Surviving as a personality disorder service

Personality disorder services working along psychotherapeutic lines gained appeal with Health Care Commissioners following the publication of the National Institute for Health and Clinical Excellence (NICE) guidelines for Borderline & Antisocial Personality Disorders and the emerging successful application of psychoanalytically derived approaches. In parallel to this creative development, the economic downturn has faced the National Health Service (NHS) with considerable challenges in its ongoing survival. The potential for creative pursuit often then sits in competition, juxtaposed with the need to survive. We examine the impact of this dynamic upon the therapeutic efforts of a newly established personality disorder service. We suggest that both conscious and unconscious aspects stirred up within such encounters are demanding of the need for development of a capacity within each to bear contact with unfamiliar experiences. Through attention to that development, both patient and clinician may further enliven and enrich individual and collective identities, such that the potential to survive creatively is actualized.     

Autistic traits in mentalization-based treatment for concurrent borderline personality disorder and substance use disorder: Secondary analyses of a randomized controlled feasibility study

Autism is suggested to be a dimensional construct and often represents a comorbid state. However, research on the clinical implications of the presence of autistic traits is scarce. This study aimed to investigate the impact of subclinical autistic traits in mentalization-based treatment (MBT) for concurrent borderline personality disorder (BPD) and substance use disorder (SUD). Based on the data of a randomized controlled feasibility study by Philips, Wennberg, Konradsson, and Franck (2018), secondary analyses were conducted. It was tested, if patients’ (N = 46) levels of autistic traits were associated with treatment outcome measured in the course of and after treatment using interviews and self-report measures. Participants’ autistic traits were not associated with the change in the severity of BPD throughout and at the end of the treatment. However, results showed associations between autistic traits and the change in patients’ consumption of alcohol in the course of MBT. Furthermore, there was an association between autistic traits and the change in mentalizing capacity at the end of MBT, indicating that elevated autistic traits were associated with an improvement in mentalizing capacity. Autistic traits on a subclinical level do not appear to be a complicating factor in MBT for concurrent BPD and SUD. On the contrary, in terms of mentalizing capacity autistic traits might be associated with a larger potential for improvement or facilitate treatment outcome. Further research is needed to explore the role of higher autistic traits in treatment of this special patient group.     

Insecure attachment and personality disorder: a twin study of adults

This study used 239 twin pairs from a volunteer community sample to investigate how anxious and avoidant attachment are related to personality disorder (PD). Factor analysis showed that self‐reported anxious attachment and 11 PD scales from the Dimensional Assessment of Personality Problems loaded onto one factor (emotional dysregulation), and avoidant attachment and four PD scales loaded onto a second factor (inhibitedness). Biometric models indicated that 40% of the variance in anxious attachment was heritable, and 63% of its association with corresponding PD dimensions was attributable to common genetic effects. Avoidant attachment was influenced by the shared environment instead of genes. Correlations between avoidance and corresponding PD dimensions were attributable to experiences in the nonshared environment that influenced both variables. Copyright © 2006 John Wiley & Sons, Ltd.     

Millon's dimensional model of personality disorders: a comparative study

Millon has proposed six fundamental dimensions of general personality functioning as providing the underlying structure of personality disorders. However, this widely-cited theoretical model has been the subject of few empirical studies. The purpose of the current study was to directly compare the validity of this model to the five-factor model with respect to their hypothesized relationships with personality disorder symptomatology. Participants were administered the predominant measures of general personality functioning for each theoretical model, along with an assessment of personality disorder symptomatology. The results found only weak support for the theoretical model of Millon. Limitations and suggestions for future research are discussed.     

Single session treatment of a borderline personality disorder

Debbie, a patient in ongoing therapy, volunteered to assist in a workshop by participating in an interview. The goals of the session were to identify some small, discrete problem that could be worked on in the limited time available, and to demonstrate how a short-term treatment can be used.The issues considered revolved around Debbie's schema. Her early abuse set several schemas that have directed Debbie's life. The goals of the therapy would be to help modify those rules. The single session was a microcosm of a longer-term therapy. Overall, from the reports of the patient and her therapist, on follow-up, she was able to do the homework with the the therapist's assistance and found that it was helpful in countering the negative thoughts. This led to a lifting of the concomitant depression and a diminution in the self-injurious behavior.Many sessions would be needed to reinforce and strengthen the exercise strated in this session. Overall, I would see this session as both a successful treatment session and a demonstration of how identifying discrete, proximal goals can benefit patients with long-standing Axis II problems. The hypotheses and questions led to data gathering and hypothesis testing. Throughout the session, it was essential to be aware of the likely schemas so that some could be used in the session, while others were clearly avoided. By developing a conceptualization or model of the problem(s), a set of interventions could be mobilized within the session and as homework between sessions. By working toward a coping model of treatment rather than attempting to cure long-standing problems, brief cognitive behavioral interventions can be successful.     

