Mickey Kongerslev

Risk factors for violence among patients with schizophrenia.

Studies of birth cohorts show evidence of greater risk of violence among patients with schizophrenia compared to the general population. However, the contribution of schizophrenia to violence is heavily debated and remains unclear. This debate has spurred research whose focus can be associated with one of the following areas: psychotic symptoms, personality disorders (in particular psychopathy), mentalizing abilities, substance abuse and demographic factors. The aim of the current review is to evaluate the predictive role of these risk factors in the occurrence of violence among patients with schizophrenia. We identified two different trajectories for violent behavior in schizophrenia: one pertains to patients with no prior history of violence or criminal behavior and for whom positive symptoms appear to explain violent behavior, and another where personality pathology, including psychopathy, predict violence, regardless of other symptomatology associated with schizophrenia. Furthermore, emergent data suggest that specific mentalizing profiles can be associated with the occurrence of violence in schizophrenia, an issue that warrants further consideration in future research.

Screening for personality disorder in incarcerated adolescent boys: preliminary validation of an adolescent version of the standardised assessment of personality - abbreviated scale (SAPAS-AV)

BackgroundPersonality disorder (PD) is associated with significant functional impairment and an elevated risk of violent and suicidal behaviour. The prevalence of PD in populations of young offenders is likely to be high. However, because the assessment of PD is time-consuming, it is not routinely assessed in this population. A brief screen for the identification of young people who might warrant further detailed assessment of PD could be particularly valuable for clinicians and researchers working in juvenile justice settings.MethodWe adapted a rapid screen for the identification of PD in adults (Standardised Assessment of Personality – Abbreviated Scale; SAPAS) for use with adolescents and then carried out a study of the reliability and validity of the adapted instrument in a sample of 80 adolescent boys in secure institutions. Participants were administered the screen and shortly after an established diagnostic interview for DSM-IV PDs. Nine days later the screen was readministered.ResultsA score of 3 or more on the screening interview correctly identified the presence of DSM-IV PD in 86% of participants, yielding a sensitivity and specificity of 0.87 and 0.86 respectively. Internal consistency was modest but comparable to the original instrument. 9-days test-retest reliability for the total score was excellent. Convergent validity correlations with the total number of PD criteria were large.ConclusionThis study provides preliminary evidence of the validity, reliability, and usefulness of the screen in secure institutions for adolescent male offenders. It can be used in juvenile offender institutions with limited resources, as a brief, acceptable, staff-administered routine screen to identify individuals in need of further assessment of PD or by researchers conducting epidemiological surveys.

Mentalizing mediates the relationship between psychopathy and type of aggression in schizophrenia.

Abstract Convincing evidence demonstrates that psychopathy is associated with premeditated aggression. However, studies have failed to explain why this association exists and whether socio-cognitive functions, such as mentalizing, could explain the relation. This cross-sectional study investigates, in 108 patients with schizophrenia, the association of psychopathy and mentalizing abilities with premeditated and impulsive aggression and probes the nature of their influence on these specific aggression patterns. Patients’ engagement in premeditated aggression was associated with diminishing mentalizing and increasing psychopathic tendencies. Moreover, mediation analyses reveal that the ability to attribute mental states to others mediates the relation between psychopathy and type of aggression. This mediation is facilitated by a specific mentalizing profile characterized by the presence of intact cognitive and deficient emotional mentalizing capacities. This study is the first to report a mediating effect of mentalizing on the relationship between psychopathy and type of aggression in schizophrenia. Implications of these results are discussed.

Hypermentalizing, attachment, and epistemic trust in adolescent BPD: Clinical illustrations

Borderline personality disorder (BPD) has been shown to be a valid and reliable diagnosis in adolescents and associated with a decrease in both general and social functioning. With evidence linking BPD in adolescents to poor prognosis, it is important to develop a better understanding of factors and mechanisms contributing to the development of BPD. This could potentially enhance our knowledge and facilitate the design of novel treatment programs and interventions for this group. In this paper, we outline a theoretical model of BPD in adolescents linking the original mentalization-based theory of BPD, with recent extensions of the theory that focuses on hypermentalizing and epistemic trust. We then provide clinical case vignettes to illustrate this extended theoretical model of BPD. Furthermore, we suggest a treatment approach to BPD in adolescents that focuses on the reduction of hypermentalizing and epistemic mistrust. We conclude with an integration of theory and practice in the final section of the paper and make recommendations for future work in this area.

Subtypes of aggression in patients with schizophrenia: the role of psychopathy

Psychopathy is strongly related to aggression in community, forensic psychiatric and offender samples, including in patients with schizophrenia. However, most studies have failed to distinguish between impulsive or premeditated aggression. In a cross-sectional study of 108 patients with schizophrenia and comorbid psychopathy, we investigated if psychopathy measured with the total Psychopathy Checklist-Revised (PCL-R) score and the factors described in the two-factor model and the facets described in the four-factor model are associated with type of aggression in schizophrenia and to explore if the three- and four-factor models are associated with premeditated aggression. Results revealed that PCL-R total score, Factor 1 and 2 of the two-factor model and Facets 1–4 of the four-factor model were related to premeditated aggression and that the four-factor model was better related to premeditated aggression than the three-factor model. These findings delineate the role of psychopathy including antisocial features in the understanding of premeditated aggression in schizophrenia.

