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

Bateman et al. BMC Psychiatry (2016) 16:304 DOI 10.1186/s12888-016-1000-9 RESEARCH ARTICLE Open Access A randomised controlled trial of mentalization-based treatment versus structured clinical management for patients with comorbid borderline personality disorder and antisocial personality disorder Anthony Bateman1,2, Jennifer O’Connell2,3, Nicolas Lorenzini2,3, Tessa Gardner2,3 and Peter Fonagy2,3* Abstract 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 Keywords: Borderline personality disorder, Antisocial personality disorder, Randomised controlled trial, Mentalizationbased treatment, Aggression, Anger, Treatment outcome Abbreviations: ASPD, Antisocial personality disorder; BDI, Beck Depression Inventory; BPD, Borderline personality disorder; BSI, Brief Symptom Inventory; GAF, Global Assessment of Functioning; GSI, Global Severity Index; HCR-20, Historical, Clinical, Risk Management-20; IIP, Inventory of Interpersonal Problems; MBT, Mentalization-Based Treatment; OAS-M, Overt Aggression Scale – Modified; RCT, Randomised controlled trial; SAS, Social Adjustment Scale; SCID, Structured Clinical Interview for DSM-IV; SCL-90-R, Symptom Checklist-90 – Revised; SCM, Structured Clinical Management; SF-36, Short Form Health Survey * Correspondence: 2 The Anna Freud Centre, London, UK 3 Research Department of Clinical, Educational and Health Psychology, University College London, London, UK Full list of author information is available at the end of the article © 2016 The Author(s). 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. Bateman et al. BMC Psychiatry (2016) 16:304 Background Borderline personality disorder (BPD) and antisocial personality disorder (ASPD) are both disorders with high levels of comorbid psychiatric illness. The most frequent comorbid psychiatric disorders in BPD are anxiety and affective disorders, with lifetime prevalence for these at approximately 85 %, followed by substance use disorders at approximately 79 % [1–4]. Co-existence of other psychiatric disorders in BPD has been reported as 41–83 % for major depression, 12–39 % for dysthymia [5], and 39 % for narcissistic personality disorder [6, 7]. Regarding antisocial personality disorder (ASPD), over 90 % of those with the condition have at least one other psychiatric disorder [8], at least 50 % have co-occurring anxiety disorders [9] and 25 % have a depressive disorder [10]. Notwithstanding the varying current views in relation to the classification of categories of personality disorder [11, 12], individuals who meet criteria for both ASPD and BPD can be considered as showing a particularly complex and severe form of personality disorder in so far as they are likely to present with particularly high levels of both DSM Axis I and Axis II comorbidity [13]. Amongst the general (UK) population, the prevalence of individuals meeting both BPD and ASPD diagnostic criteria is low (0.3 %) [14], but is increased in forensic samples with a higher degree of presumed dangerousness; it has been found to be significantly associated with a greater degree of violence [15, 16]. There is sufficient overlap between ASPD and BPD that considering them as separate disorder entities may seem unwarranted [11]. Yet, while future classifications may do away with the distinction [17], or at least substantially modify it (as implied by Section III of DSM-5), current nosology incorporates the difference notwithstanding similarities in symptomatology [18] and trait domains (namely, antagonism and disinhibition) [19]. In particular, crossover includes marked impulsivity and unpredictability, difficulties with emotional regulation and controlling anger, disregard for safety of self, and behaviour that can be considered by others to appear manipulative (for those with BPD, such behaviour is conducted with the intention of eliciting care and concern from others; for those with ASPD, such behaviour is conducted with the intention of gaining personal profit and power over others) [20–22]. Nonetheless, it is easy to see why the two disorders may be considered as distinctly different from each other. The key, frequentlynoted differences include the following: those diagnosed with ASPD tend to have an inflated self-image, whilst those diagnosed with BPD tend to have a negative and devalued self-image; those diagnosed with ASPD pose more of a risk to others due to their tendency towards interpersonal violence, whilst those diagnosed with BPD pose more of a risk to themselves due to their tendency Page 2 of 11 to self-damaging and self-destructive behaviours; those diagnosed with ASPD tend to lack empathy and be indifferent to or contemptuous of the feelings and sufferings of others, whilst (...truncated)