The mediating role of reflective functioning and general psychopathology in the relationship between childhood conduct disorder and adult aggression among offenders.

BACKGROUND: The nature of the pathway from conduct disorder (CD) in adolescence to antisocial behavior in adulthood has been debated and the role of certain mediators remains unclear. One perspective is that CD forms part of a general psychopathology dimension, playing a central role in the developmental trajectory. Impairment in reflective functioning (RF), i.e., the capacity to understand one's own and others' mental states, may relate to CD, psychopathology, and aggression. Here, we characterized the structure of psychopathology in adult male-offenders and its role, along with RF, in mediating the relationship between CD in their adolescence and current aggression. METHODS: A secondary analysis of pre-treatment data from 313 probation-supervised offenders was conducted, and measures of CD symptoms, general and specific psychopathology factors, RF, and aggression were evaluated through clinical interviews and questionnaires. RESULTS: Confirmatory factor analyses indicated that a bifactor model best fitted the sample's psychopathology structure, including a general psychopathology factor (p factor) and five specific factors: internalizing, disinhibition, detachment, antagonism, and psychoticism. The structure of RF was fitted to the data using a one-factor model. According to our mediation model, CD significantly predicted the p factor, which was positively linked to RF impairments, resulting in increased aggression. CONCLUSIONS: These findings highlight the critical role of a transdiagnostic approach provided by RF and general psychopathology in explaining the link between CD and aggression. Furthermore, they underscore the potential utility of treatments focusing on RF, such as mentalization-based treatment, in mitigating aggression in offenders with diverse psychopathologies.

Short-Term versus Long-Term Mentalization-Based Therapy for Borderline Personality Disorder: A Randomized Clinical Trial (MBT-RCT).

INTRODUCTION: Borderline personality disorder (BPD) is a severe and prevalent psychiatric disorder. Mentalization-based therapy (MBT) is an evidence-based intervention for BPD, and several countries offer treatment programs for BPD lasting for years, which is resource demanding. No previous trial has compared short-term with long-term MBT. OBJECTIVE: The aim of the study was to assess the efficacy and safety of short-term versus long-term MBT for outpatients with BPD. METHODS: Adult outpatients (≥18 years) with subthreshold or diagnosed BPD were randomly assigned (1:1) to short-term MBT (5 months) or long-term MBT (14 months). The primary outcome was BPD symptoms assessed with the Zanarini Rating Scale for Borderline Personality Disorder. Secondary outcomes were functional impairment, quality of life, global functioning, and severe self-harm. All outcomes were primarily assessed at 16 months after randomization. This trial was prospectively registered at ClinicalTrials.gov, NCT03677037. RESULTS: Between October 4, 2018, and December 3, 2020, we randomly assigned 166 participants to short-term MBT (n = 84) or long-term MBT (n = 82). Regression analyses showed no evidence of a difference when assessing BPD symptoms (MD 0.99; 95% CI: -1.06 to 3.03; p = 0.341), level of functioning (MD 1.44; 95% CI: -1.43 to 4.32; p = 0.321), quality of life (MD -0.91; 95% CI: -4.62 to 2.79; p = 0.626), global functioning (MD -2.25; 95% CI: -6.70 to 2.20; p = 0.318), or severe self-harm (RR 1.37; 95% CI: 0.70-2.84; p = 0.335). More participants in the long-term MBT group had a serious adverse event compared with short-term MBT (RR 1.63; 95% CI: 0.94-3.07; p = 0.088), primarily driven by a difference in psychiatric hospitalizations (RR 2.03; 95% CI: 0.99-5.09; p = 0.056). CONCLUSION: Long-term MBT did not lead to lower levels of BPD symptoms, nor did it influence any of the secondary outcomes compared with short-term MBT.

Mentalizing mediates the relationship between psychopathy and premeditated criminal offending in schizophrenia: a 6-year follow-up study.

