Acute experimental inflammation in healthy women attenuates empathy for psychological pain.

Administration of low-dose lipopolysaccharide (LPS) to healthy humans is a translational approach to analyze the effects of acute systemic inflammation and sickness behavior. Although studies documented that LPS-induced inflammation can alter social behavior, its impact on empathy remains poorly understood. In this double-blind, placebo-controlled study, 52 healthy female volunteers received an intravenous injection of either LPS (0.4 ng/kg body weight) or placebo and completed the Social Interaction Empathy Task (SIET) two hours after injection. Physiological responses (blood pressure, heart rate, body temperature, cytokines, cortisol) were analyzed along with sickness symptoms and mood before and after LPS or placebo administration. LPS application led to significant increases in plasma cytokines and sickness symptoms as well as low mood. Moreover, volunteers receiving LPS showed significantly less empathy for other's psychological pain than those who received placebo. Furthermore, LPS-injected volunteers with more severe sickness symptoms displayed higher pain ratings in the first-person perspective. Thus, low-grade inflammation reduces empathy for other's psychological pain which might reflect an adaptive strategy to save energy by not responding empathetically when sick oneself.

Is your pain my pain? A study exploring the relation between pain sensitivity, pain thresholds and empathy for somatic and psychological pain.

OBJECTIVES: Research has shown that empathy for both somatic and psychological pain recruits affective components of the so-called pain matrix, a set of brain regions that is activated during the perception of somatic pain. In addition, the subjective evaluation of experimentally induced somatic pain is related to empathy for somatic pain. In contrast, it is unclear whether or not the subjective sensitivity to somatic pain impacts on empathy for psychological pain. METHODS: In the present study, 55 healthy participants conducted a pain-pressure-test (PPT) and a cold-pressor test (CPT) in order to assess pain thresholds, pain tolerance and evaluation of pain during the task. They further conducted the social interaction empathy task (SIET), which investigates empathy for somatic as well as psychological pain. All participants completed the interpersonal-reactivity index (IRI) and the pain-sensitivity questionnaire (PSQ). RESULTS: Participants who are in general more sensitive to somatic pain, as indicated by high-PSQ scores, showed higher empathy, that is, higher pain ratings, for both somatic and psychological painful situations observed in others as compared to those with low-PSQ scores. High-PSQ scores and high pain and unpleasantness ratings during the CPT were correlated with empathy for pain (both pain conditions), whereas pain thresholds (PPT) and pain tolerance thresholds (CPT) did not correlate with empathy. The IRI subscore 'personal distress' correlated with psychological pain ratings. CONCLUSIONS: Thus, empathy for both somatic and psychological pain were related to the subjective evaluation of somatic pain and general pain sensitivity.

Altered Left Ventricular Myocardial Deformation in Young Women With Borderline Personality Disorder: An Echocardiographic Study.

OBJECTIVE: Borderline personality disorder (BPD) is characterized by intense mood swings, impulsivity, self-injurious behavior, poor anger control, fear of abandonment, and unstable interpersonal relationships. BPD is also associated with a heightened risk of cardiovascular disease, whereby the underlying mechanisms are insufficiently understood. Accordingly, the present study set out to examine whether individuals with BPD would show abnormal myocardial deformation and to explore the role of potential risk factors, including maladaptive stress responsivity, childhood trauma, and current stress exposure. METHODS: Fifty female patients diagnosed with BPD and 50 controls matched for sex and age underwent echocardiography to determine the global longitudinal strain (GLS) of the left ventricle. In addition, childhood trauma, chronic stress, and "allostatic load" were determined, as well as borderline symptom severity and common risk factors for cardiovascular disease. RESULTS: Aside from a significantly greater GLS in BPD patients, a multivariable regression analysis revealed that allostatic load (ß = 0.225, p = .048) was significantly associated with GLS, with childhood trauma (ß = 0.279, p = .062) approaching significance. Conversely, smoking (p = .867), chronic stress (p = .193), and borderline symptom severity (p = .342) were not associated with GLS, even though bivariate correlations were significant. CONCLUSIONS: Somatically healthy women with BPD display subtle signs of increased GLS, which is associated with allostatic load as an indicator of the "wear-and-tear" of the body. The association between childhood trauma with GLS was of similar strength but did not reach the threshold for statistical significance. This finding may support the need for primary prevention of somatic consequences of maladaptive stress responsivity in psychiatric patients.

