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

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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

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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

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.6.8

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Baseline 6 months 12 months 18 monthsAssessment Periods

SCM MBT

One Axis II Diagnosis

-.20

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Baseline 6 months 12 months 18 monthsAssessment Periods

SCM MBT

Two Axis II Diagnoses

-.20

.2.4

.6.8

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Baseline 6 months 12 months 18 monthsAssessment Periods

SCM MBT

Three Axis II Diagnoses

-.20

.2.4

.6.8

Line

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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

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Source: Zanarini et al.

Percent of sample employed or in education during study period

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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

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cognitive RS

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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%

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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?

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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 informationanthony.bateman@ucl.ac.uk

Slides available at:http://www.ucl.ac.uk/psychoanalysis/people/bateman