Languages
Pages
Legal
Personality Disorder, Mentalizing, and Psychotherapy
Prof Anthony BatemanJyvaskyla University Psychotherapy Conference 2020
Summary
n Personality disorder is being ‘refined’n Why are so many treatments effective and
what do they have in common?n Treatments are not tailored for main
challenges of personality disordern Can we add perspective to personality
disorder – a disorder of social interaction and communication
n What are the implications for further treatment to improve outcomes?
What is happening to treatment for personality disorder?
General Psychiatric Management and Dialectical Behaviour Therapyn GPM and DBT showed equivalence in outcomes on all
measuresn No differences over follow-upMcMain S, Links P, Gnam W, Guimond T, Cardish R, Korman L, et al. A randomized controlled trial of dialectical behaviour therapy versus general psychiatric management for borderline personality disorder. American Journal of Psychiatry. 2009;166:1365-74McMain S, Guimond T, Cardish R, Streiner D, Links P. Clinical outcomes and functioning post-treatment: A two-year follow-up of dialectical behavior therapy versus general psychiatric management for borderline personality disorder. American Journal of Psychiatry. 2012;169:650-61
Global Function
n 53% were neither employed nor in school, and 39% were receiving psychiatric disability support after 36 months
n EuroQol scores remained below normal and in a range comparable to patients with comorbid major depression and anxiety disorders
High Risk Suicidal Behavior in Veterans-Assessment of Predictors and Efficacy of Dialectical Behavioral TherapyGoodman et al (2014)
n Randomized controlled trial (RCT), of standard DBT (weekly individual sessions, skills training group and telephone coaching as needed) compared to TAU in 120 veterans recently discharged from an acute psychiatric inpatient stay with high risk suicidal behavior.
n The primary treatment outcome - quantification of suicidal events, as assessed by the Columbia Suicide Severity Rating Scale
n Secondary outcomes include suicidal ideation, parasuicidalevents, treatment compliance, depressed mood, substance abuse and hopelessness.
n Both groups will continue to receive standard psychopharmacology and case management services from their clinic providers. Subjects will receive a battery of assessments at month 6, 12 and 18.
Global Assessment of FunctioningClarkin JF, Levy KN, Lenzenweger MF, Kernberg O. Evaluating three treatments for borderline personality disorder. American Journal of Psychiatry. 2007;164:922-8
0
10
20
30
40
50
60
Baseline 12-month
TFPDBTSPT
Therapist profession and trainingn 7 nurses (MBT-OP = 4, SCM-OP = 3)n 3 trainee psychiatrists (MBT-OP = 2, SCM-OP = 1)n 1 accredited counselor (MBT-OP = 0, SCM-OP = 1).n MBT-OP therapists completed a 3-day basic and a 2-day
advanced training course in MBT. Supervision was offered on a weekly basis for 1 hour to all therapists as a peer group
n SCM-OP therapists attended 3 days of training on personality disorder discussing the nature of personality disorder, the common problems encountered in treatment and a focus on the SCM-OP protocol. Supervision was offered on a weekly basis for 1 hour by a senior clinician experienced in the general management of BPD.
Percent of who seriously self harmed
0
20
40
60
80Pe
rcen
t Who
Sel
f-Har
m
Baseline Six Months Twelve Months EighteenMonths
SCM MBTn.s.
p <.08p<.05
p<.05
OR for combined group: 0.49 (.35, .69) , Coefficient for group difference: 0.39 (.23, .66) (At 18 months χ2 =4.6, p<.05, RR=0.55, 95% CI: 0.33, 0.92)
Outcome of mentalization-based and supportive psychotherapy in patients with borderline personality disorder: a randomized trial.C. R. Jørgensen C. Freund, R. Bøye, et al Acta Psychiatrica Scandinavica 1-13 (2012).
Cristea et al: Therapy subgroup analysisJAMA Psychiatry. doi:10.1001/jamapsychiatry.2016.4287Published online March 1, 2017.
Treatment Trials (n) Hedges g NNT P Value
DBT 9 0.34 (0.15-0.53) 5.26
.87Psychodynamic 7 0.41 (0.12-0.69) 4.39
CBT 5 0.24 (-0.01-0.49 7.46
Other 6 0.38 (-0.15-0.92 4.72
Evidence based or promising treatments
DBTTFPMBTCATSTEPPSSFT
MBTDBT TFP
SFT
CAT
Research Question
Who specifically benefits from which treatment?