PURPOSE: Research has shown that schizophrenia augments the risk for criminal behaviour and variables both defining- and related to schizophrenia, increase criminal offending. Premeditated criminal offending is considered a severe form of criminal offending, however, very little is known about what predicts future premeditated criminal offending in schizophrenia. METHOD AND MATERIALS: In this 6-year follow-up study we explored which factors underlie future premeditated criminal behaviour in a sample of patients diagnosed with schizophrenia (N = 116). We also investigated if a specific mentalizing profile underlie part of the variance of premeditated criminal offending. RESULTS: Results showed that psychopathy underlie future premeditated crime in schizophrenia, and that a specific mentalizing profile, comprised of a dysfunctional emotional and intact cognitive mentalizing profile in relation to others, mediated parts of the relation between psychopathy and premeditated criminal offending. Finally, our results indicated that patients with schizophrenia with a specific mentalizing profile (see above) engaged in premeditated criminal behaviour earlier during the 6-year follow-up period compared to patients with other mentalizing profiles. CONCLUSIONS: Our findings suggest that mentalization should carefully be inspected in patients with schizophrenia in relation to future premeditated offending.

A clinical illustration of short-term mentalization-based therapy for borderline personality disorder.

OBJECTIVE: Mentalization-based therapy (MBT) is an evidence-supported, long-term psychotherapy program developed to treat borderline personality disorder (BPD). A short-term, 20-week adaptation to the original MBT format including case formulation, psychoeducation, and group and individual therapy has recently been proposed. The current case material will illustrate how the recent adaptation to the mentalization-based practice can enhance personality functioning using a short-term format. METHODS: Case material is presented to demonstrate the clinical application of short-term MBT in the treatment of a young woman diagnosed with BPD who has a history of failed treatment attempts and who showed signs of affective dysregulation, unstable relationships, and intense abandonment anxiety. RESULTS: The case illustration shows how short-term MBT can facilitate improvement in personality functioning, specifically targeting situations in which the patient lost her temper and became overwhelmed by abandonment anxiety. By continuously employing therapeutic shifts toward greater autonomy and agency, and by maintaining a balanced empathetic therapeutic stance, the therapists were able to enhance the patients mentalizing and personality functioning. CONCLUSIONS: Short-term MBT can be effectively implemented to enhance the mentalizing capacity and personality functioning in outpatients with BPD.

Mentalizing and Group Psychotherapy: A Novel Treatment for Antisocial Personality Disorder.

Antisocial personality disorder (ASPD) is a common condition associated with interpersonal and social violence, and current treatments are unsatisfactory. Mentalizing, which has developmental roots in attachment processes, offers a framework to reconsider treatment for ASPD, in which dysfunction of the attachment system temporarily inhibits affect regulation and reduces mentalizing abilities, resulting in impulsivity and relational reactivity. Mentalization-based treatment for ASPD (MBT-ASPD), which focuses on the mental and relational processes central to personality disorder rather than on anger management and violent behavior, is a promising intervention. Implemented as a group psychotherapy, MBT-ASPD targets the mentalizing vulnerabilities and attachment patterns of patients by using a semi-structured group process focused on personal formulation and by establishing group values to promote learning from other members and generating "we-ness." The treatment then emphasizes mentalizing in relationships. This article discusses the mentalizing model of ASPD and outlines strategies for MBT-ASPD from a therapy group conducted in Great Britain.

Mentalization-based treatment in groups for adolescents with Borderline Personality Disorder: 3- and 12-month follow-up of a randomized controlled trial.

