A mechanism-based group-psychotherapy approach to aggressive behaviour in borderline personality disorder: findings from a cluster-randomised controlled trial

Herpertz, Sabine C.; Matzke, Burkhard; Hillmann, Karen; Neukel, Corinne; Mancke, Falk; Jaentsch, B.; Schwenger, Ulrich B.; Honecker, Hannah; Bullenkamp, Robin; Steinmann, Sylvia; Krauch, Marlene; Bauer, Stephen F.; Borzikowsky, Christoph; Bertsch, Katja; Dempfle, Astrid

doi:10.1192/bjo.2020.131

Cited by 16 publications

(16 citation statements)

References 47 publications

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“…When tested against a non-specific supportive psychotherapy (NSSP), patients who participated in MAAP showed a clinically relevant 65% decrease in aggressive behavior according to the primary outcome Overt Aggression Scale Modified (OAS-M), compared with a 33% decrease in the NSSP group from the pre- to post-treatment time point. However, no significant difference in OAS-M overt aggression between MAAP and NSSP was found at post-treatment time point; at the 6-month follow-up time point, MAAP proved significantly superior to NSSP in reducing reactive aggression in BPD ( 9 ).…”

Section: Introductionmentioning

confidence: 82%

“…In total, we ran 12 therapy groups (6 x MAAP and 6 x NSSP) with three to six patients and two therapists per group. One further randomized group did not take place due to high dropout prior to group therapy start [see ( 9 ) for information on the randomized-controlled trial].…”

Section: Methodsmentioning

confidence: 99%

“…Furthermore, MAAP included several techniques taken from MBT ( 7 ). The contents of each group session are presented in Table 2 and described in detail by Herpertz et al ( 9 ).…”

Section: Methodsmentioning

confidence: 99%

“…Typically, common treatment programs for patients with BPD, such as dialectical behavior therapy [DBT, ( 6 )] and mentalization-based therapy [MBT, ( 7 )], focus on reducing emotional dysregulation, self-harm, and chronic suicidality ( 8 ) but do not specifically target aggressive behavior toward others ( 9 ). To address this gap, our group has developed an aggression-specific psychotherapeutic group intervention program called mechanism-based anti-aggression psychotherapy (MAAP) that aims to reduce aggressive behavior in patients with BPD by targeting the identified biobehavioral mechanisms of aggression in patients with BPD ( 4 , 5 ).…”

Section: Introductionmentioning

confidence: 99%

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Impact of a Mechanism-Based Anti-Aggression Psychotherapy on Behavioral Mechanisms of Aggression in Patients With Borderline Personality Disorder

et al. 2021

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Introduction: Aggressive behavior is highly prevalent in patients with borderline personality disorder (BPD) and represents a major burden for patients and their environment. Previous studies have hypothesized threat hypersensitivity, among other mechanisms, as a biobehavioral mechanism underlying aggressive behavior in patients with BPD. The effects of a 6-week mechanism-based anti-aggression psychotherapy (MAAP) for the group setting were tested in comparison to the effects of a non-specific supportive psychotherapy (NSSP) on this hypothesized mechanism and their relation to the effects on aggressive behavior.Methods: To assess mechanisms of reactive aggression, 38 patients with BPD (20 in MAAP and 18 in NSSP) and 24 healthy controls participated in an emotion classification task before and after therapy or at a similar interval of 7 weeks for controls, respectively. In addition, current reactive aggressive behavior was assessed by the externally directed overt aggression score of the Overt Aggression Scale Modified (OAS-M) at both time points. Mixed linear models were used to test for group differences and differential treatment effects.Results: Consistent with previous findings, patients showed longer response latencies and misclassified faces as angry more often than healthy controls. Comparing pre- and post-treatment measurements, the MAAP group showed an increase in response latency in classifying angry faces, whereas the NSSP group showed a decrease in latency. Furthermore, the difference between pre- and post-treatment response latencies in classifying emotional faces correlated with the reductions in reactive aggression in the MAAP group, but not in the NSSP group or healthy controls.Conclusion: The results suggest an impact of MAAP on threat sensitivity as well as cognitive control, which has also been previously hypothesized as a biobehavioral mechanism underlying reactive aggression in patients with BPD. In addition, our findings shed light on the importance of these two biobehavioral mechanisms underlying reactive aggression as mechanisms of change addressed by MAAP. Further studies are needed to determine whether the behavioral change is stable over time and to what extent this change is related to a stable reduction in reactive aggression in a larger group of patients with BPD.

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Section: Introductionmentioning

confidence: 82%

Section: Methodsmentioning

confidence: 99%

“…Furthermore, MAAP included several techniques taken from MBT ( 7 ). The contents of each group session are presented in Table 2 and described in detail by Herpertz et al ( 9 ).…”

Section: Methodsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Impact of a Mechanism-Based Anti-Aggression Psychotherapy on Behavioral Mechanisms of Aggression in Patients With Borderline Personality Disorder

et al. 2021

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“…In a proof-of-concept study, we recently tested a specific group treatment for reducing anger and aggression in BPD (41). This Mechanism-based Anti-Aggression Psychotherapy (MAAP) includes, among others, the identification of contextual factors that enhance the risk for aggression as well as the discussion of cognitive, emotional, physical, and behavioral correlates of anger.…”

