failure to conform to social norms with respect to lawful
behaviours n Deceitfulness n Impulsivity or failure to plan ahead n Irritability and aggressiveness n Reckless disregard for safety of self or other n Consistent irresponsibility n Lack of remorse None of these features is endearing to others. The self-
serving attitude of people with ASPD and unpredictability makes people wary of them.
Why consider ASPD? ASPD Highly prevalent amongst UK offending population and is associated with increase likelihood of committing violent behaviours, future reconvictions and recidivism severity.
Societal costs Physical and emotional damage to victims, criminal justice system involvement, increase of health care, lost employment opportunities, relationship breakdown; family disruption and substance misuse.
Major public health implications Associations with psychiatric co-morbidity, substance abuse, suicide, family violence and early death.
Why Consider ASPD - Recommendations and Implementation of NICE Guidance Crawford et al (2009) Service provision for men with antisocial personality disorder who make contact with mental health services services. Personality and Mental Health 3: 165–171
n ASPD who had had contact with mental health services Ø Nearly all participants met criteria for ‘probable
anxiety disorder’ Ø >50% were misusing alcohol and other drugs.
n 12 months following recruitment Ø 40% of the sample attended emergency medical
services Ø 20% had at least one period of inpatient treatment.
n Only 21% participants received follow-up care during the 12 months following recruitment.
What is mentalizing?
Mentalizing is a form of imaginative mental activity about others or oneself, namely, perceiving and interpreting human behaviour in terms of intentional mental states (e.g. needs, desires, feelings, beliefs, goals, purposes, and reasons).
Implicit- Automatic
Explicit- Controlled
Mental interior focused
Mental exterior focused
Cognitive agent:attitude propositions
Affective self:affect state propositions
Imitative frontoparietal mirror neurone system
Belief-desire MPFC/ACC inhibitory system
Impression driven
Appearance
Certainty of emotion
Treatment vectors in re-establishing mentalizing
Controlled
Inference
Doubt of cognition
Sensitivity to others Autonomy
Implicit- Automatic- Non -conscious- Immediate.
Explicit- Controlled Conscious Reflective
Mental interior cue focused
Mental exterior cue focused
Cognitive agent:attitude propositions
Affective self:affect state propositions
Imitative frontoparietal mirror neurone system
Belief-desire MPFC/ACC inhibitory system
Imbalance of mentalization generates problems Fonagy, P., & Luyten, P. (2009). Development and Psychopathology, 21, 1355-1381.
Impulsive, quick assumptions about others thoughts and feelings not reflected on or tested, cruelty
Does not genuinely appreciate others’ perspective. Pseudo-mentalizing, Interpersonal conflict ‘cos hard to consider/reflect on impact of self on others
Unnatural certainty about ideas Anything that is thought is REAL Intolerance of alternative ways of seeing things.
Overwhelming dysregulated emotions, Not balanced by cognition come To dominate behavior. Lack of contextualizing of feelings leads to catastrophyzing
Rigid assertion of self, controlling others’ thoughts and feelings.
Hypersensitive to others’ Moods, what others say. Fears ‘disappearing’
Hyper-vigilant, judging by appearance. Evidence for attitudes and other internal states hasto come from outside
Lack of conviction about own ideas Seeking external reassurance Overwhelming emptiness, Seeking intense experiences
Deficit of Reflective Function in Violent and Non-violent Prisoners with PD Levinson and Fonagy (2004)
0
2
4
6
8
10
Frequency
Deficit RF Non-deficit RF
Violent Non-violent
RF moderates the relationship between psychopathy and proactive aggressive behaviour Taubner, White, Zimmermann, Fonagy & Nolte, 2013, JACP)
0
5
10
15
300 350 400
Proa
ctive
aggr
essio
n (R
BQ)
Psychopathy (PPI-R)
low RFaverage RFhigh RF
Aggression
An evolutionary framework
n Interpersonal aggression is an important evolutionary adaptation. Ø In certain human environments it is likely to
contribute materially to the survival of the individual's genes.
Ø In other contexts it is seriously maladaptive o it undermines the possibility of safe collaboration o It decreases optimization of human capacities for
meaning generation, communication and creativity.