Mentalization-based treatment in groups (MBT-G) has never been tested in adolescents with Borderline Personality Disorder (BPD) in a randomized controlled trial. The current study aimed to test the long-term effectiveness of MBT-G in an adolescent sample with BPD or BPD features (≥ 4 DSM-5 BPD criteria). Hundred and eleven patients with BPD (n = 106) or BPD features (n = 5) were randomized to either (1) a 1-year modified MBT-G program comprising three MBT introductory sessions, five individual case formulation sessions, 37 weekly MBT group sessions, and six MBT-Parent sessions, or (2) treatment as usual (TAU), defined as at least 12 individual monthly treatment sessions with follow-up assessments at 3 and 12 months post treatment. The primary outcome was the score on the Borderline Personality Features Scale for Children (BPFS-C), and secondary outcomes included clinician-rated BPD symptoms and global level of functioning as well as self-reported self-harm, depression, externalizing and internalizing symptoms, and caregiver reports. There were no statistically significant differences between MBT-G and TAU on the primary outcome measure or any of the secondary outcomes. Both groups showed improvement on the majority of clinical and social outcomes at both follow-up points, although remission rates were modest with just 35% in MBT-G and 39% in TAU 2 years after inclusion into the study. MBT-G was not superior to TAU in improving borderline features in adolescents. Although improvement was observed equally in both interventions over time, the patients continued to exhibit prominent BPD features, general psychopathology and decreased functioning in the follow-up period, which points to a need for more research and better understanding of effective components in early intervention programs. The ClinicalTrials.gov identifier is NCT02068326.

Reduced mentalizing in patients with bulimia nervosa and features of borderline personality disorder: A case-control study.

BACKGROUND: Mentalizing, the mental capacity to understand oneself and others in terms of mental states, has been found to be reduced in some mental disorders such as Borderline Personality Disorder (BPD). Some studies have suggested that Eating Disorders (EDs) may also be associated with impairments in mentalizing, but studies have not always yielded consistent results. This is the first study to systematically investigate mentalizing impairments in patients with Bulimia Nervosa (BN) compared with controls. In addition, we investigated whether impairments in mentalizing were related to BPD features, rather than BN per se, given the high comorbidity between BPD and BN. METHODS: Patients with BN (n = 53) and healthy controls (HCs; n = 87) completed a battery of measures assessing mentalizing including the Reflective Function Questionnaires (RFQ), the Object Relations Inventory (ORI; Differentiation-Relatedness Scales) and the Reading The Mind in The Eyes Test (RMET). RESULTS: Patients with BN scored significantly lower than HCs on all tests of mentalizing, with moderate to large between-group effect sizes. These differences were partially accounted for by BPD features as assessed with the Zanarini Rating Scale for Borderline Personality Disorder (ZAN-BPD), and partially by bulimic symptoms measured with the Eating Disorder Examination Questionnaire (EDE-Q). CONCLUSIONS: Patients with BN have significantly lower levels of mentalizing as assessed with a broad range of tests compared to HCs. These differences were related to both bulimic symptoms and BPD features. Although further research in larger samples is needed, if replicated, these findings suggest that poor mentalizing may be a significant factor in BN patients and should be addressed in treatment, regardless of the presence of BPD features.

Treatment of personality disorder.

The evidence base for the effective treatment of personality disorders is insufficient. Most of the existing evidence on personality disorder is for the treatment of borderline personality disorder, but even this is limited by the small sample sizes and short follow-up in clinical trials, the wide range of core outcome measures used by studies, and poor control of coexisting psychopathology. Psychological or psychosocial intervention is recommended as the primary treatment for borderline personality disorder and pharmacotherapy is only advised as an adjunctive treatment. The amount of research about the underlying, abnormal, psychological or biological processes leading to the manifestation of a disordered personality is increasing, which could lead to more effective interventions. The synergistic or antagonistic interaction of psychotherapies and drugs for treating personality disorder should be studied in conjunction with their mechanisms of change throughout the development of each.

A randomised controlled trial of mentalization-based treatment versus structured clinical management for patients with comorbid borderline personality disorder and antisocial personality disorder.