Obsessive-compulsive disorder with and without tic disorder: a comparative study from India

Introduction: Evidence from phenomenological, family, genetic, and treatment studies from Western centers have suggested that tic-related obsessive-compulsive disorder (OCD) could be different from non-tic-related OCD. This study from India investigated the differences in OCD with and without tics, with respect to sociodemographics, symptom profile, and comorbidity, including obsessive-compulsive spectrum disorders, to examine whether the clinical profile of tic-related OCD is similar to that reported previously. Methods: Fifty subjects with OCD and tics (chronic motor tics and Tourette syndrome) were compared with 141 OCD subjects without tics. Results: Subjects having OCD with tics tended to be males, and had an earlier onset of illness. They had more of symmetry/aggressive and religious obsessions, and cleaning, ordering/arranging, hoarding, and repeating compulsions and were associated with trichotillomania and hypochondraisis. Stepwise backward (Wald) regression analysis showed that an early age of onset, male gender, aggressive obsessions, cleaning compulsions, and trichotillomania were significantly associated with tic-related OCD. Conclusion: The findings of this study from India are broadly similar to those reported previously from the West indicating the universality of differences in tic- and non-tic-related OCD. Our findings also support the existing evidence that tics contribute to the heterogeneity of OCD.     

Dialectical behavior therapy skills use as a mediator and outcome of treatment for borderline personality disorder

A central component of Dialectical Behavior Therapy (DBT) is the teaching of specific behavioral skills with the aim of helping individuals with Borderline Personality Disorder (BPD) replace maladaptive behaviors with skillful behavior. Although existing evidence indirectly supports this proposed mechanism of action, no study to date has directly tested it. Therefore, we examined the skills use of 108 women with BPD participating in one of three randomized control trials throughout one year of treatment and four months of follow-up. Using a hierarchical linear modeling approach we found that although all participants reported using some DBT skills before treatment started, participants treated with DBT reported using three times more skills at the end of treatment than participants treated with a control treatment. Significant mediation effects also indicated that DBT skills use fully mediated the decrease in suicide attempts and depression and the increase in control of anger over time. DBT skills use also partially mediated the decrease of nonsuicidal self-injury over time. Anger suppression and expression were not mediated. This study is the first to clearly support the skills deficit model for BPD by indicating that increasing skills use is a mechanism of change for suicidal behavior, depression, and anger control.     

My subdued ego: A psychodynamic case study of borderline personality disorder following relational trauma

Recent advances in the conceptualisation of borderline personality disorder (BPD) have highlighted the role of relational trauma as central to the onset of the disorder, whilst observing deficits in the structure of the self-concept as a result of developmental adversity. Understanding borderline states within a psychiatric framework alone has attracted significant criticism due to the lack of the medical model’s explanatory properties, which fail to account for the complexity and variation of borderline symptomatology. A reliance on psychodynamic formulation instead, can provide an aetiological framework where BPD can be understood as a disorder of the sense of self, originating in the client’s relational matrix. The purpose of the current paper is to discuss a borderline case study with a focus on formulation rather than diagnosis, in an attempt to shed light on the relational and unconscious processes underpinning the disorder and thus inform treatment interventions.     

Passive-aggressive (negativistic) personality disorder: a population-based twin study

The objective of this study was to investigate the familial aggregation of passive aggressive personality disorder (PAPD), and explore issues regarding PAPD raised by the DSM-IV Personality Disorder Work Group. Two thousand seven hundred and ninety-four Norwegian twins from the population-based Norwegian Institute of Public Health Twin Panel were interviewed with the Structured Interview for DSM-IV Personality (SIDP-IV). Because of the rarity of the twins meeting full diagnostic criteria for PAPD a dimensional representation of the disorder was used for the analyses. Overlap with other axis II disorders was assessed by polychoric correlations, while familial aggregation was explored by structural equation twin models. Overlap was highest with paranoid (r = 0.52) and borderline personality disorder (r = 0.53), and lowest with schizoid (r = 0.26). Significant familial aggregation was found for PAPD. The twin correlations and parameter estimates in the full model indicated genetic and shared environmental effects for females, and only shared environmental effects for males, but the prevalence of endorsed PAPD criteria in this community sample was too low to permit us to conclude with confidence regarding the relative influence of genetic and shared environmental factors on the familial aggregation of PAPD.     

