Adult antisocial syndrome co-morbid with borderline personality disorder is associated with severe conduct disorder, substance dependence and violent antisociality

Borderline personality disorder and aggressive behavior: A study based on the DSM-5 alternative model

INTRODUCTION

Unplanned reactive aggressive acts are a clinical feature of particular interest in patients with borderline personality disorder (BPD). The early identification of personality traits correlated to aggressive behavior is certainly desirable in BDP populations. This study analyzes a clinical sample of 122 adult outpatients with BPD referred to Adult Mental Health Services of the Department of Mental Health of Bologna, in Italy.

METHODS

The study examines the relationship with personality facets of the DSM-5 alternative model for personality disorders (AMPD), Personality Inventory for DSM (PID-5), with respect to the four main components of aggression measured by the Aggression Questionnaire (AQ): hostility, anger, verbal and physical aggression. Using robust regression models, the relationships between PID-5 facets and domains and the aggression components under consideration were identified.

RESULTS

Verbal and physical aggression in our sample of BPD outpatients is mainly associated to PID-5 antagonism domain. Physically aggressive behavior is also related to callousness facet.

CONCLUSIONS

The traits most consistently associated with aggression were the domain of Antagonism and the facet of Hostility. The study findings highlight the need for clinicians working with individuals with BPD to pay particular attention to traits of hostility, callousness, and hostility to understand aggression.

Proposed Specifiers for Conduct Disorder (PSCD) self-report: Factor structure and validation in a community sample of Belgian youth

The current study examined the psychometric properties of the Proposed Specifiers for Conduct Disorder (PSCD) in a sample of school-attending adolescent Belgian youth (N = 599; M age = 16.51 years, SD = 1.27). Given the recent interest in the PSCD-Short Version (PSCD-SV), this study focused on the 13-item variant of the PSCD. Study findings showed that the PSCD-SV had a hierarchical four-factor structure including the components of grandiose-manipulative (GM), callous-unemotional (CU), daring-impulsive (DI), and conduct disorder (CD). These interrelated factors were found to be internally consistent. The study also showed that the PSCD-SV total score was positively and significantly related to an alternate measure of psychopathy. Further, the study revealed the PSCD-SV was meaningfully related to the five-factor personality domains (i.e., extraversion, conscientiousness, agreeableness) as well as peer functioning and prosocial behavior. Bivariate correlations demonstrated that the dimensions differed in their associations with external correlates (e.g., peer functioning). Regression analyses showed that the GM, CU, and CD components of the PSCD-SV were uniquely associated to externalizing difficulties, whereas only the GM and CU components of the PSCD-SV were associated with low prosocial behaviors. These findings shed light on the conceptual and developmental models for the consideration of psychopathy and conduct problems. The use of the broader psychopathy condition as well as its underpinning dimensions may have important implications for assessment, treatment, and diagnostic manuals. The implications of the current study are further discussed.

Which Clinical and Demographic Factors are Related to Incarceration in Male Patients With Antisocial Personality Disorder?

Antisocial Personality Disorder (APD) is a condition largely represented in detention centers where can reach a prevalence of 60% in male prisoners. The objective of this study is to identify the clinical and demographic factors that differentiate subjects with APD and hosted in penitentiary with respect to those are treated in outpatient psychiatric clinics. We recruited 65 male patients affected by APD, whose 26 were followed up in community mental health services and 39 were serving their sentence in a detention center located in Monza. Socio-demographic and clinical data were obtained through a review of the clinical charts, and interviews with patients or their relatives (if available). We performed descriptive analyses on the total sample, then we compared the two groups identified by the type of setting (outpatient clinic vs. penitentiary) by independent sample t tests (quantitative variables) or χ2 tests (qualitative ones). For qualitative variables odds ratios (ORs) were also calculated. Outpatients with APD (with respect to those hosted in the detention center) resulted: to be older (p = .02), to be less likely married (p = .01), to have more pre-onset psychiatric comorbidity (p = .05), to have more pre-onset substance poly-misuse (p = .01), to have more previous psychiatric hospitalizations (p < .01), and to be less likely to have received lifetime psychotherapy (p < .01). Globally, the results of this study show how the presence of psychiatric comorbidity or substance abuse (with the probable access to psychiatric services) before the onset of APD prevents imprisonment. This aspect is even more surprising when we consider that the two groups of patients show no differences in the frequency of crimes. Future research will have to confirm if early mental health care can really limit the access to penitentiary of subjects affected by APD.