BACKGROUND: Antisocial personality disorder (ASPD) is an under-researched mental disorder. Systematic reviews and policy documents identify ASPD as a priority area for further treatment research because of the scarcity of available evidence to guide clinicians and policymakers; no intervention has been established as the treatment of choice for this disorder. Mentalization-based treatment (MBT) is a psychotherapeutic treatment which specifically targets the ability to recognise and understand the mental states of oneself and others, an ability shown to be compromised in people with ASPD. The aim of the study discussed in this paper is to investigate whether MBT can be an effective treatment for alleviating symptoms of ASPD. METHODS: This paper reports on a sub-sample of patients from a randomised controlled trial of individuals recruited for treatment of suicidality, self-harm, and borderline personality disorder. The study investigates whether outpatients with comorbid borderline personality disorder and ASPD receiving MBT were more likely to show improvements in symptoms related to aggression than those offered a structured protocol of similar intensity but excluding MBT components. RESULTS: The study found benefits from MBT for ASPD-associated behaviours in patients with comorbid BPD and ASPD, including the reduction of anger, hostility, paranoia, and frequency of self-harm and suicide attempts, as well as the improvement of negative mood, general psychiatric symptoms, interpersonal problems, and social adjustment. CONCLUSIONS: MBT appears to be a potential treatment of consideration for ASPD in terms of relatively high level of acceptability and promising treatment effects. TRIAL REGISTRATION: ISRCTN ISRCTN27660668 , Retrospectively registered 21 October 2008.

Mentalization-based treatment for psychotic disorder: protocol of a randomized controlled trial.

BACKGROUND: Many patients with a non-affective psychotic disorder suffer from impairments in social functioning and social cognition. To target these impairments, mentalization-based treatment for psychotic disorder, a psychodynamic treatment rooted in attachment theory, has been developed. It is expected to improve social cognition, and thereby to improve social functioning. The treatment is further expected to increase quality of life and the awareness of having a mental disorder, and to reduce substance abuse, social stress reactivity, positive symptoms, negative, anxious and depressive symptoms. METHODS/DESIGN: The study is a rater-blinded randomized controlled trial. Patients are offered 18 months of therapy and are randomly allocated to mentalization-based treatment for psychotic disorders or treatment as usual. Patients are recruited from outpatient departments of the Rivierduinen mental health institute, the Netherlands, and are aged 18 to 55 years and have been diagnosed with a non-affective psychotic disorder. Social functioning, the primary outcome variable, is measured with the social functioning scale. The administration of all tests and questionnaires takes approximately 22 hours. Mentalization-based treatment for psychotic disorders adds a total of 60 hours of group therapy and 15 hours of individual therapy to treatment as usual. No known health risks are involved in the study, though it is known that group dynamics can have adverse effects on a psychiatric disorder. DISCUSSION: If Mentalization-based treatment for psychotic disorders proves to be effective, it could be a useful addition to treatment. TRIAL REGISTRATION: Dutch Trial Register. NTR4747 . Trial registration date 08-19-2014.

Adversity, attachment, and mentalizing.

The papers in this special issue offer evidence of personality disorder as a dysfunction of higher-order cognition, which is conceptualized variously as a disorder of mentalizing, metacognition, mindfulness, social cognition and reflective function. While there may be differences in the scope of these concepts, they all imply that higher-order mental processing is at the core of personality function. In this commentary, the authors use mentalizing as an umbrella term for these concepts, and argue that it is the complex interaction of adversity, attachment and mentalizing that leads to the characteristic symptoms of borderline personality disorder and other personality disorders. Evidence is provided from the papers in this special issue, comments made on the findings and further avenues for research are recommended.

Borderline Personality Disorder and Mood Disorders: Mentalizing as a Framework for Integrated Treatment.

Borderline personality disorder (BPD) frequently co-occurs with mood disorders and each influences the course and response to treatment of the other, potentially reducing beneficial outcome. Mentalizing, the ability to infer one's own and others' mental states, is a key factor in both disorders, being a major component of affect regulation and self-identity as well as a central aspect of interpersonal relationships and social function. In this article, we suggest that using mentalization-based treatment may lead to better outcome by addressing the mentalizing problems arising from the dual pathway that leads from depressed mood and BPD to disruption of mentalizing. Some clinical interventions are described to address the mentalizing problems associated with depression and BPD.