Who needs specialist treatment?
Who specifically benefits from
MBT-BPD?
Coefficient of difference between slopes=-.14 (-.21, -0.08), p<.000
Nineteen patients were not free of self-harm, suicide or hospitalization after 18-months of MBT. Who were they?
0 10 20 30 40 50 60 70 80 90
Eating Disorder (p<.03)
Narcissistic Personality
Disorder (p<.04)
Antisocial Problems (p<.03)
On Benefit (p<.05)
Per
cent
No clinical change Significant change
Which, if any, do you think moderates outcome?
Predictive Recovery by Axis II Pathology
-.20
.2.4
.6.8
Line
ar P
redi
ctio
n of
Rec
over
y
Baseline 6 months 12 months 18 monthsAssessment Periods
SCM MBT
One Axis II Diagnosis
-.20
.2.4
.6.8
Line
ar P
redi
ctio
n of
Rec
over
y
Baseline 6 months 12 months 18 monthsAssessment Periods
SCM MBT
Two Axis II Diagnoses
-.20
.2.4
.6.8
Line
ar P
redi
ctio
n of
Rec
over
y
Baseline 6 months 12 months 18 monthsAssessment Periods
SCM MBT
Three Axis II Diagnoses
-.20
.2.4
.6.8
Line
ar P
redi
ctio
n of
Rec
over
yBaseline 6 months 12 months 18 months
Assessment Periods
SCM MBT
Four Axis II Diagnoses
But what about the long-term outcomes?
Remissions and Recurrences Among 275 Patients with BPD
0102030405060708090
2-Years 4-Years 6-Years (10-16Years)
Remission RecurrancePe
rcen
t
Source: Zanarini et al.
Percent of sample employed or in education during study period
0.0
20.0
40.0
60.0
80.0
100.0
Year
pio
r to
rand
omiz
atio
n
PH-tr
eatm
ent
Follo
w-u
ptre
atm
ent
To 1
8 m
onth
spo
st-
disc
harg
e
19-3
6 m
onth
spo
st d
isch
arge
37-6
0 m
onth
spo
st d
isch
arge
Perc
ent e
mpl
oyed
or i
n ed
ucat
ion
MBT-PHTAU
a a c
Other treatments
n DBTØ18 year cohort follow up in Germany. Low life satisfaction and
poor global function (Zeitler et al 2018)n CBT
Ø6 year follow-up that only one fifth of patients had showed improvement in affective disturbance and their quality of life remained poor (Davidson)
Differential improvement rates of BPD symptom clusters
n Impulsivity and associated self mutilation and suicidality that show dramatic change § The dramatic symptoms (self mutilation, suicidality,
quasi-psychotic thoughts) recede (? respond to treatment)
n Deficits of social and interpersonal function are likely to remain present in at least half the patients.
Meta analysis of long term follow-upAlvarez-Tomas (2018) Long-term clinical and functional course of borderline personality disorder: A meta-analysis of prospective studies European Psychiatry
n Meta-analysis suggests individuals with BPD do not reach normative functional adjustment in the long-term
n Research indicates that a relevant proportion may suffer from persistent impairments over timeØLower age better remission overallØLength of illness with greater functional impairment
over timeØSex – female less likely to be associated with
improved functioning
Conclusionsn Differences in outcomes between
treatments are small and likely to be non-existent in general treatment services
n We do not know who benefits from which treatment preferentially
n Outcomes are good in terms of impulsivity and symptoms
n Long term outcomes particularly in social and interpersonal functioning show persistent impairment
Can we do better than agreeing with the Do Do Bird?
“Everybody has won, and all must have prizes.”
What do treatments have in common?
