Peter Fonagy

Selective serotonin reuptake inhibitors in childhood depression: systematic review of published versus unpublished data

BACKGROUND Questions concerning the safety of selective serotonin reuptake inhibitors (SSRIs) in the treatment of depression in children led us to compare and contrast published and unpublished data on the risks and benefits of these drugs. METHODS We did a meta-analysis of data from randomised controlled trials that evaluated an SSRI versus placebo in participants aged 5-18 years and that were published in a peer-reviewed journal or were unpublished and included in a review by the Committee on Safety of Medicines. The following outcomes were included: remission, response to treatment, depressive symptom scores, serious adverse events, suicide-related behaviours, and discontinuation of treatment because of adverse events. FINDINGS Data for two published trials suggest that fluoxetine has a favourable risk-benefit profile, and unpublished data lend support to this finding. Published results from one trial of paroxetine and two trials of sertraline suggest equivocal or weak positive risk-benefit profiles. However, in both cases, addition of unpublished data indicates that risks outweigh benefits. Data from unpublished trials of citalopram and venlafaxine show unfavourable risk-benefit profiles. INTERPRETATION Published data suggest a favourable risk-benefit profile for some SSRIs; however, addition of unpublished data indicates that risks could outweigh benefits of these drugs (except fluoxetine) to treat depression in children and young people. Clinical guideline development and clinical decisions about treatment are largely dependent on an evidence base published in peer-reviewed journals. Non-publication of trials, for whatever reason, or the omission of important data from published trials, can lead to erroneous recommendations for treatment. Greater openness and transparency with respect to all intervention studies is needed.

The capacity for understanding mental states: The reflective self in parent and child and its significance for security of attachment

Epidemiologists and psychoanalysts have been equally concerned about the intergenera-tional concordance of disturbed patterns of attachment. Mary Mains introduction of the Adult Attachment Interview (AAI) has provided the field with an empirical tool for examining the concordance of parental and infant attachment patterns. In the context of a prospective study of the influence of parental patterns of attachment assessed before the birth of the first child upon the childs pattern of attachment to that parent at 1 year and at 18 months, the Anna Freud Centre—University College London Parent-Child Project reported a significant level of concordance between parental security and the infants security with that parent. In the context of this study, a new measure, aiming to assess the parents capacity for understanding mental states, was developed and is reported on in this paper. The rating of Reflective-Self Function, based upon AAI transcripts, correlated significantly with infant security classification based on Strange Situation assessments. The philosophical background and clinical importance of the measure are discussed.

Adult attachment predicts maternal brain and oxytocin response to infant cues.

Infant cues, such as smiling or crying facial expressions, are powerful motivators of human maternal behavior, activating dopamine-associated brain reward circuits. Oxytocin, a neurohormone of attachment, promotes maternal care in animals, although its role in human maternal behavior is unclear. We examined 30 first-time new mothers to test whether differences in attachment, based on the Adult Attachment Interview, were related to brain reward and peripheral oxytocin response to infant cues. On viewing their own infants smiling and crying faces during functional MRI scanning, mothers with secure attachment showed greater activation of brain reward regions, including the ventral striatum, and the oxytocin-associated hypothalamus/pituitary region. Peripheral oxytocin response to infant contact at 7 months was also significantly higher in secure mothers, and was positively correlated with brain activation in both regions. Insecure/dismissing mothers showed greater insular activation in response to their own infants sad faces. These results suggest that individual differences in maternal attachment may be linked with development of the dopaminergic and oxytocinergic neuroendocrine systems.

Randomized controlled trial of outpatient mentalization-based treatment versus structured clinical management for borderline personality disorder.

OBJECTIVE This randomized controlled trial tested the effectiveness of an 18-month mentalization-based treatment (MBT) approach in an outpatient context against a structured clinical management (SCM) outpatient approach for treatment of borderline personality disorder. METHOD Patients (N=134) consecutively referred to a specialist personality disorder treatment center and meeting selection criteria were randomly allocated to MBT or SCM. Eleven mental health professionals equal in years of experience and training served as therapists. Independent evaluators blind to treatment allocation conducted assessments every 6 months. The primary outcome was the occurrence of crisis events, a composite of suicidal and severe self-injurious behaviors and hospitalization. Secondary outcomes included social and interpersonal functioning and self-reported symptoms. Outcome measures, assessed at 6-month intervals, were analyzed using mixed effects logistic regressions for binary data, Poisson regression models for count data, and mixed effects linear growth curve models for self-report variables. RESULTS Substantial improvements were observed in both conditions across all outcome variables. Patients randomly assigned to MBT showed a steeper decline of both self-reported and clinically significant problems, including suicide attempts and hospitalization. CONCLUSIONS Structured treatments improve outcomes for individuals with borderline personality disorder. A focus on specific psychological processes brings additional benefits to structured clinical support. Mentalization-based treatment is relatively undemanding in terms of training so it may be useful for implementation into general mental health services. Further evaluations by independent research groups are now required.

