Symptom, alexithymia and self-image outcomes of Mentalisation-based treatment for borderline personality disorder: a naturalistic study

Löf et al. BMC Psychiatry (2018) 18:185 https://doi.org/10.1186/s12888-018-1699-6 RESEARCH ARTICLE Open Access Symptom, alexithymia and self-image outcomes of Mentalisation-based treatment for borderline personality disorder: a naturalistic study J. Löf1, D. Clinton2,3* , V. Kaldo4 and G. Rydén5 Abstract Background: Mentalisation-based treatment (MBT) in borderline personality disorder (BPD) has a growing evidence base, but there is a lack of effectiveness and moderator studies. The present study examined the effectiveness of MBT in a naturalistic setting and explored psychiatric and psychological moderators of outcome. Method: Borderline and general psychiatric symptoms, suicidality, self-harm, alexithymia and self-image were measured in a group of BPD patients (n = 75) receiving MBT; assessments were made at baseline, and subsequently after 6, 12 and 18 months (when treatment ended). Borderline symptoms were the primary outcome variable. Results: Borderline symptoms improved significantly (d = 0.79, p < .001), as did general psychiatric symptoms, suicidality, self-harm, self-rated alexithymia and self-image. BPD severity or psychological moderators had no effect on outcome. Younger patients improved more on self-harm, although this could be explained by the fact that older patients had considerably lower baseline self-harm. Conclusions: MBT seems to be an effective treatment in a naturalistic setting for BPD patients. This study is one of the first studies of MBT showing that outcomes related to mentalisation, self-image and self-rated alexithymia improved. Initial symptom severity did not influence results indicating that MBT treatment is well adapted to patients with severe BPD symptoms. Trial registration: The study was retrospectively registered 25 September 2017 in the ClinicalTrials.gov PRS registry, no. NCT03295838. Keywords: Borderline personality disorder, Psychotherapy, Treatment outcome, Pragmatic clinical trials as topic, Mentalization-based treatment, Alexithymia Background Mentalisation-based treatment (MBT) [1, 2] posits that insecure attachment impairs the ability to reflect on one’s own and other’s inner mental states, especially in affectively stressful states, and that deficits in the ability to mentalise are conducive of psychopathology [3, 4]. Treatment is relational and focuses on better understanding and use of mentalising skills in order to promote affect tolerance and * Correspondence: 2 Center for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Norra stationsgatan 69, 7 tr, 113 64 Stockholm, Sweden 3 Institute for Eating Disorders, Oslo, Norway Full list of author information is available at the end of the article the ability to think flexibly while experiencing intense affect, rather than using self-harm or other kinds of impulsive behaviour to regulate affect states. The efficacy of MBT in the treatment of borderline personality disorder (BPD) has been demonstrated in three randomised controlled trials (RCTs) [1, 2, 5]. Two long-term follow-up studies suggest that the effects of MBT are lasting [6, 7], and improved mentalising has been shown in two studies with adolescents with borderline problems [5, 8], but so far not in relation to adult patients. Although these studies provide important evidence concerning the therapeutic potential of MBT, a number of important problems remain. Few studies have been © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Löf et al. BMC Psychiatry (2018) 18:185 conducted outside the UK, where MBT was developed. What’s more, efficacy studies have for the most part been carried out by the researchers who designed and developed MBT, which leaves these studies open to criticisms of bias and allegiance effects. A randomised controlled trial in Denmark carried out by an independent group of researchers [9] compared MBT with supportive psychodynamic group psychotherapy at the end of treatment 2 years after intake. Both treatment arms showed significant improvements, but MBT was superior to the control treatment only in regard to patients’ general assessment of functioning (GAF). However, GAF ratings were made by therapists who were not blind to treatment arm, which could have compromised validity. There was also a skewed allocation to treatment conditions in the Danish study and a general lack of adherence to the MBT treatment manual, along with a lack of expert supervision in MBT. There has been a lack of naturalistic studies examining the effectiveness of MBT as it is implemented in community-based psychiatric settings, which also limits the evidence base. Although two studies have employed naturalistic designs and demonstrated good effectiveness of MBT on BPD symptoms and functioning [10, 11] they were not community-based. Moreover, in one of these studies [11] it is not clear how BPD diagnosis was established, nor whether diagnoses were valid and reliable since no information was provided on possible exclusion criteria. Bateman and Fonagy have performed further analyses of their own data and found that comorbidity of BPD with other personality disorders is a factor necessitating MBT rather than supportive treatment [12]. Their study raises the question of systematic treatment selection, which in a recent study has been shown to be effective for psychodynamic therapy (PDT) [13]. Systematic treatment selection would allow for the identification of lower mentalisation abilities, as well as more personality and interpersonal problems, indicating a need for mentalisation-based interventions. In particular, hypermentalising, negatively biased overinterpretation of interpersonal situations, has been shown to be connected to the severity of borderline problems and may possibly mediate change in MBT [14, 15]. Alexithymia has been shown to be highly related to BPD [16, 17]. The concept can be defined as difficulties in identifying and distinguishing feelings from bodily sensations and problems in expressing these feelings to others. It is considered to be an aspect of affective mentalisation (i.e. of the self ) [18]. Negative self-image has been shown to moderate change in PDT in that baseline severity is related to greater symptom reduction [19]. In line with this result and the theory behind the treatment, it is possible that low mentalisation ability could be related to Page 2 of 9 suitability for MBT. Evidence was, however, (...truncated)