The developmental framework
n Human infants are born with the potential to be aggressive and even violent
n In the majority of cases this potential is not fulfilled
n Through development, given adequate environmental support, individuals gradually increasingly desist from physical and relational aggression
The mechanism for the development of violence: A failure of inhibition
n Family processes conceptualized as promoting aggression may interfere with the socialization of aggression Ø low income, low maternal education reflects
family environments in which children cannot learn to inhibit physical aggression, as well as difficulty learning alternative strategies to solve problems
Ø Characterised by disrespect for the child o Parenting qualities of disrespect for child o Similar qualities in the broader social environment
Antisocial personality disorder: a disorder of self and other
Self problems in ASPD in clinical practice n Fixed perspective about self e.g. misunderstood,
ill-treated ‘v’ self-important, grandiose self n Reduced interest in other and if present is self-
serving n Rigid representation of others to support self
representation, especially of officials/establishment/systems
n Schematic representations of self in world Ø Hierarchical relationships
n Reduced sense of internal world and seek confirmation from other of their world view
Empathy
Empathy n Empathy is not all or nothing – can be
concerned about someone’s distress with little understanding or have full understanding
n Two way phenomenon – self-other and other-self
n Constrains the individual and is associated with pro-social behaviours and necessary for altruism
n Other-oriented empathy is negatively correlated with a range of antisocial behaviors, including aggression
Empathy in psychopathic and ASPD offenders Domes et al (2013) Journal of Personality Disorders 27: 67-84 Multi-faceted Empathy Test
Empathy
n Offenders show empathy deficits in both the cognitive and the emotional domain when compared with the non-offender controls
n Confounded by education levels to some extent with higher educational level associated with better cognitive empathy
n Delinquency and violent offending may be more associated with reduced empathy than psychopathy itself
n Clinical Note Ø How to increase emotional empathy without increasing, for
example, recognition of other vulnerability and opportunity to increase exploitation?
Ø How to increase perspective taking and not mimicry and dissimulation?
Ø How to increase other empathy and the two-way components of empathy?
Emotional recognition
Forest plots for facial cues for the six emotions. Dawel et al 2012
Fore
st p
lots
mea
n ef
fect
siz
es v
ocal
cue
s fo
r the
si
x em
otio
ns. D
awel
et a
l 201
2.
Shame
Centrality of ‘moral’ emotions n Shame and guilt are ‘‘negative” or uncomfortable
emotions Ø Shame involves a negative evaluation of the
entire self vis-à-vis social and moral standards. Ø Guilt focuses on specific behaviors (not the
self) that are inconsistent with such standards. n Shame and guilt lead to different ‘‘action
tendencies” (Lindsay-Hartz, 1984) Ø Guilt is apt to motivate reparations. Ø Shame is apt to motivate efforts to hide or
disappear or attack
Shame
n Different types of shame described Ø malignant aggressive (blame, attack, avoid) Ø benign life shame (motivating, behaving
morally/socially/interpersonally) n Shame
Ø Low concern for others and High concern for self
Ø Threat of social exclusion Ø Triggers physical pain which suggests
immediate action if not moderated
Shame and aggression
n Positive correlations: Ø shame-proneness and physical aggression Ø shame-proneness and verbal aggression for adults, college
students, adolescents, and children Ø shame proneness and anger, hostility, and externalization of
blame n Male college students’ anger fully mediated the relationship between
shame and psychological abuse of a partner n Clinical Note
Ø Negative feelings of shame may lead to externalization of blame which may lead to higher levels of verbal and physical aggression
Ø Clinician needs to be sensitive to unmasking/exposing in group Ø Aggressive and antisocial individuals often use cognitive
distortions related to others to justify their activities
Therapeutic Challenge
The Therapeutic Challenge
Self Other
The stabilisation of mental processes on ASPD+BPD depends on rigid externalization of the alien self
Threats to this externalisation cause arousal of the attachment system and experience of problematic emotions (shame)
Inability to control internal states leads to increase externalization
Mentalization failure Shame, Anger, Fear
Violent control of the perceived
source of threat
Paradox of treatment
n Less is More – overactivation increases coercive behaviours and aggression
n Focus on imbalances in mentalizing Ø Identify absent mentalizing rather than
symptoms resulting from non-mentalizing e.g. aggression
Ø Bolster good interpersonal mentalizing and reduce focus on poor mentalizing
Ø Rebalance dimensions by increasing absent pole rather than decreasing overactive pole
Externalising and drop-out from treatment Henriette Löffler-Stastka; Victor Blueml; Christa Boes; Psychotherapy Research 2010, 20, 295-308.