Impact of Psychiatric and Related Somatic Medications on the Duration and Severity of COVID-19: A Retrospective Explorative Multi-center Study from the German Metropolitan Ruhr-area.

INTRODUCTION: Several psychiatric and somatic medications are assumed to improve COVID-19-symptoms. These include antidepressants, antipsychotics, and anticonvulsants as well as anticoagulants, statins, and renin-angiotensin-aldosterone-system (RAAS)-inhibitors for somatic comorbid conditions. All these agents may reduce the hyperinflammatory response to SARS/CoV-2 or the related negative cardio-cerebrovascular outcomes. METHODS: In a retrospective longitudinal, multi-center inpatient study, we sought to explore the influence of psychiatric medications on COVID-19, comprising the period from diagnosing SARS/CoV-2-infection via PCR (nasopharyngeal swab) up to the next 21 days. Ninety-six psychiatric inpatients (mean age [SD] 65.5 (20.1), 54% females) were included. The primary outcome was the COVID-19-duration. Secondary outcomes included symptom severity and the presence of residual symptoms. RESULTS: COVID-19-related symptoms emerged in 60 (62.5%) patients, lasting 6.5 days on average. Six (6.3%) 56-95 years old patients died from or with COVID-19. COVID-19-duration and residual symptom-presence (n=22, 18%) were not significantly related to any substance. Respiratory and neuro-psychiatric symptom-load was significantly and negatively related to prescription of antidepressants and anticoagulants, respectively. Fatigue was negatively and positively related to RAAS-inhibitors and proton-pump-inhibitors, respectively. These significant relationships disappeared with p-value adjustment owed to multiple testing. The mean total psychiatric burden was not worsened across the study. DISCUSSION: None of the tested medications was significantly associated with the COVID-19-duration and -severity up to the end of post-diagnosing week 3. However, there were a few biologically plausible and promising relationships with antidepressants, anticoagulants, and RAAS-inhibitors before p-value adjustment. These should encourage larger and prospective studies to re-evaluate the influence of somatic and psychiatric routine medications on COVID-19-related health outcomes.

Quo Vadis Psychiatry? Why It Is Time to Endorse Evolutionary Theory.

ABSTRACT: In recent decades, psychiatry and the neurosciences have made little progress in terms of preventing, diagnosing, classifying, or treating mental disorders. Here we argue that the dilemma of psychiatry and the neurosciences is, in part, based on fundamental misconceptions about the human mind, including misdirected nature-nurture debates, the lack of definitional concepts of "normalcy," distinguishing defense from defect, disregarding life history theory, evolutionarily uninformed genetic and epigenetic research, the "disconnection" of the brain from the rest of the body, and lack of attention to actual behavior in real-world interactions. All these conceptual difficulties could potentially benefit from an approach that uses evolutionary theory to improve the understanding of causal mechanisms, gene-environment interaction, individual differences in behavioral ecology, interaction between the gut (and other organs) and the brain, as well as cross-cultural and across-species comparison. To foster this development would require reform of the curricula of medical schools.

Psychometric properties of the German version of the fears of compassion scales.

The cultivation of compassion is associated with beneficial effects on physical and psychological health, satisfaction with life and social relationships. However, some individuals, especially those high in psychopathological symptoms or those with particular disorders such as borderline personality disorder (BPD) may demonstrate pronounced fears of engagement in compassionate experiences or behaviours. Furthermore, fears of compassion have been found to impede progress in psychotherapy. The 38-item fears of compassion scales (FCS) is a self-report questionnaire for measuring trait levels of fears of compassion (a) one receives from others (FCFO), (b) one feels towards others (FCTO) and (c) one feels for oneself (self-compassion; FSC). The FCS is an internationally used instrument of proven validity and reliability in both clinical and nonclinical samples. In the present study, a German translation of the FCS including its three subscales was provided, and the psychometric properties were examined in 430 participants from four different samples: (a) a sample from the general population; (b) a mixed sample of psychiatric residential and outpatients; (c) a clinical sample of residential and outpatients with a primary diagnosis of BPD and (d) a sample of healthy control participants. Internal consistencies were excellent for the German version of the FSC and acceptable to excellent for its subscales. Correlations with established measures of mental health demonstrate its validity. Additionally, the German FCS discriminates significantly between individuals from the general population and patients, thus supporting its specificity. The German FCS is suitable to detect potential obstacles in cultivating compassion in psychotherapeutic treatments and beyond.

Mapping adaptation, deviance detection, and prediction error in auditory processing.