Neural correlates of aggression in personality disorders from the perspective of DSM-5 maladaptive traits: a systematic review

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published in 2013, includes an alternative model of personality disorders (AMPD) focusing on a maladaptive trait model utilized to diagnose several personality disorders. Borderline personality disorder (BPD) and antisocial personality disorder (ASPD) are two conditions categorized by AMPD that exhibit high rates of violence and aggression. Several of the traits outlined in the AMPD, including hostility, impulsivity, risk-taking, and callousness, have been previously linked to aggression in BPD and ASPD. However, to the best of our knowledge, there has never been a synthesis of neuroimaging studies that have investigated links between these traits and aggression in BPD and ASPD. To overcome this gap, we conducted a systematic review under the PRISMA framework to locate neuroimaging articles published since the release of AMPD linking trait anger/hostility, impulsivity, risk-taking, and callousness to aggression in BPD and ASPD. Key findings included the following: i) anger/hostility, associated with alterations in the interplay between prefrontal and subcortical regions (primarily the amygdala), may be a common factor explaining aggressive reactions to response to interpersonal threat or provocation; ii) alterations of fronto-temporal-limbic regions and serotonergic and endocannabinoid signaling systems may link impulsivity to aggression in BPD and ASPD; iii) weaker cortico-striatal connectivity could relate to greater risk taking and greater proclivity for violence. Insufficient evidence from neuroimaging articles was discerned to describe a relationship between callousness and aggression. Overall, results of this review reveal a relative paucity of neuroimaging studies examining AMPD traits relevant to aggression in BPD and ASPD. In addition to encouraging further investigation of neuroimaging markers of AMPD traits linked to aggression, we recommend multi-methodological designs, including the incorporation of other biomarkers, such as hormones and indices of physiological arousal, to fully expand our understanding of aggression in BPD and ASPD.

Just Like a Woman: Gender Role Stereotypes in Forensic Psychiatry

The relationship between violence, gender and mental health is a complex one which is yet to be fully understood. Gender role stereotypes are social constructs that can powerfully influence and regulate human behaviour, including violence; and so it is likely that they also influence the nexus of violence management and mental health which is at the core of forensic psychiatry. In this article, we examine how gender role stereotypes might influence the practice of forensic psychiatry: specifically, in relation to women as violent offenders, as patients in secure psychiatric care and as clinicians working in forensic settings. We identify areas of development in women's forensic mental health services, and examine whether patriarchal influences and gender role stereotypes may have inadvertently impacted upon these changes. We also consider whether these changes may maintain pre-existing barriers to treatment for both men and women.

The dual mediating roles of impulsivity and emotion regulation of the borderline personality disorder-violence relationship: A structural equation modeling approach

Although the past research has indicated that features of borderline personality disorder (BPD) increase the risk for violence, much less research has examined the mediators of this relationship. This study examined the mediating roles that impulsivity and emotion dysregulation may play in explaining the relationship between BPD and violence. The Pathways to Desistance data were used in analyses. Generalized structural equation modeling was used to estimate the direct effect of BPD features on violent offending risk and to examine the mediating roles of emotion dysregulation and impulsivity. Results indicated that the direct effect of BPD symptoms on violence was mediated to non-significance by key constructs, and the magnitude of the effect was reduced by around 40%. The total indirect effect was significant, and the mediation was attributed mainly to impulsivity. This indicates the importance of structuring treatment programming for BPD patients around impulsivity for reducing violence. Programming focused on improving impulsivity among individuals suffering from BPD may aid in reducing violent offending among this population, particularly those prior histories of involvement with the criminal justice system.