Mentalization-based therapy (MBT): an overview.

OBJECTIVE: This paper provides an overview of mentalization-based therapy (MBT). Multiple strands of research evidence converge to suggest that affect dysregulation, impulsivity and unstable interpersonal relationships are core features of borderline personality disorder (BPD). The MBT approach to BPD attempts to provide a theoretically consistent way of conceptualising the inter-relationship of these features. METHODS: MBT makes mentalizing a core focus of therapy and was initially developed for the treatment of BPD in routine clinical services, delivered in group and individual modalities. This article provides a brief overview of mentalizing and its relevance to BPD, provides an overview of MBT and notes a number of current trends in MBT. RESULTS: MBT provides clinicians with an empirically supported approach to BPD and its treatment. CONCLUSIONS: Whilst mentalizing is viewed as an integrative framework for therapy, more knowledge is needed as to which of the therapies are of most benefit for individual patients.

Study Protocol for a randomized controlled trial of mentalization based therapy against specialist supportive clinical management in patients with both eating disorders and symptoms of borderline personality disorder.

BACKGROUND: The NOURISHED study: Nice OUtcomes for Referrals with Impulsivity, Self Harm and Eating Disorders.Eating Disorders (ED) and Borderline Personality Disorder (BPD) are both difficult to treat and the combination presents particular challenges. Both are associated with vulnerability to loss of mentalization (awareness of one's own and others' emotional state). In BPD, Mentalization Based therapy (MBT) has been found effective in reducing symptoms. In this trial we investigate the effectiveness and cost-effectiveness of MBT adapted for Eating disorders (Mentalization Based Therapy for Eating Disorders (MBT-ED)) compared to a standard comparison treatment, Specialist Supportive Clinical Management (SSCM-ED) in patients with a combination of an Eating Disorder and either a diagnosis of BPD or a history of self-harm and impulsivity in the previous 12 months. METHODS/DESIGN: We will complete a multi-site single-blind randomized controlled trial (RCT) of MBT-ED vs SSCM-ED. Participants will be recruited from three Eating Disorder Services and two Borderline Personality Disorder Services in London. Participants allocated to MBT-ED will receive one year of weekly group and individual therapy and participants allocated to SSCM-ED will receive 20 sessions of individual therapy over 1 year. In addition, participants in both groups will have access to up to 5 hours of dietetic advice. The primary outcome measure is the global score on the Eating Disorders Examination. Secondary outcome measures include total score on the Zanarini BPD scale, the Object Relations Inventory, the Depression Anxiety Stress Scales, quality of life and cost-effectiveness. Measures are taken at recruitment and at 6 month intervals up to 18 months. DISCUSSION: This is the first Randomised Controlled Trial of MBT-ED in patients with eating disorders and symptoms of BPD and will provide evidence to inform therapy decisions in this group of patients. During MBT-ED mentalization is encouraged, while in SSCM-ED it is not overtly addressed. This study will help elucidate mechanisms of change in the two therapies and analysis of therapy and interview transcripts will provide qualitative information about the conduct of therapy and changes in mentalization and object relations. TRIAL REGISTRATION: ISRCTN51304415.

Mentalizing mediates the relationship between psychopathy and type of aggression in schizophrenia.

Convincing evidence demonstrates that psychopathy is associated with premeditated aggression. However, studies have failed to explain why this association exists and whether socio-cognitive functions, such as mentalizing, could explain the relation. This cross-sectional study investigates, in 108 patients with schizophrenia, the association of psychopathy and mentalizing abilities with premeditated and impulsive aggression and probes the nature of their influence on these specific aggression patterns. Patients' engagement in premeditated aggression was associated with diminishing mentalizing and increasing psychopathic tendencies. Moreover, mediation analyses reveal that the ability to attribute mental states to others mediates the relation between psychopathy and type of aggression. This mediation is facilitated by a specific mentalizing profile characterized by the presence of intact cognitive and deficient emotional mentalizing capacities. This study is the first to report a mediating effect of mentalizing on the relationship between psychopathy and type of aggression in schizophrenia. Implications of these results are discussed.