Common factors in successful treatment of BPD
§ Extensive effort to maintain engagement in treatment (validation in conjunction with emphasis on the need to address behaviors that interfere with therapy)
§ Valid (evidence-based) model of pathology that is explained and feels relevant to the patient
§ Active therapist stance—that is, an explicit intent to validate and demonstrate empathy and generate a strong attachment relationship
§ Reinforcement of epistemic trust (Sperber et al., 2010)—that is, facilitating a belief in the possibility that something can be learned in therapy
Common factors in successful treatment of BPD
§ Focus on emotion processing and the connection between action and feeling (e.g., suicidal ideation is associated with abandonment feelings)
§ Inquiry into patients’ mental states (behavioral analysis, clarification, confrontation)
§ Enccourage activity, proactivity, and self-agency (that is, the therapist avoids the expert stance and rather “sits side by side” with the adolescent in a partnership)
§ Manualized and adherence to the manual is monitored
Common factors in successful treatment of BPD
§ Therapy can be taught as part of a relatively brief training programme
§ Therapist and client must feel a commitment to the approach
§ Supervision is essential to identify deviation from the manualized structure and provide support for adherence
Effective treatments for BPD are rich in the four ‘c’s
§ Coherence: offering a coherent (understandable) approach to illness and cure that provides the patient with hope
§ Consistency: identifying a well-balanced set of interventions based on the theory of disorder & its cure
§ Continuity: adherence to model throughout the treatment, without which re-establishment of epistemic trust is inconceivable
§ Communication: no communication is possible without the communicator having in mind the perspective of the receiver
Do these commonalities effect change and if so how?
Mentalizing as an
Integrativeframework
Cognitive Behaviourism: The value of understanding the relationship between my thoughts and feelings
and my behaviour.
Systems Theory: The value of understanding the relationship
between the thoughts and feelings of family members and their behaviours,
and the impact of these on each other.
Psychodynamic: The value of understanding the nature of resistance
to therapy, and the dynamics here-and-now in the therapeutic
relationship.
BIOLOGICAL, SOCIAL and ECOLOGICAL: The valueof understanding the impact of
context upon mental states: development,deprivation, opportunity, hunger, fear...
COMMON LANGUAGE
MINDBRAIN
The learner
1. The learner’s imagined
self narrative
5. Opening of epistemic channel for knowledge
transfer
4. The epistemic match
2. The informer’s image of the learner’s self
narrative
3. The learner’s image of the informer’s
image of the learner’s self
narrative
The informer
What is personality disorder?
Are treatments targeting core pathology?
Definition of personality disordern Personality disorder
Øenduring and pervasive disturbance in how individuals experience and interpret themselves, others, and the world that results in maladaptive patterns of cognition, emotional experience, emotional expression, and behaviour.
Ø inflexible and are associated with significant problems in psychosocial functioning that are particularly evident in interpersonal relationships, manifested across a range of personal and social situations (ie, not limited to specific relationships or situations).
DSM-5 Section III Criterion A: Level of Personality Functioning
Self1. Identity: Experience of oneself as unique with clear boundaries between self
and others’ stability of self-esteem and accuracy of self-appraisal; capacity for, and ability to regulate, a range of emotional experience.
2. Self-direction: Pursuit of coherent and meaningful short-term goals and life goals; utilization of constructive and prosocial internal standards of behavior; ability to self-reflect productively.
Interpersonal1. Empathy: Comprehension and appreciation of others’ experiences and
motivations; tolerance of differing perspectives; understanding the effects of one’s own behavior on others.
2. Intimacy: Depth and duration of connection with others; desire and capacity for closeness; mutuality of regard reflected in interpersonal behavior.
ICD-11 severity criterion
If general guidelines for a PD are met, a level of severity is provided and is based upon the following:
A) Degree and pervasiveness of self-dysfunction, as in identity, self-worth, and self-regulation.B) Degree and pervasiveness of interpersonal dysfunction across various contexts (e.g. romantic relationships, school/work, parent-child, family, friendships, peer contexts).C) Pervasiveness, severity, and chronicity of emotional, cognitive, and behavioral manifestations of the personality dysfunction. D) Extent to which these dysfunctions cause personal suffering and psychosocial impairment.
Maladaptive self-and
other relatedness
Implications for understanding and treating borderline personality disorder
as a social vulnerability disorder
Borderline Personality Disorder
Self-ConceptSocial
Interaction
Emotion Dysregulation
Mentalizing Positive Emotions in Borderline Personality Psychopathology and Psychotherapy: A randomized phase-based multiple-baseline studyTine Harpøth, Mickey Kongerslev, Anthony Bateman & Erik Simonsen Psychiatric Research Unit, Region of Zealand, Denmark
n The ”broaden and build” theory proposes that positive emotions - independently of negative emotions - help people build lasting resources.
n Enhancing positive emotions through psychological interventions may increase resilience.