Various studies have suggested that auditory deviance detection is organized in a hierarchical manner with ascending levels of complexity. Event-related potentials (ERP) are considered to reflect different cortical processing stages. In the current electroencephalographic study, we employed an auditory sequence oddball paradigm to investigate different levels of cortical auditory processing and the contribution of neuronal habituation and prediction error mechanism to N1 and Mismatch Negativity (MMN). Our findings suggest that N1 reflects a lower cortical process primarily involved in the encoding of simple physical features and is thus mainly modulated by neuronal attenuation and not complex top-down mechanisms. By analyzing within-sequence signal differences, we divided the MMN into distinct subcomponents reflecting different hierachical levels of auditory processing. We determined a "first-order" MMN that reflects the processing of simple deviant features (such as frequency) and "higher-order" MMNs that occur at regularity violation of complex patterns or unexpected inputs that do not allow further predictions. In our source localization analysis, both the primary auditory cortex and left IFG were primarily involved in the detection of simple, physically deviant features, while the right IFG was associated with the processing of novel, unexpected auditory inputs and the ACC with regularity violation of known patterns. Summarizing, our results might contribute to a better understanding of the different complexities of neuronal habituation and prediction error mechanisms at different levels of cortical auditory processing.

Lateralization of increased density of Iba1-immunopositive microglial cells in the anterior midcingulate cortex of schizophrenia and bipolar disorder.

There is increasing evidence from genetic, biochemical, pharmacological, neuroimaging and post-mortem studies that immunological dysregulation plays a crucial role in the pathogenesis of psychoses. The involvement of microglia in schizophrenia and bipolar disorder (BD) has remained controversial, however, since results from various post-mortem studies are still inconclusive. Here, we analyzed the estimated density of microglia of age-matched individuals with schizophrenia (n = 17), BD (n = 13), and non-psychiatric control subjects (n = 17) in the anterior midcingulate cortex (aMCC), a brain area putatively involved in the pathogenesis of psychoses, using ionized calcium binding adaptor molecule 1 (Iba1)-immunohistochemistry. The microglial cells displayed a homogenously distributed Iba1-staining pattern in the aMCC with slightly varying activation states in all three groups. The estimated microglial densities did not differ significantly between individuals with schizophrenia, BD and control subjects. Remarkably, when both hemispheres were investigated separately within the three groups, the density was significantly lateralized towards the right aMCC in schizophrenia (p = 0.01) and-even more evident-in BD subjects (p = 0.008). This left-right lateralization was not observed in the control group (p = 0.52). Of note, microglial density was significantly lower in BD individuals who did not commit suicide compared with BD individuals who died from suicide (p = 0.002). This difference was not observed between individuals with BD who committed suicide and controls. The results, tentatively interpreted, suggest a hitherto unknown increased lateralization of microglial density to the right hemisphere in both psychiatric groups. If confirmed in independent samples, lateralization should be considered in all post-mortem studies on microglia. Density differences between suicide and non-suicide individuals needs further elucidation.

Exploring nonverbal synchrony in borderline personality disorder: A double-blind placebo-controlled study using oxytocin.

OBJECTIVES: Interpersonal dysfunction is a central feature of borderline personality disorder (BPD), and the neuropeptide oxytocin (OT) has been shown to impact patients' behaviour in numerous ways. Nonverbal signals such as the coordination of body movement (nonverbal synchrony) are associated with the success of interpersonal exchanges and could thus be influenced by features of BPD and by the administration of OT. DESIGN: We explored the effect of intranasal OT (inOT) on nonverbal synchrony in sixteen patients with BPD and fifteen healthy controls (CTL) randomly assigned to two double-blind clinical interviews under inOT and placebo (PL). METHODS: Nonverbal synchrony was assessed by automated video-analyses of subject's and interviewer's body movement. Lagged cross-correlations were used to objectively quantify coordination in dyads. RESULTS: Synchrony was higher than pseudosynchrony (= synchrony expected by chance), and there was a differential effect of inOT between groups: While healthy controls displayed increased synchrony under inOT, patients with BPD showed low levels of synchrony under inOT. Additionally, patient's synchrony was negatively associated with self-reported childhood trauma. CONCLUSIONS: Nonverbal synchrony in clinical interviews is influenced by inOT, and this effect depends on subject's diagnosis. In line with previous research implying positive associations between nonverbal synchrony and relationship quality, inOT led to an increase of synchrony in healthy controls, but not in patients with BPD. Low levels of synchrony under inOT in patients and its association with childhood trauma suggest that additional mechanisms such as rejection sensitivity might mediate BPD patients' nonverbal behaviour. PRACTITIONER POINTS: Intranasal oxytocin (inOT) attenuated nonverbal synchrony - a proxy for relationship quality - in patients with borderline personality disorder (BPD), while it increased nonverbal synchrony in healthy controls (CTL). Available models (rejection sensitivity; social salience) suggest that inOT may alter the way patients with BPD assess social situations, and this alteration is expressed by changes in nonverbal coordination. Patients with BPD display low levels of synchrony which are even below expected pseudosynchrony based on chance. The association between self-reported childhood trauma and lower synchrony in BPD was most evident for patient's imitative behaviour: Under inOT, patients with high scores of childhood trauma refrained from imitating their interview partners. Study limitations include small sample sizes and limited data on the psychological impact of the clinical interviews.