The rupture and repair of cooperation in borderline personality disorder.

To sustain or repair cooperation during a social exchange, adaptive creatures must understand social gestures and the consequences when shared expectations about fair exchange are violated by accident or intent. We recruited 55 individuals afflicted with borderline personality disorder (BPD) to play a multiround economic exchange game with healthy partners. Behaviorally, individuals with BPD showed a profound incapacity to maintain cooperation, and were impaired in their ability to repair broken cooperation on the basis of a quantitative measure of coaxing. Neurally, activity in the anterior insula, a region known to respond to norm violations across affective, interoceptive, economic, and social dimensions, strongly differentiated healthy participants from individuals with BPD. Healthy subjects showed a strong linear relation between anterior insula response and both magnitude of monetary offer received from their partner (input) and the amount of money repaid to their partner (output). In stark contrast, activity in the anterior insula of BPD participants was related only to the magnitude of repayment sent back to their partner (output), not to the magnitude of offers received (input). These neural and behavioral data suggest that norms used in perception of social gestures are pathologically perturbed or missing altogether among individuals with BPD. This game-theoretic approach to psychopathology may open doors to new ways of characterizing and studying a range of mental illnesses.

Handbook of mentalization-based treatment

About the Editors. List of Contributors. Foreword by Susan W. Coates. Preface by Jon G. Allen and Peter Fonagy. Part I: CONCEPTUAL AND CLINICAL FOUNDATIONS. 1 Mentalizing in Practice (Jon G. Allen). 2 Mentalizing from a Psychoanalytic Perspective: Whats New? (Jeremy Holmes). Part II: DEVELOPMENTAL PSYCHOPATHOLOGY. 3 The Mentalization-Focused Approach to Social Development (Peter Fonagy). 4 Mentalizing Problems in Childhood Disorders (Carla Sharp). 5 A Neurobiological Perspective on Mentalizing and Internal Object Relations in Traumatized Patients with Borderline Personality Disorder (Glen O. Gabbard, Lisa A. Miller and Melissa Martinez). Part III: INCORPORATING MENTALIZING IN ESTABLISHED TREATMENTS. 6 Integrating Mentalization-Based Treatment and Traditional Psychotherapy to Cultivate Common Ground and Promote Agency (Richard L. Munich). 7 Cognitive Behavioral Therapy Promotes Mentalizing (Throstur Bjorgvinsson and John Hart). 8 Enhancing Mentalizing Capacity through Dialectical Behavior Therapy Skills Training and Positive Psychology (Lisa Lewis). Part IV: MENTALIZATION-BASED THERAPY. 9 Mentalizing and Borderline Personality Disorder (Anthony Bateman and Peter Fonagy). 10 Short-Term Mentalization and Relational Therapy (SMART): An Integrative Family Therapy for Children and Adolescents (Pasco Fearon, Mary Target, Peter Fonagy, Laurel L. Williams, Jacqueline McGregor, John Sargent and Efrain Bleiberg). 11 Training Psychiatry Residents in Mentalization-Based Therapy (Laurel L.Williams, Peter Fonagy, Mary Target, Pasco Fearon, John Sargent, Efrain Bleiberg and Jacqueline McGregor). 12. Treating Professionals in Crisis: A Mentalization-Based Specialized Inpatient Program (Efrain Bleiberg). 13. Enhancing Mentalizing through Psycho-Education (G. Tobias G. Haslam-Hopwood, Jon G. Allen, April Stein and Efrain Bleiberg). Part V: PREVENTION. 14. Minding the Baby: A Mentalization-Based Parenting Program (Lois S. Sadler, Arietta Slade and Linda C. Mayes). 15. Transforming Violent Social Systems into Non-Violent Mentalizing Systems: An Experiment in Schools (Stuart W. Twemlow and Peter Fonagy). 16. Does Mentalizing Promote Resilience? (Helen Stein). Epilogue (Robert Michels). Index.