Substance use disorders and criminal justice contact among those with co-occurring antisocial and borderline personality disorders: Findings from a nationally representative sample

One variant of borderline personality disorder (BPD), frequently encountered in forensic and correctional samples, is the 'dissocial' subtype that combines borderline and antisocial traits. We tested the hypothesis that this subtype, defined by the co-occurrence of antisocial personality disorder (ASPD) and BPD (ASPD + BPD), would be associated with high rates of substance use disorder and contact with the criminal justice (CJ) system in a large nationally representative sample of North American adults (N = 36 309). Results suggested that the dissocial variant of BPD was associated with a high risk for substance use disorders and CJ contact. The odds of these outcomes were significantly raised about fivefold in ASPD + BPD individuals in comparison with those who lacked either an ASPD or BPD diagnosis. ASPD + BPD, compared with BPD alone, was also associated with significantly (p < 0.0001) greater severity of borderline symptoms. Although CJ contact appears to be strongly driven by ASPD, substance use, primarily driven by severity of borderline symptoms, added to the risk of CJ contact. It is suggested that, in the 11th Revision of the International Classification of Diseases terms, the dissocial borderline variant is a severe form of personality disorder characterized by high levels of traits within domains of negative emotionality and dissociality. Further studies will be required to verify this suggestion. © 2020 The Authors Personality and Mental Health Published by John Wiley & Sons Ltd.

Oxytocin receptor gene, childhood maltreatment and borderline personality disorder features among male inmates in China

BACKGROUND

Borderline personality disorder (BPD) is caused by a variety of biological and environmental factors. Accumulating evidence suggests that childhood maltreatment is a risk environmental factor in the development of BPD, but research on the genetic pathology of BPD is still in its early stages, and very little is known about the oxytocin receptor (OXTR) gene. The purpose of this study is to further explore the interactive effects between OXTR gene polymorphisms and childhood maltreatment on BPD risk.

METHODS

Among the 1804 Chinese Han male inmates, 765 inmates who had BPD or antisocial personality disorder (ASPD) or highly impulsive or violent crime were considered as high-risk inmates and included in this study. Childhood maltreatment, BPD, antisocial personality disorder (ASPD) and impulsivity were measured by self-reported questionnaires. Peripheral venous blood was collected for the genotype test.

RESULTS

Analyses revealed that the BP group (inmates with BPD features) had higher rs53576 AA genotype frequency and rs237987 AA genotype frequency than the non-BP group, while the statistical significances were lost after Bonferroni correction. Total childhood maltreatment score, emotional abuse and neglect could positively predict BPD risk. Among the high-risk samples, rs53576 GG genotype carriers had higher BPD scores at higher levels of physical abuse and sexual abuse and had lower BPD scores at lower levels of physical abuse and sexual abuse.

CONCLUSIONS

The findings suggest that the interaction between OXTR gene variations and childhood maltreatment is an important mechanism for the development of BPD. The moderating role of the OXTR gene provides evidence for gene plasticity.

Dialectical Behavior Therapy for Men With Borderline Personality Disorder and Antisocial Behavior: A Clinical Trial

In addition to suicidal behaviors, men with borderline personality disorder (BPD) often display antisocial behavior that could impair contacts with mental health services. While research has established effective treatments for women with BPD, this is not yet the case for men. The authors evaluated 12 months of dialectical behavior therapy (DBT) for 30 men with BPD and antisocial behavior, using a within-group design with repeated measurements. The authors found moderate to strong, statistically significant pre-to posttreatment reductions of several dysfunctional behaviors, including self-harm, verbal and physical aggression, and criminal offending (rate ratios 0.17-0.39). Symptoms of BPD and depression were also substantially decreased. The dropout rate was 30%, and completing participants reported high satisfaction with treatment and maintained their improvements at 1-year follow-up. The authors conclude that DBT could be an effective treatment alternative for men with BPD and antisocial behavior, and it merits future studies with more rigorous design.

Borderline personality disorder and violence

OBJECTIVE

This paper aims to provide a selective review of the co-occurrence of borderline personality disorder (BPD) and violence, a much less explored aspect of aggression with this cohort.

CONCLUSIONS

Violence in BPD patients is expressed particularly towards intimate partners and known persons, usually in the homes of perpetrators. Anger, impulsivity and avoiding abandonment are traits associated with violence while suicidal behaviour, identity disturbance and affective instability are not. These patients are disproportionately found in higher levels of secure care although most violence occurs in the community. In males it is more likely driven by substance use, often at transition from adolescence to adulthood, while more severe borderline pathology is implicated in women. Early identification of an at-risk cohort is recommended with development of collaborative safety plans with patients that include identification of a 'risk signature' that guides risk management. A multi-modal approach using risk management protocols with availability of contingency plans within a multi-agency forum in a local context is recommended.

