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Abstract Introduction Poor mentalizating has been described as a characteristic of Antisocial Personality Disorder (ASPD), along with the well-established role of aggressiveness. In the current study, we tested this hypothesis focusing on a specific aspect of mentalization (i.e., mindfulness). Method We explored the unique and joint contribution of aggression dimensions and mindfulness facets to ASPD traits in an offender sample (N = 83). Results Mindfulness deficits were associated with ASPD traits, and a unique association emerged between difficulties in Acting with Awareness and ASPD. Likewise, physical aggression confirmed its association with ASPD traits. Moderation analyses revealed that mindfulness interacted with aggression in predicting ASPD. Specifically, at low levels of mindfulness, the association between aggression and ASPD dropped to nonsignificance. Conclusions Results suggest that fostering self-mentalizing is a relevant treatment target when treating persons with ASPD.

Introduction Understanding the psychological mechanisms associated with Antisocial Personality Disorder (ASPD) and related aggression is needed in order to fine tune treatment and address the appropriate targets in psychotherapy. Actually, even in the most recent descriptions, the diagnosis of ASPD (DSM-5) [1] is mostly made according to behavioral indexes, which provide insufficient information to the treating clinician [2]. A deeper understanding of underlying psychological factors is urgent in light of recent evidence counteracting the longstanding pessimism about the possibility to treat individuals with antisocial traits or full-blown disorders. Evidence is emerging that at least some with these problems can be treated albeit with limited success[3,4]. Thus, a more comprehensive knowledge about what predates antisocial behaviors, and in particular aggression, may guide the clinician and tackle the underpinnings of the disorder with the potential to dismantle the mechanisms leading the person to attack others or violate the rules [5,6]. (See Fig. 1.) (See Table 1, Table 2 and Table 3.) Interaction effect (i.e., Physical Aggression × Act with Awareness) ... Figure 1. Interaction effect (i.e., Physical Aggression × Act with Awareness) significantly predicted Antisocial Personality Disorder (ASPD) traits. Simple slopes analysis here reported showed that, at higher levels of mindfulness (indexed by Act with Awareness scale), participants with higher levels of aggression (here, Physical Aggression) reported significantly higher levels of ASPD traits than those with lower level of aggression. On the contrary, among participants with lower levels of mindfulness, the association between aggression and ASPD traits was nonsignificant, such that no differences emerged in levels of ASPD traits between those scoring higher and lower on aggression. Figure options Table 1. Descriptive statistics and intercorrelations among key variables. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 1. ASPD --- .549** .246* .478** .225* .077 -.216* -.463** -.340** .047 2. Physical Aggression --- .380** .664** .403** .069 -.302** -.365** -.296** -.030 3. Verbal Aggression --- .392** .218* .076 .044 -.070 -.110 -.013 4. Anger --- .499** -.011 -.335** -.418** -.402** -.043 5. Hostility --- .045 -.262* -.389** -.269* .130 6. Observe --- .295** -.230* -.419** .467** 7. Describe --- .529** .241* .253* 8. Act with Awareness --- .648** -.218* 9. Non Judge --- -.359** 10. Non React --- Mean 60.39 21.12 13.96 16.96 21.13 23.10 26.28 30.59 28.08 19.31 Standard Deviation 20.36 6.95 3.79 5.34 5.99 6.50 5.69 6.53 6.05 4.34 Note. ASPD = Antisocial Personality Disorder scale of the Millon Clinical Multiaxial Inventory–III. Physical Aggression to Hostility are scales of the Aggression Questionnaire. Observe to Non React are scales of the Five Facet Mindfulness Questionnaire. * p < .05, two-tailed. ** p < .01, two-tailed Table options Table 2. Multiple regression analyses examining the unique associations of aggression (Model 1, left side) and mindfulness (Model 2, right side) dimensions with ASPD traits (N = 83). Model 1 (criterion variable: ASPD dimensional score) Model 2 (criterion variable: ASPD dimensional score) Predictors B β Predictors B β Physical Aggression 1.231 .420** Observe -.228 .075 Verbal Aggression .063 .012 Describe .412 .115 Anger .851 .223 Act with Awareness -1.513 -.485** Hostility -.199 -.059 Non Judge -.397 -.118 Non React -.452 -.096 Model 1 Summary Model 2 Summary R2 .327** R2 .230** Cohen f2 .486 Cohen f2 .299 Note. In Model 1, all predictors are scales of the Aggression Questionnaire. In Model 2, all predictors are scales of the Five Facet Mindfulness Questionnaire. In both models, the criterion variable (i.e., ASPD) is the Antisocial Personality Disorder scale of the Millon Clinical Multiaxial Inventory–III. Both unstandardized (B) and standardized (β) regression coefficients are reported. In each regression model, R2 indicates the proportion of variance in the dependent variable explained by . Cohen f2 is an index of effect size. ** p < .01, two-tailed. Table options Table 3. Hierarchical multiple regression analysis predicting MCMI–III ASPD score (N = 83). Predictor B β R2 (Cohen f2) ∆R2 (Cohen f2) F ∆F Step 1 .381** (.616) 24.658** AQ Physical Aggression 1.286 .439** FFMQ Act with Awareness -.944 -.303** Step 2 .492** (.969) .111** (.125) 25.517** 17.229** AQ Physical Aggression 1.325 .452** FFMQ Act with Awareness -1.000 -.321** Physical Aggression × Act with Awareness .142 .334** Note. MCMI–III ASPD = Antisocial Personality Disorder scale of the Millon Clinical Multiaxial Inventory–III. AQ = Aggression Questionnaire. FFMQ = Five Facet Mindfulness Questionnaire. Both unstandardized (B) and standardized (β) regression coefficients are reported. In each regression model, ΔR2 indicates the proportion of variance in the criterion variable (i.e., the MCMI–III ASPD scale) accounted for by the interaction term alone, whereas Step 1 R2 indicate the percentage of variance explained by Physical Aggression and Act with Awareness only, and Step 2 R2 indicate the overall portion of variance in the criterion variable explained by the model as a whole (i.e., by the two predictors and their interaction). At each R2 (and ΔR2) value correspond an F (or ∆F) to assess the statistical significance of the result. Cohen f2 is an index of effect size. * p < .05, two-tailed. * p < .01, two-tailed. Table options According to some scholars [7–11], one putative mechanism underlying aggressive behavior in individuals with ASPD is a deficit in aspects of what has been named mentalization [12,41] or metacognition [13,14,51]. Mentalization is defined as the capacity to reflect and think about one’s mental states, to distinguish one’s own mental states from others, and to understand the actions of oneself and others as meaningful (i.e., based on intentional mental states) [15]. Mentalizing failures pave the way for violent acts [16]. When levels of arousal are high, persons with ASPD tend to fail in understanding both their own mental states and the one of the others. In presence of disturbing bodily sensations elicited by the others, a sense of threat and humiliation and shame are likely activated [17], the world is perceived as hostile and malevolent and violent reactions are likely to occur [8,18,19]. Overall, when persons with ASPD feel that their self-worth is threatened, the emotional inability to think about one’s feelings makes this sensation impossible to regulate, with physical or psychological aggression as the only strategy they think is effective. For example, under the menace of abandonment and the consequent feeling of humiliation, a man with ASPD can think that insulting or menacing the partner is the only meaningful solution to protect oneself from these feelings [8,17]. In parallel, metacognition [13,14,51] refers to a series of processes that people enact in order to recognize mental states both in the self and in others; metacognition includes reflecting about mental states, such as grasping cause-effect connections between relational events, beliefs, emotions, and behaviors; it also involves the capacity to recognize that one’s own beliefs are subjective and that what happens among humans may be seen differently when one looks at thing from a different angle. Metacognition also includes mastery, which is the use of knowledge on mental states for purposeful problem solving. Studies on the role of mentalizing and metacognitive dysfunctions in aggression suggest they actually play a role in aggressive behaviors. Dolan and Fullam [20] found that people with ASPD (either with or without comorbid psychopathy) reported impairments in mentalization, as elicited by a subtle mentalization task (i.e., the faux pas task), in spite of intact abilities in cognitive theory of mind; ASPD participants were able to detect and understand faux pas, but showed indifference with regard to the impact of faux pas. Further, mentalization deficits were associated with psychopathic traits and proactive aggression in adolescents, and mentalization also played a moderating role such that among adolescents with high psychopathic traits, those with greater mentalization abilities reported lower rates of aggression [21]. Beyond confirming the role of mentalization deficits in antisociality and aggression, these findings suggested that increased mentalization could serve as a protective factor toward aggression among people with antisocial/psychopathic traits, possibly representing an important treatment target. Beeney et al. [22] further reported that mentalization deficits mediated the relationship between attachment insecurities and ASPD traits in both personality disordered outpatients and community participants. Moreover, poor emotional awareness has been linked to sadistic and antisocial personality features among nonclinical participants [23,24]. Finally, a deficit in mentalized affectivity (i.e., alexithymia) [25, 53] was related to both antisocial and psychopathic traits in a sample of addicted patients [26]. At least in persons with psychosis, impaired metacognition mediates the relation between psychopathic tendencies and aggression. In particular, a specific pattern of deficits associated with psychopathic tendencies and aggression emerged, with relatively intact cognitive metacognitive skills, and impaired emotional metacognitive abilities [27]. Of note, in populations with schizophrenia and a history of criminal behavior, poor metacognition is also related to poor social functioning [28], suggesting that impairments in this capacity bear severe damages to these persons’ life. One prominent aspect of the metacognitive or mentalizing network of abilities is mindfulness. Mindfulness has mainly been conceptualized as the proneness to be attentive to and aware of what is taking place in one’s inner world in the present, as well as the ability to keep one’s consciousness active to the present reality [29,30]. Conversely, lack of awareness of self-states and of the ability to purposefully regulate attention and calm oneself down are