Mentalization and the Changing Aims of Child Psychoanalysis

The interface of empirical work with child psychoanalysis at the Anna Freud Centre is part of the tradition of systematic study and research pioneered over many years by Anna Freud and her colleagues (A. Freud, 1962; Sandier, 1962; A. Freud 1965). George Moran initiated a program of work at the Anna Freud Centre, which, starting with the work on juvenile onset diabetes (Fonagy et al., 1991b), led us to ask fundamental questions about the nature of the child psychoanalysis, with important implications for technique. We acknowledged our debt by dedicating the lecture on which this paper is based to George Moran, whom we see as a worthy successor to Marianne Kris, both of them working within the tradition of Anna Freud. This article starts with observations that imply the need for a change in some aspects of our psychoanalytic model. Throughout child psychoanalysis is used to illustrate both the need for change and the character of the revision that is required. The authors, however, assert that, as is so of...

What's in a Smile? Maternal Brain Responses to Infant Facial Cues

OBJECTIVES. Our goal was to determine how a mothers brain responds to her own infants facial expressions, comparing happy, neutral, and sad face affect. METHODS. In an event-related functional MRI study, 28 first-time mothers were shown novel face images of their own 5- to 10-month-old infant and a matched unknown infant. Sixty unique stimuli from 6 categories (own-happy, own-neutral, own-sad, unknown-happy, unknown-neutral, and unknown-sad) were presented randomly for 2 seconds each, with a variable 2- to 6-second interstimulus interval. RESULTS. Key dopamine-associated reward-processing regions of the brain were activated when mothers viewed their own infants face compared with an unknown infants face. These included the ventral tegmental area/substantia nigra regions, the striatum, and frontal lobe regions involved in (1) emotion processing (medial prefrontal, anterior cingulate, and insula cortex), (2) cognition (dorsolateral prefrontal cortex), and (3) motor/behavioral outputs (primary motor area). Happy, but not neutral or sad own-infant faces, activated nigrostriatal brain regions interconnected by dopaminergic neurons, including the substantia nigra and dorsal putamen. A region-of-interest analysis revealed that activation in these regions was related to positive infant affect (happy > neutral > sad) for each own–unknown infant-face contrast. CONCLUSIONS. When first-time mothers see their own infants face, an extensive brain network seems to be activated, wherein affective and cognitive information may be integrated and directed toward motor/behavioral outputs. Dopaminergic reward-related brain regions are activated specifically in response to happy, but not sad, infant faces. Understanding how a mother responds uniquely to her own infant, when smiling or crying, may be the first step in understanding the neural basis of mother–infant attachment.

Mentalization based treatment for borderline personality disorder.

Mentalizing is the process by which we make sense of each other and ourselves, implicitly and explicitly, in terms of subjective states and mental processes. It is a profoundly social construct in the sense that we are attentive to the mental states of those we are with, physically or psychologically. Given the generality of this definition, most mental disorders will inevitably involve some difficulties with mentalization, but it is the application of the concept to the treatment of borderline personality disorder (BPD), a common psychiatric condition with important implications for public health, that has received the most attention. Patients with BPD show reduced capacities to mentalize, which leads to problems with emotional regulation and difficulties in managing impulsivity, especially in the context of interpersonal interactions. Mentalization based treatment (MBT) is a time-limited treatment which structures interventions that promote the further development of mentalizing. It has been tested in research trials and found to be an effective treatment for BPD when delivered by mental health professionals given limited additional training and with moderate levels of supervision. This supports the general utility of MBT in the treatment of BPD within generic mental health services.

ATTACHMENT AND BORDERLINE PERSONALITY DISORDER: A Theory and Some Evidence

An attachment theory approach to severe personality disorder is described. Evidence is presented that suggests that representations of attachment relationships and attachment behaviors of patients with this diagnosis are commonly disorganized in character. It is argued that the capacity to develop mental representations of mental states in self and other (reflective function) develops in the context of attachment relationships and that disorganization of attachment undermines this process. Such disorganization can be associated with trauma but may also be linked to other biological and psychosocial deficits. Many of the clinical characteristics of patients with borderline personality disorder may be seen as consequences of disordered self-organization and a limited rudimentary capacity to think about behavior in mental state terms. The relevance of this model for the practice of psychotherapy with this group of patients is discussed.