Gibbon Simon, Khalifa Najat R, Cheung Natalie H-Y, Völlm Birgit A, McCarthy Lucy
Arnold Lodge, Nottinghamshire Healthcare NHS Foundation Trust, Leicester, UK.
Department of Psychiatry, Queen's University, Kingston, Canada.
Cochrane Database Syst Rev. 2020 Sep 3;9(9):CD007668. doi: 10.1002/14651858.CD007668.pub3.
Antisocial personality disorder (AsPD) is associated with poor mental health, criminality, substance use and relationship difficulties. This review updates Gibbon 2010 (previous version of the review).
To evaluate the potential benefits and adverse effects of psychological interventions for adults with AsPD.
We searched CENTRAL, MEDLINE, Embase, 13 other databases and two trials registers up to 5 September 2019. We also searched reference lists and contacted study authors to identify studies.
Randomised controlled trials of adults, where participants with an AsPD or dissocial personality disorder diagnosis comprised at least 75% of the sample randomly allocated to receive a psychological intervention, treatment-as-usual (TAU), waiting list or no treatment. The primary outcomes were aggression, reconviction, global state/functioning, social functioning and adverse events.
We used standard methodological procedures expected by Cochrane.
This review includes 19 studies (eight new to this update), comparing a psychological intervention against TAU (also called 'standard Maintenance'(SM) in some studies). Eight of the 18 psychological interventions reported data on our primary outcomes. Four studies focussed exclusively on participants with AsPD, and 15 on subgroups of participants with AsPD. Data were available from only 10 studies involving 605 participants. Eight studies were conducted in the UK and North America, and one each in Iran, Denmark and the Netherlands. Study duration ranged from 4 to 156 weeks (median = 26 weeks). Most participants (75%) were male; the mean age was 35.5 years. Eleven studies (58%) were funded by research councils. Risk of bias was high for 13% of criteria, unclear for 54% and low for 33%. Cognitive behaviour therapy (CBT) + TAU versus TAU One study (52 participants) found no evidence of a difference between CBT + TAU and TAU for physical aggression (odds ratio (OR) 0.92, 95% CI 0.28 to 3.07; low-certainty evidence) for outpatients at 12 months post-intervention. One study (39 participants) found no evidence of a difference between CBT + TAU and TAU for social functioning (mean difference (MD) -1.60 points, 95% CI -5.21 to 2.01; very low-certainty evidence), measured by the Social Functioning Questionnaire (SFQ; range = 0-24), for outpatients at 12 months post-intervention. Impulsive lifestyle counselling (ILC) + TAU versus TAU One study (118 participants) found no evidence of a difference between ILC + TAU and TAU for trait aggression (assessed with Buss-Perry Aggression Questionnaire-Short Form) for outpatients at nine months (MD 0.07, CI -0.35 to 0.49; very low-certainty evidence). One study (142 participants) found no evidence of a difference between ILC + TAU and TAU alone for the adverse event of death (OR 0.40, 95% CI 0.04 to 4.54; very low-certainty evidence) or incarceration (OR 0.70, 95% CI 0.27 to 1.86; very low-certainty evidence) for outpatients between three and nine months follow-up. Contingency management (CM) + SM versus SM One study (83 participants) found evidence that, compared to SM alone, CM + SM may improve social functioning measured by family/social scores on the Addiction Severity Index (ASI; range = 0 (no problems) to 1 (severe problems); MD -0.08, 95% CI -0.14 to -0.02; low-certainty evidence) for outpatients at six months. 'Driving whilst intoxicated' programme (DWI) + incarceration versus incarceration One study (52 participants) found no evidence of a difference between DWI + incarceration and incarceration alone on reconviction rates (hazard ratio 0.56, CI -0.19 to 1.31; very low-certainty evidence) for prisoner participants at 24 months. Schema therapy (ST) versus TAU One study (30 participants in a secure psychiatric hospital, 87% had AsPD diagnosis) found no evidence of a difference between ST and TAU for the number of participants who were reconvicted (OR 2.81, 95% CI 0.11 to 74.56, P = 0.54) at three years. The same study found that ST may be more likely to improve social functioning (assessed by the mean number of days until patients gain unsupervised leave (MD -137.33, 95% CI -271.31 to -3.35) compared to TAU, and no evidence of a difference between the groups for overall adverse events, classified as the number of people experiencing a global negative outcome over a three-year period (OR 0.42, 95% CI 0.08 to 2.19). The certainty of the evidence for all outcomes was very low. Social problem-solving (SPS) + psychoeducation (PE) versus TAU One study (17 participants) found no evidence of a difference between SPS + PE and TAU for participants' level of social functioning (MD -1.60 points, 95% CI -5.43 to 2.23; very low-certainty evidence) assessed with the SFQ at six months post-intervention. Dialectical behaviour therapy versus TAU One study (skewed data, 14 participants) provided very low-certainty, narrative evidence that DBT may reduce the number of self-harm days for outpatients at two months post-intervention compared to TAU. Psychosocial risk management (PSRM; 'Resettle') versus TAU One study (skewed data, 35 participants) found no evidence of a difference between PSRM and TAU for a number of officially recorded offences at one year after release from prison. It also found no evidence of difference between the PSRM and TAU for the adverse event of death during the study period (OR 0.89, 95% CI 0.05 to 14.83, P = 0.94, 72 participants (90% had AsPD), 1 study, very low-certainty evidence).