Reactivity to sensations in borderline personality disorder: a preliminary study

Individuals with borderline personality disorder (BPD) are widely considered to have problems with emotional reactivity. However, the specific kinds of stimuli that are associated with heightened emotional reactivity in BPD have not been well characterized. Thus, it is unclear whether the emotional dysfunction in BPD occurs in response to any emotionally evocative stimuli, or to specific classes of stimuli. In this study, we used subjective measures (self-report and interview-based) to compare reactivity to sensations (auditory, gustatory, olfactory, tactile, visual) between participants with BPD (n = 30) and healthy controls (n = 50). Controlling for trait negative emotional reactivity, individuals with BPD reported being significantly more reactive across sensory stimuli. However, the difference between controls and BPD was significantly greater for reactivity to auditory stimuli compared to other sensory stimuli. Findings from this study provide preliminary data suggesting individuals with BPD may be characterized by heightened self-reported reactivity to aversive sounds.     

Affect and alcohol use: an ecological momentary assessment study of outpatients with borderline personality disorder

Alcohol use may be viewed as an attempt (albeit maladaptive) to regulate negative emotional states. We examined associations between both negative and positive affects and alcohol use in outpatient women diagnosed with borderline personality disorder (BPD; n=74), a prototype of emotional dysregulation, as well as a psychiatric control group of women with current depressive disorder (major depressive disorder/dysthymic disorder [MDD\DYS]; n=50). Participants completed randomly prompted reports of mood and alcohol use up to six times a day over a 28-day period using electronic diaries. Mean levels of either positive or negative affects did not distinguish between drinkers and nondrinkers in either diagnostic group. However, levels of both negative and positive affects were positively associated with alcohol use at the momentary level in BPD drinkers. More robust findings were obtained with respect to within-person affective variability, which was related to alcohol use in multiple ways. BPD drinkers showed higher within-person variability for most negative affects than BPD nondrinkers; MDD\DYS drinkers in general showed less within-person variability than MDD\DYS nondrinkers for negative affects. Multilevel lagged analyses for BPD drinkers indicated that alcohol use was positively related to variability in all affects, concurrently, but fewer significant effects of affect variability on the next day's drinking or significant effects of alcohol use on the next day's affect variability were observed. Among MDD\DYS drinkers, we observed more significant associations between affect variability on next day's alcohol use and of alcohol use on next day's affect variability. We discuss theoretical and methodological issues relevant to these findings as well as implications for future research.     

Word use of outpatients with a personality disorder and concurrent or previous major depressive disorder

In a recent study, Rude, Gortner, and Pennebaker (2004) found word use to be related to depression and vulnerability to depression in the essays of college students. We sought to replicate and extend these findings in a clinical sample. Written essays of 304 psychiatric outpatients with a personality disorder and a mixed psychiatric profile on DSM-IV axis-I and 108 healthy controls were examined with word count software. Data on the tendency to be discrepant about the current self compared to a more ideal self were also gathered. We found that psychiatric outpatients in general used more words referring to the self and negative emotion words and fewer positive emotion words, compared to healthy controls. However, word-use proved unrelated to depression specifically. Actual-ideal self discrepancies were related to patient status and to current depression. Contrary to our hypothesis, these discrepancies did not correlate with the use of words referring to the self. We conclude that the negative content and self-focus of written essays and high levels of discrepancy reflect a negative thinking style that is common to a range of psychiatric disorders rather than being specific to depression.     

Externalizing pathology and the five-factor model: a meta-analysis of personality traits associated with antisocial personality disorder, substance use disorder, and their co-occurrence

In this meta-analysis we examined Five-Factor Model of personality (FFM) characteristics of externalizing disorders. Two pathologies, Antisocial Personality Disorder (APD) and Substance Use Disorder (SUD), have significant levels of co-occurrence that may be due to shared personality traits. Results from 63 samples (N = 15,331) were analyzed in order to summarize and compare five-factor results for APD, SUD, and co-occurring APD/SUD. Shared and unique personality features were identified at both the domain and the facet level of the FFM. Moderation analyses indicated that sample source (clinical versus community) and diagnosis (psychopathy versus DSM-based APD) accounted for some of the variability at the domain level. Results are discussed with respect to personality and externalizing disorders.     