Maladaptive Aggression: With a Focus on Impulsive Aggression in Children and Adolescents

Objective: Aggressive behavior is among the most common reasons for referral to psychiatric clinics and confers significant burden on individuals. Aggression remains poorly defined; there is currently no consensus on the best ways to recognize, diagnose, and treat aggression in clinical settings. In this review, we synthesize the available literature on aggression in children and adolescents and propose the concept of impulsive aggression (IA) as an important construct associated with diverse and enduring psychopathology. Methods: Articles were identified and screened from online repositories, including PubMed, PsychInfo, the Cochrane Database, EMBase, and relevant book chapters, using combinations of search terms such as "aggression," "aggressive behavio(u)r," "maladaptive aggression," "juvenile," and "developmental trajectory." These were evaluated for quality of research before being incorporated into the article. The final report references 142 sources, published from 1987 to 2019. Results: Aggression can be either adaptive or maladaptive in nature, and the latter may require psychosocial and biomedical interventions when it occurs in the context of central nervous system psychopathology. Aggression can be categorized into various subtypes, including reactive/proactive, overt/covert, relational, and IA. IA in psychiatric or neurological disorders is reviewed along with current treatments, and an algorithm for systematic evaluation of aggression in the clinical setting is proposed. Conclusions: IA is a treatable form of maladaptive aggression that is distinct from other aggression subtypes. It occurs across diverse psychiatric and neurological diagnoses and affects a substantial subpopulation. IA can serve as an important construct in clinical practice and has considerable potential to advance research.

The Development of the ICD-11 Classification of Personality Disorders: An Amalgam of Science, Pragmatism, and Politics

The nomenclature of personality disorders in the 11th revision of the International Classification of Diseases and Related Health Problems represents the most radical change in the classification history of personality disorders. A dimensional structure now replaces categorical description. It was argued by the Working Group that only a dimensional system was consistent with the empirical evidence and, in the spirit of clinical utility, the new system is based on two steps. The first step is to assign one of five levels of severity, and the second step is to assign up to five prominent domain traits. There was resistance to this structure from those who feel that categorical diagnosis, particularly of borderline personality disorder, should be retained. After lengthy discussion, described in detail here, there is now an option for a borderline pattern descriptor to be selected as a diagnostic option after severity has been determined.

The Violent Accounts of Men Diagnosed With Comorbid Antisocial and Borderline Personality Disorders

This study explored the violent offence accounts of life-sentenced prisoners diagnosed with comorbid antisocial personality disorder (ASPD) and borderline personality disorder (BPD). The aim of the current study was to gain needed clinical insight into the mechanisms involved in this specific group offenders' use of violence against others. Six adult male personality-disordered offenders were interviewed via a semistructured interview schedule to collate individual offence accounts. Interview transcripts were analyzed by the lead researcher (first author) using interpretative phenomenological analysis (IPA) who compared and contrasted findings to develop superordinate themes across the group. External auditing analysis was conducted by the second researcher. Four superordinate themes resulted. These were "A victim of a hostile and rejecting world," "Self as unacceptable to others," "Unwanted emotions that cannot be tolerated or controlled," and "Violent revenge as catharsis." The results support the view that emotional dysregulation is central in driving acts of violence in those with comorbid ASPD/BPD; nevertheless, shame was particularly prevalent. Thus an argument is made for the adaptation of evidence-based treatments for this specific forensic population to ensure a particular focus on helping men tolerate feelings of shame. The limitations of the study are also discussed.

Distinct pathological profiles of inmates showcasing cluster B personality traits, mental disorders and substance use regarding violent behaviors

High rates of violence are found amid offenders with severe mental illnesses (SMI), substance use disorders (SUDs) and Cluster B personality disorders. Elevated rates of comorbidity lead to inconsistencies when it comes to this relationship. Furthermore, overlapping Cluster B personality traits have been associated with violence. Using multiple correspondence analysis and cluster analysis, this study was designed to differentiate profiles of 728 male inmates from penitentiary and psychiatric settings marked by personality traits, SMI and SUDs following different violent patterns. Six significantly differing clusters emerged. Cluster 1, "Sensation seekers", presented recklessness with SUDs and low prevalence's of SMI and auto-aggression. Two clusters committed more sexual offenses. While Cluster 2, "Opportunistic-sexual offenders", had more antisocial lifestyles and SUDs, Cluster 6, "Emotional-sexual offenders", displayed more emotional disturbances with SMI and violence. Clusters 3 and 4, representing "Life-course-persistent offenders", shared early signs of persistent antisocial conduct and severe violence. Cluster 3, "Early-onset violent delinquents", emerged as more severely antisocial with SUDs. Cluster 4, "Early-onset unstable-mentally ill delinquents", were more emotionally driven, with SMI and auto-aggression. Cluster 5, "Late-start offenders", was less severely violent, and emotionally driven with antisocial behavior beginning later. This study suggests the presence of specific psychopathological organizations in violent inmates.