Getting to the bottom of things: The value of evolutionary approaches in discerning the origin of psychopathology.

The network approach as a novel way of understanding psychopathology has helped address some of the existing issues associated with traditional biological interpretations. Nonetheless, it has similarly failed in explaining the fundamental etiology of mental conditions - a persistent conundrum that arguably could be adequately addressed only by evolutionary formulations, specifically evolutionary mismatch and life history theories.

Childhood trauma and dissociative symptoms predict frontal EEG asymmetry in borderline personality disorder.

Frontal EEG asymmetry (FEA) has been studied as both state and trait parameter in emotion regulation and affective disorders. Its significance in borderline personality disorder (BPD) remains largely unknown. Twenty-six BPD patients and 26 healthy controls underwent EEG before and after mood induction using aversive images. A slight but significant shift from left- to right-sided asymmetry over prefrontal electrodes occurred across all subjects. In BPD baseline FEA over F7 and F8 correlated significantly with childhood trauma and functional neurological "conversion" symptoms as assessed by respective questionnaires. Regression analysis revealed a predictive role of both childhood trauma and dissociative neurological symptoms. FEA offers a relatively stable electrophysiological correlate of BPD psychopathology that responds only minimally to acute mood changes. Future studies should address whether this psychophysiological association is universal for trauma- and dissociation-related disorders, and whether it is responsive to psychotherapy.

Forgiveness and cognitive control - Provoking revenge via theta-burst-stimulation of the DLPFC.

In order to act in a socially acceptable way, the ability to forgive is indispensable. It has been suggested that forgiveness relies on cognitive control, more specifically inhibition. In this study, we combined an ultimatum game (UG) and a dictator game (DG) with inhibitory, continuous theta-burst stimulation (cTBS; verum vs. placebo, within-subjects design) of the right dorsolateral prefrontal cortex (DLPFC) to investigate the effect of reduced cognitive control on forgiveness. To this end, participants played an UG against fair and unfair opponents, where they had to accept or reject (fair and unfair) monetary offers, and then received a cTBS prior to playing a DG against the same opponents with reversed roles. The participants now had the possibility to forgive the unfair opponents (allocation of a fair amount of money) or to take revenge whereby the cTBS effects were assessed with functional near-infrared spectroscopy. Following verum cTBS, participants allocated significantly less money to their unfair opponents than in the placebo cTBS condition. Also, reaction times (RTs) differed significantly between verum and placebo cTBS for unfair opponents (higher RTs following verum stimulation) but not for fair opponents. These results strongly indicate that cognitive control is a fundamental requirement for overcoming unwanted emotional responses.

Endogenous oxytocin is associated with the experience of compassion and recalled upbringing in Borderline Personality Disorder.

BACKGROUND/OBJECTIVE: The role of the neuropeptide oxytocin (OT) in Borderline Personality Disorder (BPD) is poorly understood. It is particularly unknown how early experiences with caregivers moderate the action of OT in BPD. Here, we examined the association of plasma OT levels in BPD patients with the experience of compassion and recalled parental behavior during childhood. METHODS: Fifty-seven BPD patients and 43 healthy controls participated in the study. OT plasma levels were analyzed by radioimmunoassay. Subjects additionally completed questionnaires focusing on fears of compassion (FOC) and recalled upbringing ("Questionnaire of Recalled Parental Rearing Behavior/Fragebogen zum erinnerten elterlichen Erziehungsverhalten," FEE). RESULTS: BPD patients had significantly lower OT plasma levels than healthy controls and differed significantly on all FOC and FEE scales; BPD patients had higher FOC scores (indicating more aversion of being compassionate to themselves and others and receiving compassion from others). They also differed in recalled parenting. In the BPD group, scores of the FOC scale "fear of compassion from others" were significantly negatively correlated with OT levels. Moreover, recalled "emotional warmth" of their parents during childhood was positively correlated with OT plasma levels of BPD subjects. No such correlations were found in the control group. CONCLUSION: Our results corroborate findings from previous studies reporting lower OT levels in patients with BPD. Moreover, peripheral OT seems to be linked with the tolerance of compassionate feelings and early experiences with caregivers. This is consistent with other findings that OT is an important mediator of the experience of emotional warmth from others.