Mentalizing individuals, families and systems: Towards a translational socioecological approach.

Mentalization-based treatment (MBT) is a spectrum of interventions that share a central focus on improving the capacity for mentalizing. Although MBT was originally developed as a treatment for individuals with borderline personality disorder, its scope and focus have been broadened to become a socioecological approach that stresses the role of broader sociocultural factors in determining the closely related capacities for mentalizing and epistemic trust. This special issue brings together some of the newest developments in MBT that illustrate this shift. These contributions also highlight several current limitations in mentalization-based approaches, providing important pointers for further research. In this editorial, we first outline the broadening scope of the mentalizing approach, and then provide a discussion of each of the contributions to this special issue in the context of the need for further research concerning some of the key assumptions of mentalization-based approaches and their implementation in clinical practice. We close this editorial with considerations concerning future research.

Impact of clinical severity on outcomes of mentalisation-based treatment for borderline personality disorder.

BACKGROUND: Evidence of remission from borderline personality disorder (BPD) without specialised treatment is accumulating. AIMS: To establish whether specialised treatments are indicated for patients with clinically severe disorder. METHOD: The impact of clinical severity on outcomes of a randomised controlled trial of mentalisation-based treatment (MBT) was contrasted with structured clinical management (SCM). Severity indicators were defined as severity of comorbid psychiatric syndromes, severity of BPD, severity of personality disturbance and severity of symptom distress. Logistic regressions were used to predict the likelihood of recovery at 18 months, and mixed-effects regression analysis was applied to examine the association of severity and rates of improvement across time in the two treatment groups. RESULTS: None of the severity criteria predicted outcome at the end of treatment on logistic regression. However, testing the significance of distribution of cases of recovery v. non-recovery suggested that multiple Axis II diagnoses and symptom distress influenced outcomes. CONCLUSIONS: Borderline personality disorder with significant Axis II comorbidity is a possible but uncertain indicator for specialist treatment. Patients whose only personality disorder diagnosis is BPD do equally well with SCM. Prospective studies are needed.

The MBT Adherence and Competence Scale (MBT-ACS): development, structure and reliability.

The properties of the 17-item Mentalization-Based Treatment Adherence and Competence Scale (MBT-ACS) were investigated in a reliability study in which 18 psychotherapy sessions, comprising two sessions by nine different therapists, were rated by seven different raters. The overall reliabilities for adherence and competence for seven raters were high, .84 and .88 respectively. The level of reliability declined by number of raters but was still acceptable for two raters (.60 and .68). The reliabilities for the various items differed. The MBT-ACS was found to be an appropriate rating measure for treatment fidelity and useful for the purposes of quality control and supervision. The reliability may be enhanced by redefining some items and reducing their numbers.

Mentalization-Based Treatment.

The concept of mentalizing has captured the interest and imagination of an astonishing range of people-from psychoanalysts to neuroscientists, from child development researchers to geneticists, from existential philosophers to phenomenologists-all of whom seem to have found it useful. According to the Thompson Reuter maintained Web of Science, the use of the term in titles and abstracts of scientific papers increased from 10 to 2,750 between 1991 and 2011. Clinicians in particular have enthusiastically embraced the idea, and have put it to innovative use in their practices. Mentalization-based treatment (MBT)-making mentalizing a core focus of therapy-was initially developed for the treatment of borderline personality disorder (BPD) in routine clinical services delivered in group and individual modalities. Therapy with mentalizing as a central component is currently being developed for treatment of numerous groups, including people with antisocial personality disorder, substance abuse, eating disorders, and at-risk mothers with infants and children (A. Bateman & Fonagy, 2011). It is also being used with families and adolescents, in schools, and in managing social groups (Asen & Fonagy, 2011; Fonagy et al., 2009; Twemlow, Fonagy, & Sacco, 2005a, 2005b). In this article, we focus on MBT in the treatment of BPD.