Prevalence Rates of Personality Disorder and Its Association With Methamphetamine Dependence in Compulsory Treatment Facilities in China

Methamphetamine use is popular and rapidly increasing in China, and the co-occurrence of personality disorders has an impact on treatment outcomes and may increase vulnerability of developing dependence. The aim of the present study was to investigate the prevalence rates of personality disorders in methamphetamine users and further explore the association between personality disorders and methamphetamine use status. Five hundred and seventy-seven male methamphetamine users were recruited. The self-developed questionnaire was used for demographics, and a Structural Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) (SCID-I/II) was performed covering psychiatric diagnosis. Our study found the prevalence of antisocial personality disorder in male methamphetamine users was 71.4%, followed by borderline (20.2%) and obsessive-compulsive (17.9%) personality disorder. Borderline and antisocial personality disorders were found to be risk factors of methamphetamine dependence (adjusted odds ratio = 2.891, p = 0.007 and adjusted odds ratio = 1.680, p = 0.042). These findings suggested personality disorders were highly prevalent in male methamphetamine users, and the comorbidity of antisocial and borderline personality disorders are especially associated with methamphetamine dependence.

A cross-national comparison of violence among young men in China and the UK: psychiatric and cultural explanations

PURPOSE

Public health psychiatry has a key role in violence prevention. Cross-national comparisons of violence and associated psychiatric morbidity can indicate targets for preventive interventions.

METHOD

Data on young adult men in households, 18-34 years, were drawn from the Second Men's Modern Lifestyles survey in Great Britain (n = 2046) and from a corresponding survey in Chengdu, China (n = 4132), using a translated questionnaire. Binary logistic regression models were carried out to estimate the cross-national differences for different types of violence and to identify explanatory variables.

RESULTS

Chinese men were less likely to report violence in the past 5 years (AOR 0.59, 95% CI 0.48-0.72, P < 0.001). All levels of violence were lower among Chinese men except intimate partner violence (AOR 2.43, 95% CI 1.65-3.59, P < 0.001) and a higher proportion of Chinese men were only violent towards their partners (AOR 7.90, 95% CI 3.27-19.07, P < 0.001).

CONCLUSIONS

Cross-national differences were explained by British men's reports of early violence persisting into adulthood, confidence in fighting ability, perception that violence is acceptable behaviour, and experience of violent victimization. More British men screened positive for antisocial personality disorder and substance misuse. Attitudes which condone violence and a serious problem of alcohol-related, male-on-male violence are key targets for preventive interventions among British men. The higher prevalence of life course-persistent antisocial behaviour among British men is of concern and requires further investigation. Higher prevalence of intimate partner violence among Chinese men reflects patriarchal approaches to conflict resolution and confirms an important public health problem in China which requires further cross-national investigation.

A prospective, longitudinal, study of men with borderline personality disorder with and without comorbid antisocial personality disorder

BACKGROUND

Some evidence suggests that the prevalence of Borderline Personality Disorder (BPD) is elevated among male criminal offenders. It is not presently known whether offending, and violent offending, are limited to those presenting comorbid Antisocial Personality Disorder (ASPD) who have a childhood history of conduct problems and whether offending is linked to psychopathic traits.

METHODS

A community sample of 311 males followed from age 6 to 33 years, one third of whom had a criminal charge between ages 18 and 24, completed diagnostic interviews and the Psychopathy Checklist-Revised interview. Information on childhood included parent-reported family characteristics and teacher-rated of hurtful and uncaring behaviours, conduct problems, hyperactivity and inattention, and anxiety at age 6, 10, and 12 years. Health files were obtained as were records of criminal convictions from age 12 to 33.