Section: Discussionmentioning

confidence: 99%

Don't Make Me Angry: Frustration-Induced Anger and Its Link to Aggression in Women With Borderline Personality Disorder

et al. 2021

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Aggression is a prominent interpersonal dysfunction of individuals with borderline personality disorder (BPD). In BPD aggression is predominantly reactive in nature, often triggered by frustration, provocation, or social threat and is associated with intense anger and an inability to regulate this strong, negative emotion. Building on previous research, we were interested in investigating negative emotionality in general and anger in particular in women with BPD before and after frustration induction. To achieve this, 60 medication-free women with BPD and 32 healthy women rated the intensity of negative emotions (angry, frustrated, upset, embarrassed, nervous) before and after performing a Titrated Mirror Tracing Task, which reliably induces frustration and distress. As expected, women with BPD reported significantly greater intensity of negative emotions before and after frustration than healthy women. Specifically, they showed a significantly stronger frustration-induced increase in anger, while other negative emotions remained unaffected by frustration induction. This anger increase was significantly related to aggressive behavior reported in the 2 weeks prior to the experiment, as well as to the level of frustration experienced in the experiment itself, but not with emotion dysregulation. The current data confirm the important role of frustration-induced anger independent of emotion dysregulation in BPD, in particular with regard to aggression, a prominent interpersonal dysfunction of this disorder. These findings underline the importance of interventions with particular focus on anger.

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Algorithm‐based modular psychotherapy vs. cognitive‐behavioral therapy for patients with depression, psychiatric comorbidities and early trauma: a proof‐of‐concept randomized controlled trial

Schramm,

Elsaesser,

Jenkner

et al. 2024

World Psychiatry

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Effect sizes of psychotherapies currently stagnate at a low‐to‐moderate level. Personalizing psychotherapy by algorithm‐based modular procedures promises improved outcomes, greater flexibility, and a better fit between research and practice. However, evidence for the feasibility and efficacy of modular‐based psychotherapy, using a personalized treatment algorithm, is lacking. This proof‐of‐concept randomized controlled trial was conducted in 70 adult outpatients with a primary DSM‐5 diagnosis of major depressive disorder, a score higher than 18 on the 24‐item Hamilton Rating Scale for Depression (HRSD‐24), at least one comorbid psychiatric diagnosis according to the Structured Clinical Interview for DSM‐5 (SCID‐5), a history of at least “moderate to severe” childhood maltreatment on at least one domain of the Childhood Trauma Questionnaire (CTQ), and exceeding the cut‐off value on at least one of three measures of early trauma‐related transdiagnostic mechanisms: the Rejection Sensitivity Questionnaire (RSQ), the Interpersonal Reactivity Index (IRI), and the Difficulties in Emotion Regulation Scale‐16 (DERS‐16). Patients were randomized to 20 sessions of either standard cognitive‐behavioral therapy alone (CBT) or CBT plus transdiagnostic modules according to a mechanism‐based treatment algorithm (MoBa), over 16 weeks. We aimed to assess the feasibility of MoBa, and to compare MoBa vs. CBT with respect to participants’ and therapists’ overall satisfaction and ratings of therapeutic alliance (using the Working Alliance Inventory ‐ Short Revised, WAI‐SR), efficacy, impact on early trauma‐related transdiagnostic mechanisms, and safety. The primary outcome for efficacy was the HRSD‐24 score at post‐treatment. Secondary outcomes included, among others, the rate of response (defined as a reduction of the HRSD‐24 score by at least 50% from baseline and a score <16 at post‐treatment), the rate of remission (defined as a HRSD‐24 score ≤8 at post‐treatment), and improvements in early trauma‐related mechanisms of social threat response, hyperarousal, and social processes/empathy. We found no difficulties in the selection of the transdiagnostic modules in the individual patients, applying the above‐mentioned cut‐offs, and in the implementation of MoBa. Both participants and therapists reported higher overall satisfaction and had higher WAI‐SR ratings with MoBa than CBT. Both approaches led to major reductions of depressive symptoms at post‐treatment, with a non‐significant superiority of MoBa over CBT. Patients randomized to MoBa were nearly three times as likely to experience remission at the end of therapy (29.4% vs. 11.4%; odds ratio, OR = 3.2, 95% CI: 0.9‐11.6). Among mechanism‐based outcomes, MoBa patients showed a significantly higher post‐treatment effect on social processes/empathy (p<0.05) compared to CBT patients, who presented an exacerbation on this domain at post‐treatment. Substantially less adverse events were reported for MoBa compared to CBT. These results suggest the feasibility and acceptability of an algorithm‐based modular psychotherapy complementing CBT in depressed patients with psychiatric comorbidities and early trauma. While initial evidence of efficacy was observed, potential clinical advantages and interindividual heterogeneity in treatment outcomes will have to be investigated in fully powered confirmation trials.

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A mechanism-based group-psychotherapy approach to aggressive behaviour in borderline personality disorder: findings from a cluster-randomised controlled trial

Cited by 16 publications

References 47 publications

Impact of a Mechanism-Based Anti-Aggression Psychotherapy on Behavioral Mechanisms of Aggression in Patients With Borderline Personality Disorder

Impact of a Mechanism-Based Anti-Aggression Psychotherapy on Behavioral Mechanisms of Aggression in Patients With Borderline Personality Disorder

Don't Make Me Angry: Frustration-Induced Anger and Its Link to Aggression in Women With Borderline Personality Disorder

Algorithm‐based modular psychotherapy vs. cognitive‐behavioral therapy for patients with depression, psychiatric comorbidities and early trauma: a proof‐of‐concept randomized controlled trial

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