features of mindfulness deficit which also describe mentalizing and metacognitive failures. Of note, such an impairment in mindfulness abilities is consistent with the above mentioned characteristic of ASPD. More specifically, as defined here, mindfulness encompasses the ability to: attend to external and internal sensory stimuli and associated cognitions and emotions; label and describe inner experiences with words; act with awareness of personal motives (i.e., the capacity to pay an ongoing attention and be aware of present activities as they relate to inner experiences); assume a non-judgmental stance towards one’s own thoughts and emotions while thinking about them; and to be able to perceive thoughts and feelings—especially if distressing—without feeling overwhelmed or compelled to emotionally react to them [31]. It is therefore warranted to investigate the role of mindfulness measures as an index of dysfunctions in the mentalizing or metacognitive network. To date, the link between mindfulness and ASPD has rarely, to the best of our knowledge, been investigated. Fossati et al. [32] found that mindfulness deficits were related to self-reported (but not assessed by an interviewer) ASPD traits in an outpatient clinical sample. However, full blown ASPD was only marginally represented in that sample, thus limiting the generalizability of these findings. In the current study, we tested the following hypotheses in a chronically violent population: first, we expected that mindfulness and aggression dimensions were related to one another, and were in turn associated with ASPD traits. Then, we investigated whether specific dimensions of mindfulness and aggression predicted ASPD traits. Furthermore, we tested a moderation model in order to elucidate whether mindfulness played a role in the association between trait aggression and ASPD traits, for example if the role of aggressiveness as a core component of ASPD actually depends on levels of mindfulness.

Results The means, standard deviations, and intercorrelations for all measures are listed in Table 1. Although in the present study we used the dimensional score of ASPD traits, it may be worth noting that in our sample 22 participants (26.5%) had a diagnosis of ASPD according to the MCMI-III benchmarks [33]. Inspection of the correlation matrix revealed that ASPD was positively related to all aggression dimensions, and negatively with three mindfulness facets. Specifically, low levels of Describe, Act with Awareness, and Non Judge were associated with greater levels of ASPD traits. The same three scales of the FFMQ were also negatively related to Physical Aggression, Anger, and Hostility. Partly consistent with previous study involving nonmeditating samples (e.g., [37,52]), the Observe scale of the FFMQ showed nonsignificant relations with ASPD and aggression, and negative correlations with others mindfulness facets, as did the FFMQ Non React scale. Regression models predicting ASPD dimensional score were significant for both aggression dimensions , F(4, 78) = 9.488, p < .001, and mindfulness facets, F(5, 77) = 4.596, p < .01. Specifically, as shown in Table 2, the Physical Aggression scale of the AQ uniquely and independently explained roughly the 33% of variance in ASPD, with large effect size. Thus, at higher levels of Physical Aggression higher levels of ASPD traits were present. Likewise, the FFMQ Act with Awareness facet showed medium effect size in predicting ASPD scores, explaining 23% of unique variance, meaning that lower levels of Act with Awareness corresponded to higher levels of ASPD traits. As a result, the interaction hypothesis was tested between the Physical Aggression scale of the AQ and the Act with Awareness scale of the FFMQ, hypothesizing a moderating role of the latter in the association between Physical Aggression and ASPD. As shown in Table 3, hierarchical regression analysis revealed that both Physical Aggression (positively) and Act with Awareness (negatively) were significantly related to ASPD when controlling for the shared variance between each other (Step 1), accounting for about 38% of variance and showing a large effect size. Moreover, in Step 2, the interaction of Physical Aggression and Act with Awareness was significant, explaining an incremental amount of variance above and beyond their independent contribution. According to Aiken and West’s [38] benchmark, the interaction effect was small to medium in magnitude, accounting for approximately 11% of variance in ASPD. As a whole, the model explained roughly 49% of the variance in ASPD dimensional score, with a large effect size. Simple slopes analysis further revealed a significant positive association between Physical Aggression and ASPD among participants with higher levels of mindfulness (indicated by scores greater than one SD above the mean on the Act with Awareness scale of the FFMQ; Physical Aggression B = 2.250, β = .768, p < .001; Act with Awareness B = -1.000, β = -.321, p < .001; interaction B = .142, β = .473, p < .001). Conversely, among participants with low levels of mindfulness, the association between Physical Aggression and ASPD traits was trivial and nonsignificant (B = .400, β = .136, p = .23), whereas both Act with Awareness (B = -1.000, β = -.321, p < .001) and the interaction term (B = .142, β = .446, p < .001) remained significant predictors of ASPD. A graphical depiction of the moderation effect is reported in Figure 1. VIF values never exceeded 2.49, signifying that least squares method could be used since multicollinearity did not bias regression results.