RESULTS

At age 33, 4% of the men presented BPD and not ASPD, 16% ASPD and not BPD, 8% BPD + ASPD, and 72% neither disorder (ND). Comorbid disorders were common: BPD were distinguished by high levels of anxiety disorders, BPD and BPD + ASPD by depression disorders, and BPD, BPD + ASPD, and ASPD by substance dependence. Official files indicated use of health services by all participants. One-third of participants with BPD and BPD + ASPD acquired a diagnosis of a personality disorder. More than one-third of participants with BPD + ASPD obtained scores indicative of the syndrome of psychopathy. Convictions for violent crimes varied across groups: In adolescence, BPD none, BPD + ASPD 16%, ASPD 16%, and ND 3.6%; from age 18 to 33, BPD 18%, ASPD 19%, BPD + ASPD 52%, and ND 4.4%. Offenders with BPD + ASPD were convicted, on average, for four times more violent crimes than offenders with ASPD and seven times more than ND offenders. In childhood, men with BPD + ASPD and with ASPD had obtained similarly elevated ratings for disruptive behaviours as compared to ND.

CONCLUSION

BPD comorbid with ASPD was associated with violent criminal offending in adolescence and most strongly in adulthood, elevated levels of psychopathic traits, and childhood disruptive behaviour. BPD showed similar characteristics but to a much less degree.

Using the Personality Assessment Inventory Antisocial and Borderline Features Scales to Predict Behavior Change: A Multisite Longitudinal Study of Youthful Offenders

A substantial amount of research has examined the developmental trajectory of antisocial behavior and, in particular, the relationship between antisocial behavior and maladaptive personality traits. However, research typically has not controlled for previous behavior (e.g., past violence) when examining the utility of personality measures, such as self-report scales of antisocial and borderline traits, in predicting future behavior (e.g., subsequent violence). Examination of the potential interactive effects of measures of both antisocial and borderline traits also is relatively rare in longitudinal research predicting adverse outcomes. The current study utilizes a large sample of youthful offenders ( N = 1,354) from the Pathways to Desistance project to examine the separate effects of the Personality Assessment Inventory Antisocial Features (ANT) and Borderline Features (BOR) scales in predicting future offending behavior as well as trends in other negative outcomes (e.g., substance abuse, violence, employment difficulties) over a 1-year follow-up period. In addition, an ANT × BOR interaction term was created to explore the predictive effects of secondary psychopathy. ANT and BOR both explained unique variance in the prediction of various negative outcomes even after controlling for past indicators of those same behaviors during the preceding year.

Improving risk management for violence in mental health services: a multimethods approach

Background

Mental health professionals increasingly carry out risk assessments to prevent future violence by their patients. However, there are problems with accuracy and these assessments do not always translate into successful risk management.

Objectives

Our aim was to improve the accuracy of assessment and identify risk factors that are causal to be targeted by clinicians to ensure good risk management. Our objectives were to investigate key risks at the population level, construct new static and dynamic instruments, test validity and construct new models of risk management using Bayesian networks.

Methods and results

We utilised existing data sets from two national and commissioned a survey to identify risk factors at the population level. We confirmed that certain mental health factors previously thought to convey risk were important in future assessments and excluded others from subsequent parts of the study. Using a first-episode psychosis cohort, we constructed a risk assessment instrument for men and women and showed important sex differences in pathways to violence. We included a 1-year follow-up of patients discharged from medium secure services and validated a previously developed risk assessment guide, the Medium Security Recidivism Assessment Guide (MSRAG). We found that it is essential to combine ratings from static instruments such as the MSRAG with dynamic risk factors. Static levels of risk have important modifying effects on dynamic risk factors for their effects on violence and we further demonstrated this using a sample of released prisoners to construct risk assessment instruments for violence, robbery, drugs and acquisitive convictions. We constructed a preliminary instrument including dynamic risk measures and validated this in a second large data set of released prisoners. Finally, we incorporated findings from the follow-up of psychiatric patients discharged from medium secure services and two samples of released prisoners to construct Bayesian models to guide clinicians in risk management.

