The Index Offence Representation Scales; a predictive clinical tool in the management of dangerous, violent patients with personality disorder?

Mentalizing mediates the association between emotional abuse in childhood and potential for aggression in non-clinical adults

BACKGROUND

Emotional abuse in childhood has been linked to a higher expression of aggressive behavior in adulthood. The identification of protective factors that mitigate this association is needed. Mentalizing-the capacity to understand behavior in terms of intentional mental states-appears to be a promising candidate factor that possibly modifies maladaptive consequences of early emotional abuse.

OBJECTIVE

This study investigated associations between the history of emotional abuse, aggressive behavior in adulthood and mentalizing capacities in a non-clinical sample of adults.

METHODS

214 healthy adults completed questionnaires measuring retrospectively rated experiences of emotional abuse in childhood, mentalizing capacities and aggressive behavior in a cross-sectional design.

RESULTS

Results indicated associations between emotional abuse in childhood, uncertainty about mental states, and aggressive behavior in adulthood. Moreover, certainty about mental states counteracted the negative effect of emotional abuse and partially mediated the associations between emotional abuse and aggressive behavior in adulthood.

CONCLUSION

This study extends current research and sheds further light on the relationship between emotional abuse in childhood, the health-promoting capacity of mentalizing, and aggressive behavior in non-clinical adults.

Mentalization for Offending Adult Males (MOAM): study protocol for a randomized controlled trial to evaluate mentalization-based treatment for antisocial personality disorder in male offenders on community probation

Background

Antisocial personality disorder (ASPD), although associated with very significant health and social burden, is an under-researched mental disorder for which clinically effective and cost-effective treatment methods are urgently needed. No intervention has been established for prevention or as the treatment of choice for this disorder. Mentalization-based treatment (MBT) is a psychotherapeutic treatment that has shown some promising preliminary results for reducing personality disorder symptomatology by specifically targeting the ability to recognize and understand the mental states of oneself and others, an ability that is compromised in people with ASPD. This paper describes the protocol of a multi-site RCT designed to test the effectiveness and cost-effectiveness of MBT for reducing aggression and alleviating the wider symptoms of ASPD in male offenders subject to probation supervision who fulfil diagnostic criteria for ASPD.

Methods

Three hundred and two participants recruited from a pool of offenders subject to statutory supervision by the National Probation Service at 13 sites across the UK will be randomized on a 1:1 basis to 12 months of probation plus MBT or standard probation as usual, with follow-up to 24 months post-randomization. The primary outcome is frequency of aggressive antisocial behaviour as assessed by the Overt Aggression Scale – Modified. Secondary outcomes include violence, offending rates, alcohol use, drug use, mental health status, quality of life, and total service use costs. Data will be gathered from police and criminal justice databases, NHS record linkage, and interviews and self-report measures administered to participants. Primary analysis will be on an intent-to-treat basis; per-protocol analysis will be undertaken as secondary analysis. The primary outcome will be analysed using hierarchical mixed-effects linear regression. Secondary outcomes will be analysed using mixed-effects linear regression, mixed-effects logistic regression, and mixed-effects Poisson models for secondary outcomes depending on whether the outcome is continuous, binary, or count data. A cost-effectiveness and cost-utility analysis will be undertaken.

Discussion

This definitive, national, multi-site trial is of sufficient size to evaluate MBT to inform policymakers, service commissioners, clinicians, and service users about its potential to treat offenders with ASPD and the likely impact on the population at risk.

Trial registration

ISRCTN 32309003. Registered on 8 April 2016.

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.