Complex case: A biofeedback intervention to control impulsiveness in a severely personality disordered forensic patient by Rick Howard, Klaus Schellhorn and John Lumsden

Abstract

With this case report of successful biofeedback treatment for a severely disordered and treatmentrefractory forensic patient, the authors contribute to arguments for consideration of the inclusion of biofeedback for a group of extremely challenging patients. The term ‘complex patient’ barely captures the patient MN, whose psychopathology cuts across diagnostic borders and includes a mixed personality disorder with borderline, antisocial and histrionic features, paedophilia, attentional difficulties that may meet criteria for Attention Deficit Disorder/ Attention Deficit Hyperactivity Disorder, borderline intellectual functioning and an unspecified mood disorder. Prior to his transfer from a prison to a forensic hospital, the unremitting severity of his sexual deviance led to placement on a testosteronelowering agent, and his level of mood instability resulted in treatment with carbamazepine. Strengths of this case report include the extensive initial psychometric and psychological evaluation of the patient and the documentation of significant post-treatment improvement in biobehavioral (Flanker test) and electrophysiological (Go/No Go contingent negative variation) measures, as well as patient self-report of decreased impulsivity and improvement in attention/cognition at the study endpoint and at 3months of follow-up. This paper is a welcome addition to the literature on therapeutic interventions in severely personality disordered patients from several perspectives. Much of this patient’s history and behavioural presentation are characteristics of antisocial personality disorder (ASPD) and accompanying paedophilia, areas of psychopathology much neglected in psychiatric literature, with diagnoses for which therapeutic pessimism bordering on nihilism has led in the US to relegation of these patients to the criminal justice system. Patients with ASPD have significant deficits in mentalization, attachment and impulse control (Leichsenring et al., 2003), ego weaknesses that make them poor candidates for many psychotherapies and that render these patients destructive to a hospital-based therapeutic milieu. Indeed, MN had shown poor motivation and compliance with routine psychotherapies in the past. An advantage for forensic-type patients of neurofeedback treatments is that they work at basic neurophysiologic levels and focus on brain functioning rather than psychopathology; consequently these procedures largely bypass the need