REVIEW: PSYCHOPATHOLOGIES IN CAPTIVE NONHUMAN PRIMATES AND APPROACHES TO DIAGNOSIS AND TREATMENT.

Despite the growing knowledge and literature on primate medicine, assessment and treatment of behavioral abnormalities in nonhuman primates (NHPs) is an underdeveloped field. There is ample evidence for similarity between humans and great apes, including basic neurologic physiology and emotional processes, and no substantial argument exists against a concept of continuity for abnormal conditions in NHPs that emerge in response to adverse experiences, akin to human psychopathology. NHPs have served as models for human psychopathologies for many decades, but the acquired knowledge has only hesitantly been applied to primates themselves. This review aims to raise awareness among the veterinary community of the wealth of literature on NHP psychopathologies in human medicine and anthropology literature and calls for the necessity to include mental health assessments and professionally structured treatment approaches in NHP medicine. Growing understanding about causes and pathogenesis of abnormal behavior in NHP will not only help to prevent the development of undesirable behaviors but also allow for treatment and management of long-lived, already affected animal patients.

Outcome-focused judgements of moral dilemmas in schizophrenia.

Previous research on moral judgement in healthy adults suggests a complex interplay of automatic, emotional and deliberative processing. We aimed to advance understanding of these processes by examining moral judgement in individuals with schizophrenia, a population characterised by social-cognitive deficits and interpersonal difficulties. Forty-five patients with schizophrenia and 27 healthy controls judged high-conflict moral dilemmas in response to 3rd-person (i.e. "Is it morally okay to [perform X]?") and 1st-person (i.e. "Would you [perform X]?") probes. Controls were less utilitarian for 3rd-person than 1st-person probes, while this discrepancy did not hold for patients. Utilitarianism in patients correlated with higher levels of interpersonal conflict. Findings suggest that people with schizophrenia focus equally on outcomes across moral-judgement conditions that ought normally to elicit an outcome-action discrepancy, suggesting that they are less influenced by an automatic aversive response to harmful acts in dilemma scenarios, consistent with a dual-process model of moral judgement.

Judgment of moral and social transgression in schizophrenia.

INTRODUCTION: Despite evidence of pervasive social-cognitive deficits in schizophrenia, little is known of moral cognition in this population. While recent research indicates that impairment of explicit moral reasoning is explained by these individuals' other cognitive deficits, their capacities for basic moral judgment are unknown. METHODS: 45 people with schizophrenia and 27 healthy controls completed the Moral-Conventional Distinction Task: a classic task that assesses judgment of violations of moral or social convention on permissibility, severity, and authority-contingence. Justifications of judgments were also probed. Basic cognition was indexed by measures of IQ, verbal memory, and information processing speed. Self-report inventories were used to assess different facets of 'empathy' (e.g., perspective-taking, or theory of mind, and empathic concern), and aggressive tendencies. RESULTS: Groups did not differ significantly in judgments of permissibility or authority-contingency, or justifications of judgments. Patients did, however, rate violations of social (but not moral) convention more harshly. They also took longer to judge impermissibility of moral (but nor social) transgressions. Slower moral judgment in patients was associated with lower levels of self-reported empathic concern, while harsher condemnation of social transgression was associated with poorer (self-reported) perspective-taking. CONCLUSIONS: Findings provide no evidence that moral judgment is fundamentally compromised in schizophrenia. Evidence of slower moral judgment in schizophrenia does suggest, however, that patients were less influenced by automatic aversive responses to amoral conduct. The association found between poorer (self-reported) perspective-taking and greater condemnation of social transgressions also suggests that an insensitivity to others' extenuating motives may exacerbate social misunderstandings in schizophrenia.

Impairments of spontaneous and deliberative mentalizing co-occur, yet dissociate, in schizophrenia.