Conclusions

Risk factors for violence identified at the population level, including paranoid delusions and anxiety disorder, should be integrated in risk assessments together with established high-risk psychiatric morbidity such as substance misuse and antisocial personality disorder. The incorporation of dynamic factors resulted in improved accuracy, especially when combined in assessments using actuarial measures to obtain levels of risk using static factors. It is important to continue developing dynamic risk and protective measures with the aim of identifying factors that are causally related to violence. Only causal factors should be targeted in violence prevention interventions. Bayesian networks show considerable promise in developing software for clinicians to identify targets for intervention in the field. The Bayesian models developed in this programme are at the prototypical stage and require further programmer development into applications for use on tablets. These should be further tested in the field and then compared with structured professional judgement in a randomised controlled trial in terms of their effectiveness in preventing future violence.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

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.

Empathy Impairments in Intimate Partner Violence Perpetrators With Antisocial and Borderline Traits: A Key Factor in the Risk of Recidivism

Antisocial, borderline, and narcissistic personality traits have been described as characteristics of intimate partner violence (IPV) perpetrators. Furthermore, deficits in cognitive empathy and impairments in emotional decoding processes may at least partially explain conduct disorders and social dysfunction in general. However, previous research has not explored potential associations between empathy deficits and the aforementioned traits or whether they are reflected in recidivism in IPV perpetrators. Accordingly, the main aim of this study was to explore associations between empathy deficits, antisocial, borderline, and narcissistic traits and the risk of recidivism in this population. The sample consisted of 144 IPV perpetrators (mean age = 41 years). High antisocial and borderline personality traits in this sample were associated with a high risk of recidivism, these relationships being moderated by poor empathy skills. Moreover, in IPV perpetrators with both antisocial and borderline personality traits, the risk of recidivism was higher than in those with only one of these traits. In contrast, narcissistic traits were unrelated to the risk of recidivism and impairments in empathy. The results of our study highlight the importance of empathy deficits and may help professionals to develop specific intervention programs focusing on improving empathy skills in antisocial and borderline IPV perpetrators.

Possible role of a dysregulation of the endogenous opioid system in antisocial personality disorder

Around half the inmates in prison institutions have antisocial personality disorder (ASPD). A recent theory has proposed that a dysfunction of the endogenous opioid system (EOS) underlies the neurobiology of borderline personality disorder (BPD). In the present theoretical paper, based on a comprehensive database and hand search of the relevant literature, this hypothesis is extended to ASPD, which may be the predominant expression of EOS dysfunction in men, while the same pathology underlies BPD in women. According to evidence from human and animal studies, the problematic behaviours of persons with antisocial, callous, or psychopathic traits may be seen as desperate, unconscious attempts to stimulate their deficient EOS, which plays a key role in brain reward circuits. If the needs of this system are not being met, the affected persons experience dysphoric mood, discomfort, or irritability, and strive to increase binding of endogenous opioids to receptors by using the rewarding effects of aggression by exertion of physical or manipulative power on others, by abusing alcohol or substances that have the reward system as target, by creating an "endorphin rush" by self-harm, by increasing the frequency of their sexual contacts, or by impulsive actions and sensation seeking. Symptoms associated with ASPD can be treated with opioid antagonists like naltrexone, naloxone, or nalmefene.

Borderline personality disorder: Prevalence and psychiatric comorbidity among male offenders on probation in Sweden

INTRODUCTION

Borderline personality disorder (BPD) is a severely disabling condition, associated with substantially increased risk of deliberate self-harm and, particularly in men, also with interpersonal violence and other criminal behavior. Although BPD might be common among prison inmates, little is known about prevalence and psychiatric comorbidity in probationers and parolees.

METHOD

In 2013, a consecutive sample of 109 newly admitted adult male offenders on probation or parole in all three probation offices of Stockholm, Sweden, completed self-report screening questionnaires for BPD and other psychiatric morbidity. Participants scoring over BPD cut-off participated in a psychiatric diagnostic interview.

RESULTS

We ascertained a final DSM-5 BPD prevalence rate of 19.8% (95% CI: 12.3-27.3%). The most common current comorbid disorders among subjects with BPD were antisocial personality disorder (91%), major depressive disorder (82%), substance dependence (73%), attention deficit hyperactivity disorder (ADHD) (70%), and alcohol dependence (64%). Individuals diagnosed with BPD had significantly more current psychiatric comorbidity (M=6.2 disorders) than interviewed participants not fulfilling BPD criteria (M=3.6). Participants with BPD also reported substantially more symptoms of ADHD, anxiety and depression compared to all subjects without BPD.