Deriving ICD‐11 personality disorder domains from dsm‐5 traits: initial attempt to harmonize two diagnostic systems

The personality disorder domains proposed for the ICD‐11 comprise Negative Affectivity, Detachment, Dissociality, Disinhibition, and Anankastia, which are reasonably concordant with the higher‐order trait domains in the Alternative DSM‐5 Model for Personality Disorders.

Self-reported patterns of impairments in mentalization, attachment, and psychopathology among clinically referred adolescents with and without borderline personality pathology

BackgroundPrevious research, which primarily focused on adult samples, suggests that individuals with borderline personality disorder (BPD) display high levels of psychopathology, dysfunctional mentalization and problematic attachment to others. The current study investigated whether impairments in mentalization, attachment, and psychopathology are more severe in outpatient adolescents with BPD than in a clinical comparison group.MethodsConsecutive referrals to a child and adolescent psychiatric clinic were clinically assessed with a battery of self-report instruments to assess mentalization, attachment, and psychopathology. Specifically, in regard to BPD a self-report questionnaire was employed to decide if patients were classified into the BPD or the clinical comparison group. The main outcome variables of adolescents with a primary diagnosis of BPD were then compared with those of a clinical comparison group comprising patients receiving psychiatric diagnoses other than BPD.ResultsRelative to the clinical group without BPD, and after controlling for sociodemographic variables, the BPD group displayed poorer mentalizing abilities, more problematic attachments to parents and peers, and higher self-reported levels of psychopathology.ConclusionsThe results of this study suggest that BPD is a severe mental condition in adolescents and is characterized by poor mentalizing abilities, attachment problems and high levels of psychopathology compared to adolescents with psychiatric disorders other than BPD. Hence, clinicians should consider BPD when conducting diagnostic assessments, and evidence-based treatments for this vulnerable group should be developed.

Does Affective Theory of Mind Contribute to Proactive Aggression in Boys with Conduct Problems and Psychopathic Tendencies

Adolescent psychopathic tendencies are associated with phenotypic increases in proactive aggression. However, the extent to which an understanding of others’ affective mental states, or affective theory of mind (ToM), contributes to proactive aggression remains unknown. We examined how performance on a well-known test of affective ToM, based on cropped images of the eye region, contributes to reactive and proactive types of aggression in a mixed ethnicity sample of 80 incarcerated adolescent boys. A hierarchical regression model showed that affective ToM predicted proactive aggression over and above the influence of clinically rated psychopathic tendencies. Importantly, affective ToM was unrelated to reactive aggression. Our results suggest that being able to recognize others’ affective mental states may be an important factor in aggressing against others for personal gain. These findings have implications for interventions designed to enhance ToM in youth with conduct problems.

The Mentalization-Based Therapy Adherence and Quality Scale (MBT-AQS): Reliability in a clinical setting

Abstract The Mentalization-Based Treatment Adherence and Quality Scale (MBT-AQS) is a 17-item measure of treatment adherence and quality of individual mentalization-based therapy (MBT). Until now, reliability research on the scale has primarily been conducted by highly experienced raters from the Norwegian MBT Quality Lab who were part of its development. Hence, it can be questioned whether only experts in research settings can achieve satisfying levels of reliability on the scale. In this study, we investigated whether a satisfying level of reliability on the MBT-AQS could be obtained by experienced MBT therapists in a clinical setting following a brief one-day training course. The overall reliabilities for six raters were good for adherence (.67) and for quality (.62). Thus, the MBT-AQS was found to be an appropriate MBT adherence rating instrument with clinical and educational utility outside of the Norwegian MBT Quality Lab. However, ambiguity of some constructs, low frequency of certain item ratings and low levels of MBT quality challenge reliability. This is discussed in the context of utilizing the scale for clinical and supervising purposes

Low vocational outcome among people diagnosed with Borderline Personality Disorder during first admission to mental health services in Denmark: a nationwide 9-year register-based study

Earlier studies report that although people with borderline personality disorder (BPD) experience symptom reduction in the long term, they continue to have difficulties in work recovery. This nationwide 9-year register-based study (N = 67,075) investigated the long-term labor-market attachment of all individuals diagnosed with BPD during first admission to Danish mental health services in comparison with other psychiatric disorders. Controlling for baseline characteristics and co-occurring secondary psychiatric diagnoses, the BPD group had 32% lower odds (OR = 0.68; 95% CI [0.61, 0.76]) of being in work/under education after 9 years. Individuals diagnosed with BPD also showed more impairment in long-term vocational outcome than other personality disorders, and lower labor-market attachment than other psychiatric disorders except for schizophrenia, schizotypal and delusional disorders, and mental and behavioral disorders due to psychoactive substance use. Intervention programs addressing social psychiatric aspects of BPD in terms of work functioning is henceforth an important area for future research.