AUTHORS' CONCLUSIONS: There is very limited evidence available on psychological interventions for adults with AsPD. Few interventions addressed the primary outcomes of this review and, of the eight that did, only three (CM + SM, ST and DBT) showed evidence that the intervention may be more effective than the control condition. No intervention reported compelling evidence of change in antisocial behaviour. Overall, the certainty of the evidence was low or very low, meaning that we have little confidence in the effect estimates reported. The conclusions of this update have not changed from those of the original review, despite the addition of eight new studies. This highlights the ongoing need for further methodologically rigorous studies to yield further data to guide the development and application of psychological interventions for AsPD and may suggest that a new approach is required.
反社会人格障碍（AsPD）与心理健康不佳、犯罪行为、物质使用及人际关系困难相关。本综述更新了吉本2010年（该综述的上一版本）的内容。
评估针对成年AsPD患者的心理干预的潜在益处和不良影响。
我们检索了截至2019年9月5日的Cochrane系统评价数据库（CENTRAL）、医学期刊数据库（MEDLINE）、荷兰医学文摘数据库（Embase）、其他13个数据库以及两个试验注册库。我们还检索了参考文献列表并联系了研究作者以识别研究。
针对成年人的随机对照试验，其中被诊断为AsPD或反社会人格障碍的参与者至少占随机分配接受心理干预、常规治疗（TAU）、等候名单或无治疗的样本的75%。主要结局为攻击行为、再次定罪、整体状态/功能、社会功能和不良事件。
我们采用了Cochrane期望的标准方法程序。
本综述纳入了19项研究（本次更新新增8项），比较了心理干预与TAU（在某些研究中也称为“标准维持治疗”（SM））。18项心理干预中的8项报告了关于我们主要结局的数据。4项研究专门针对AsPD患者，15项针对AsPD患者亚组。仅有10项涉及605名参与者的研究提供了数据。8项研究在英国和北美进行，1项在伊朗、丹麦和荷兰各进行了1项。研究持续时间为4至156周（中位数 = 26周）。大多数参与者（75%）为男性；平均年龄为35.5岁。11项研究（58%）由研究委员会资助。13%的标准偏倚风险高，54%不明确，33%低。认知行为疗法（CBT）+TAU与TAU 一项研究（52名参与者）发现，对于门诊患者，在干预后12个月，CBT + TAU与TAU在身体攻击方面无差异证据（优势比（OR）0.92，95%置信区间0.28至3.07；低确定性证据）。一项研究（39名参与者）发现，对于门诊患者，在干预后12个月，用社会功能问卷（SFQ；范围 = 0 - 24）测量，CBT + TAU与TAU在社会功能方面无差异证据（平均差（MD）-1.60分，95%置信区间 - 5.21至2.01；极低确定性证据）。冲动生活方式咨询（ILC）+TAU与TAU 一项研究（118名参与者）发现，对于门诊患者，在9个月时，ILC + TAU与TAU在特质攻击方面无差异证据（用布斯 - 佩里攻击性问卷简表评估；MD 0.07，置信区间 - 0.35至0.49；极低确定性证据）。一项研究（142名参与者）发现，对于门诊患者，在3至9个月随访期间，ILC + TAU与单独的TAU在死亡不良事件（OR 0.40，95%置信区间0.04至4.54；极低确定性证据）或监禁（OR 0.70, 95%置信区间0.27至1.86；极低确定性证据）方面无差异证据。应急管理（CM）+SM与SM 一项研究（83名参与者）发现，与单独的SM相比，CM + SM可能改善门诊患者在6个月时用成瘾严重程度指数（ASI）的家庭/社会得分测量的社会功能（范围 = 0（无问题）至1（严重问题）；MD -0.08，95%置信区间 - 0.14至 - 0.02；低确定性证据）。“醉酒驾驶”项目（DWI）+监禁与监禁 一项研究（52名参与者）发现，对于囚犯参与者，在24个月时，DWI +监禁与单独监禁在再次定罪率方面无差异证据（风险比0.56，置信区间 - 0.19至）。