Engagement in treatment n Explanation of model n Involvement of experts by experience
Ø Completer sits in group and holds advice ‘surgery’
n Treatment in probation system rather than mental health
n Identification of joint goals n Broader focus than aggression/violent
events – these are an end-product and not the problem
Core areas for treatment of ASPD n Increase
Ø A) affective understanding o Recognition and acceptance of emotion in self –
shame and other emotions o Accurate understanding of emotion in other –
observe embodied mentalizing o Increase in empathy for others - ?increase eye
focus Constraint by others emotion Ø B) Relational pattern (self/other) identification
o Processing of positive experience of self with others
o Recognition of fixed relational patterns outside and in group
Core areas for treatment of ASPD
n Decrease Ø Concern for self in affect arousal and rapid switch
to control other Ø Externalising core aspects of self Ø Self-serving uses of others
Key mentalizing components in MBT-ASPD Group n Identification of non-mentalizing interactions n Focus on emotions
Ø Understanding emotional cues - external mentalizing and its link to internal states
Ø Recognition of emotions in others – other/affective mentalizing – cognitive and emotional empathising (look angry but feel hurt and desperate)
Ø Identification and naming of current feelings in self
Key mentalizing components in MBT-ASPD Group n Focus on relational process
Ø Exploration of sensitivity to hierarchy and authority – self/cognitive
Ø Generation of an interpersonal process to understand subtleties of others’ experience in relation to ones’ own – self/other mentalizing – two-way mentalizing
Ø Identification of interpersonal patterns Ø Explication of threats to loss of mentalizing which
lead to teleological understanding of motivation – self/other mentalizing and self/affective mentalizing
Antisocial Personality Disorder
Bateman, A., O'Connell, J., Lorenzini, N., Gardner, T., & Fonagy, P. (2016). A randomised controlled trial of Mentalization-Based Treatment versus Structured
Clinical Management for patients with comorbid borderline personality disorder and antisocial personality disorder. BMC Psychiatry, 304, 304-311.
N=40 difference between groups at 18-months -0.45 (-0.80, -0.11), p<.011
N=40 difference between groups at 18-months
-0.61 (95% CI: -1.05, -0.17), p<.007
N=40 difference between groups at 18-months -0.64 (95% CI: -1.09, -0.18), p<.006
N=40 difference between groups at 18-months
-0.48 (95% CI: -0.78, -0.18), p<.002
difference between groups at 18-months -0.58 (95% CI: -0.89, -0.28), p<.000
N=40
difference between groups at 18-months -0.48 (95% CI: -0.69, -0.18), p<.000
difference between groups at 18-months -0.28 (95% CI: -0.68, -0.08), p<.02
difference between groups at 18-months -0.58 (95% CI: -0.89, -0.28), p<.003
MOAM
Mentalization for Offending Adult Males
ISRCTN32309003 DOI 10.1186/ISRCTN32309003
Evidence: Currently no treatment with a robust evidence base for alleviating ASPD
Research: Paucity of high quality studies is notable
Preliminary support for MBT: Pilot of MBT for ASPD at two UK centers suggests that treatment can be learned and reliably applied Next logical step: RCT comparing MBT to Usual Services to determine its clinical and cost-effectiveness
Outcomes Primary Outcome
Reduction in the frequency of aggressive acts
Secondary Outcomes:
Criminal: other (re)offending behaviour
Mental Health : anxiety and depression, drug and alcohol use, self-harm and suicidal behaviour, impulsivity, and beliefs
Health: quality of life, health and functioning
Service use: services including A & E and use of social services during the treatment and follow-up period.
Cost-benefit analysis to determine the actual cost of service delivery in both treatment conditions and whether MBT-ASPD leads to reduction in costs compared to PAU.
Research Design n Multi-site randomized control trial in a real life NHS setting. n Recruitment target 302 participants across 14 sites n Participants randomly allocated to MBT or Probation as Usual (PAU) n User Voice Peer Researchers collecting data alongside traditional Research
Assistants n Participants are followed up every 3 months for 24 months post randomisation.
-Primary outcome measures and offending records obtained every 3 months post randomisation -Secondary outcomes collected every 6 months
MBT PAU Random allocation
• Site • Age (21-25; 26-39; 40+) • Sentence (community or on licence after prison) • Length (12 months or 12 months or more)