OBJECTIVES: Evidence of impairment in explicit mentalizing in people with schizophrenia has inspired interventions to improve awareness of others' mental states in these individuals. Less is known of implicit mentalizing in schizophrenia, with current findings mixed. We sought to resolve previous inconsistencies using Heider & Simmel's (H&S) classic animation to elicit spontaneous mentalizing and examined relations between spontaneous and deliberative mentalizing. METHODS: Forty-five schizophrenia outpatients and 27 general-community controls completed two explicit theory-of-mind (TOM) tasks and then described the H&S animation (to elicit spontaneous social attributions about emotionally driven, as well as goal-driven, behaviours), before and after an instruction to think of the shapes as people. Accuracy of basic and social facts and frequencies of personification and different mental-state terms were recorded. RESULTS: Explicit TOM performance was impaired in patients. Patients also generated fewer social (but not basic) facts than controls to describe the H&S animation, and used less mental-state language, before, and even more so, after the 'people' instruction, despite that both groups had used more personification terms after the 'people' instruction. Measures of explicit and spontaneous mentalizing contributed independently to discriminating between groups. CONCLUSIONS: Patients respond less to the bottom-up signals of agency that ought normally to elicit spontaneous social attributions, even when cued to think of the stimuli as people, and the stimuli depict emotionally driven, as well as goal-driven, behaviour. That impairments of spontaneous and deliberative mentalizing dissociate in schizophrenia suggests that training deliberative mentalizing may not be enough; interventions to improve spontaneous mentalizing are also needed. PRACTITIONER POINTS: Findings People with schizophrenia were less likely than controls to spontaneously attribute causal mental states when viewing dynamic signals of emotionally driven and goal-driven behaviours. These impairments were even more pronounced when participants were instructed to think of the stimuli as people, suggesting that perceiving others in social roles does not prompt people with schizophrenia to anthropomorphize about others as agents motivated by their own inner worlds. Impairments of spontaneous mentalizing were found to co-occur independently with explicit mentalizing deficits in schizophrenia, consistent with the claim that humans can access two distinct systems for understanding others' minds. Findings suggest that interventions to improve conscious deliberative mentalizing in schizophrenia may not be enough; we also need to target implicit mentalizing processes. Limitations The patient sample was chronic and only mildly symptomatic. As such, findings cannot be generalized to other stages and phases of the illness. All patients were also medicated, allowing for the possibility that automatic responses to socially salient stimuli may have been pharmacologically attenuated. Future research may examine whether unmedicated young people at ultra-high risk of psychosis show a similar profile of mentalizing impairment. Future work may also examine whether impairments of deliberative and spontaneous mentalizing associate differentially with social functioning and different cognitive domains in schizophrenia.

Exploring the effectiveness of combined mentalization-based group therapy and dialectical behaviour therapy for inpatients with borderline personality disorder - A pilot study.

OBJECTIVES: Borderline personality disorder (BPD) is characterized by emotional instability, interpersonal dysfunction, and other features that typically develop before a background of insecure attachment and traumatic experiences. Dialectical behaviour therapy (DBT) has proven highly effective in reducing self-harm and improving emotion regulation, whereby problems concerning social cognition, which are also characteristic of BPD, may need additional approaches such as mentalization-based treatment (MBT). METHODS: Here, we examined, in a pilot study, the effectiveness of MBT given adjunct to DBT, compared to DBT alone, in an inpatient sample with BPD, whereby mentalization was measured using a novel cartoon-based task. RESULTS: Both treatments were highly effective in reducing symptom severity. The combination of DBT and MBT was superior in reducing fearful attachment and in improving affective mentalizing. CONCLUSIONS: Mentalization-based treatment in combination with DBT may improve certain aspects of social cognitive skills and attachment security, as compared to DBT alone, although the exact mechanisms that led to these changes need to be studied further. PRACTITIONER POINTS: Clinical implications Dialectical behaviour therapy (DBT) can usefully be combined with mentalization-based treatment (MBT). The combination of DBT and MBT reduces self-harm more than DBT alone. DBT plus MBT may lead to a reduction in fearful attachment and improvement of affective mentalizing. Short-term combinations of evidence-based borderline treatments may enrich psychiatric inpatient care. Therefore, such approaches deserve further research. Limitations The treatment condition was therapeutically more intense than the control condition. The study lacked a follow-up assessment. The impact of comorbid conditions on treatment response was not taken into account. Adherence to the manualized approach was not measured.