CONCLUSIONS

BPD affected one fifth of probationers and was related to serious mental ill-health known to affect recidivism risk. The findings suggest further study of possible benefits of improved identification and treatment of BPD in offender populations.

Personality disorders and violence: what is the link?

Despite a well-documented association between personality disorders (PDs) and violence, the relationship between them is complicated by the high comorbidity of mental disorders, the heterogeneity of violence (particularly in regard to its motivation), and differing views regarding the way PDs are conceptualised and measured. In particular, it remains unclear whether there is a causal relationship between PDs and violence, and what the psychological mechanisms might be that mediate such a relationship. Here, a perspective on PD and violence is offered that views the relationship between them through the lenses of the Five Factor Model of personality and a quadripartite typology of violence. Evidence is reviewed suggesting that emotion dysregulation/impulsiveness, psychopathy, and delusional ideation conjointly contribute to the increased risk of violence shown by people with PD, and do so by contributing to a broad severity dimension of personality dysfunction. This view is consistent with the abandonment of personality disorder categories in the forthcoming eleventh edition of the International Classification of Diseases (ICD-11), where severity of personality disorder is defined in terms of the degree of harm to self and others.

Behavioural stimulation and sensation-seeking among prisoners: applications to substance dependency

BACKGROUND

Sensation-seeking among prisoners with substance dependence difficulties (drug and/or alcohol) was examined. This topic is under-researched in a prisoner sample.

AIMS

The aims are to examine the association between sensation-seeking, other personality variables, and substance dependency among prisoners, and to examine if sensation-seeking can be refined.

METHODS

Adult male prisoners (n=200) completed self-report measures examining the constructs of interest.

RESULTS

Sensation-seeking comprised extraversion and openness to experience. It was more appropriately described as Behavioural-Stimulation-and-Sensation-Seeking (BStim-SS). BStim-SS is related to drug and poly-substance dependency but not alcohol-only dependency. Increased impulsivity was related to all substance use dependencies.

CONCLUSIONS AND IMPLICATIONS FOR PRACTISE

BStim-SS presents as a valuable concept to apply to forensic populations. It captures the need for behavioural and emotional stimulation and lends support to Reward Discounting theory as valuable concept to apply across substance dependency. Implications for practise include: • A need to identify a broader concept of sensation-seeking for prisoner samples; • The recognition of differences within substance dependent samples, with impulsivity presenting differently across drug and/or alcohol dependent groups; • Recognition that concepts regularly applied to community samples need to be examined more specifically among forensic samples to ascertain validity.

A new look at borderline personality disorder and related disorders: hyper-reactivity in the limbic system and lower centers

Borderline Personality Disorder (BPD) has been often described recently as a condition characterized by emotional dysregulation. Several other conditions share this attribute; namely, Bipolar Disorder (BD), Attention-Deficit/Hyperactivity Disorder (ADHD), Intermittent Explosive Disorder (IED), and Major Depressive Disorder (MDD). The dysregulation is not always in the same direction: BPD, BD, ADHD, and IED, for example, show over-reactivity or "hyperactivity" of emotional responses, whereas patients with MDD show emotional sluggishness and underactivity. At the clinical/descriptive level the "over-reactive" conditions appear separate and distinct. BPD constitutes a large domain within the psychopathological arena, appearing to contain within it a variety of etiologically diverse subtypes. Among the latter is a type of BPD linked closely with Bipolar Disorder; family studies of either condition show an overrepresentation of both: BPD patients with bipolar relatives; Bipolar patients with BPD relatives. A significant percentage of children with ADHD go on to develop either BPD or BD as they approach adulthood. If one shifts the spotlight to neurophysiology, as captured by MRI studies, however, it emerges that an important subtype of BPD, and also BD, ADHD, and IED-share common features of abnormalities and peculiarities in the limbic system and in the cortex, especially the prefrontal cortex. Deeper subcortical regions such as the periaqueductal gray may also be implicated in strong emotional reactions. The diversity of clinical "over-reactive" conditions appear to harken back to a kind of unity at the brain-change level. There are therapeutic implications here, such as the advisability of mood stabilizers in many cases of BPD, not just for Bipolar Disorder.