n Specific intervention ‘mentalizing positive emotions’n Outcomes: General psychopathology; personality
disorders and BPD pathology; Differential emotions;Resilience (Ego-resilience scale (ER-89) and Perseverance and passion for long-term goals (GRIT-S); Life SatisfactionSatisfaction with Life Scale (SWLS);Therapeutic alliance (patient-rated) Working Alliance Inventory (WAI)
n I depend on others a lotn I can‘t manage when people don‘t respond
to men I am an outsidern I am different from others (shame)n Others will reject men I do not deserve being part of the group
(guilt)n I am ugly (self-contempt- self disgust)
Reported Social Cognitions in BPD
Rejection-sensitivity in different patient populations
Stäbler et al., 2011
Rejection Sensitivity in acute and remitted BPD patients
HC
RS
Q-S
co
re (
0-3
0)
0
5
10
15
20
acuteBPD
remittedBPD
HC
RSQ-Score
0
1
2
3
4
5
acuteBPD
remittedBPD
HC
RSQ-Score
0
1
2
3
4
5
acuteBPD
remittedBPD
cognitive RS
affective RS
HC acuteBPD
remittedBPD
N=77 N=15N=75
Bungert et al. BPDED, 2015
UCLA Loneliness Scale (n=40 female BPD; 40 HC)
Figure 1. Graph of social judgement scores for each of six dimensions.
Nicol K, Pope M, Sprengelmeyer R, Young AW, Hall J (2013) Social Judgement in Borderline Personality Disorder. PLoS ONE 8(11): e73440. doi:10.1371/journal.pone.0073440http://journals.plos.org/plosone/article?id=info:doi/10.1371/journal.pone.0073440
Approachable asUnapproachable
Unapproachable asApproachable
Trustworthy as Untrustworthy
Untrustworthy as Trustworthy
Judgment bias for approachability and trustworthiness of faces.
NSNS
BPD
ControlP<.001
P<.001
Direction of bias
Nicol et al., 2013 Plos One
Trust in Borderline Personality DisorderKing-Casas, Sharp, Lomax-Bream, Lohrenz, Fonagy, & Montague (2008) Science, 321, 806-810.
n Studying social behavior in task that involvesØLive interaction with unknown but real personØEngages mesocorticolimbic dopaminergic reward
circuit
n Total patients screened è assessed è scanned: ØBPD: 1,060 è 224 è 62ØMood control: 622 è 235 è 22ØNormal control: 877 è 398 è 116
X 3
Investor Trustee
$20
A dynamic version of the Trust game (10 rounds)BPD: The absence of Basic Trust
Camerer & Weigelt, (Econometrica, 1988)Berg, Dickhaut & McCabe (Games and Economic Behavior, 1995)
Average Repayment:
repay everything
repay nothing
repay investment (33%)
Investor SentMU sent / MU available
36 non-psychiatric investors42 BPD investors
Trustee RepaidMU sent / MU available
rounds
60%
50%
40%
30%
20%
10%1 3 4 7 95 6 8 102
60%
50%
40%
30%
20%
10%1 3 4 7 95 6 8 102
36 non-psychiatric trustees42 BPD trustees
Effects of inclusion on subsequent interaction
A Neural Signature of ‘Borderlineness’ in Trust Task
Did you feel ostracized?
BPD patients significantly more often feel ostracized under inclusion and uncontrollable conditionsStaebler et al., 2011; Domsalla, Lis, Bohus et al., 2013
Becomeacquainted
Appraisal
Exclusion
Inclusion
ReappraisalSocial
Cooperation
VR Group Interaction Paradigm
Social expectations before and after feedback
Do you expect that people will invite you?
0
2
4
6
8
10
12
Inklusion Exklusion
HCBPD
70
58
47
35
23
11
0
%
Inclusion Exclusion
Social expectations before and after feedback
Would you like to invite others?
nSocial inclusion in the VRGIPØHas little influence on people with BPDØIncreases suspicionØBPD become less co-operative than under
exclusion conditions
Results
n Start from a position of distrustn Assume you are to be disadvantaged and
seen as an outsidern Sensitivity to unfairnessn Interprete social cues as being an outsidern Positive social cues aversive and increase
suspicionn Feel impoverished and become either
mean or over-generous in social interaction
Summary
Implications for
treatment
Treatment implicationsn Benign social interaction process in clinicn Psychoeducation about social interactionn Identification of attachment strategiesn Exploration of personal and social valuesn Active involvement of
family/police/probationn Focus on trust/distrustn Staged treatment – impulsivity emotional
regulation interpersonal interaction social process
Thank you for mentalizing!
For further [email protected]
Slides available at:http://www.ucl.ac.uk/psychoanalysis/people/bateman
Top Related