The development of a psychodynamic treatment for patients with borderline personality disorder: a preliminary study of behavioral change.

This study examines the effectiveness of a modified psychodynamic treatment called Transference Focused Psychotherapy (TFP) designed specifically for patients, with borderline personality disorder (BPD). Twenty-three female patients diagnosed with DSM-IV BPD began twice-weekly TFP. Patients were assessed at baseline and at the end of 12 months of treatment with diagnostic instruments, measures of suicidality, self-injurious behavior, and measures of medical and psychiatric service utilization. Compared to the year prior to treatment, the number of patients who made suicide attempts significantly decreased, as did the medical risk and severity of medical condition following self-injurious behavior. Compared to the year prior, study patients during the treatment year had significantly fewer hospitalizations as well as number and days of psychiatric hospitalization. The dropout rate was 19.1%. This uncontrolled study is highly suggestive that this structured and manualized psychodynamic treatment modified for borderline patients shows promise for the ambulatory treatment of these patients and warrants further study.     

The MCMI-III personality disorders scores predicted by the NEO-FFI-R and the ZKPQ-50-CC: a comparative study

This study was designed to compare the NEO-FFI-R versus the ZKPQ-50-CC in their relationships with the fourteen MCMI-III personality disorder scales in a Spanish non-clinical sample (N = 674). Previous studies showed consistent relationships between the Five Factor Model and the DSM-IV personality disorders (PD), but there is no comparative study between both Five Factor and Zuckerman's personality models. The aim was to replicate previous results about relationships between the Big-Five and PDs using the revised short version of the NEO-PI-R, and to compare the NEO-FFI-R versus the ZKPQ-50-CC regarding the relationships with MCMI-III personality disorder scales. Results showed no sharp differences between the NEO-FFI-R and ZKPQ-50-CC scales. Each instrument explained around 30% of the PDs MCMI-III scales variance. Using conjointly the 10 personality scales from the NEO-FFI-R and ZKPQ-50-CC, the PDs accounted variance rose to 38%. Differences and similarities between both short personality questionnaires are discussed.     

Integrated treatment: a conceptual framework for an evidence-based approach to the treatment of personality disorder

Evidence that various therapies are effective in treating personality disorder and that outcome does not differ substantially across treatments suggests that it is time replace concerns about the efficacy of specific therapies and which form of therapy to use with an evidence-based approach that combines methods that work from all therapies. A framework is proposed for selecting and combining eclectic treatment methods and delivering them in a coordinated way. The framework has two components: (1). a system for conceptualizing personality disorder based on empirical knowledge about the structure, etiology, development, and stability of personality pathology to use as a guide to selecting interventions and planning the sequence in which they will be used; and (2), a model of therapeutic change based on the general literature on psychotherapy outcome and specific studies of PD treatments. The framework proposes that integrated treatment be organized around general principles of therapeutic change common to all effective therapies supplemented with more specific treatment methods taken from the different therapies as needed to tailor treatment to individual patients and treat specific problems and psychopathology. The coordinated delivery of such a diverse array of interventions is achieved by using a phases of treatment scheme that proposes that treatment focus on specific symptoms and problems is a systematic and orderly way according to their stability and potential for change.     

Borderline personality: traits and disorder

Although the 5-factor model (FFM) has been advocated as an alternative to representing the construct of borderline personality, some argue that this diagnosis carries essential information that is not well captured by the FFM. The present study examined antecedent, concurrent, and predictive markers of construct validity in a sample of 362 patients with personality disorders. The results indicated that neuroticism best distinguished borderline and nonborderline patients, whereas the FFM as a whole captured a sizable proportion of the variance in the borderline diagnosis. However, the residual of the borderline diagnosis that was not explained by the FFM was found to be significantly related to childhood abuse history, family history of mood and substance use disorders, concurrent symptoms, and 2-year and 4-year outcomes. Thus, some elements of the borderline diagnosis may not be fully captured in a 5-factor representation.     

A pilot study of the DBT coach: an interactive mobile phone application for individuals with borderline personality disorder and substance use disorder

Dialectical behavior therapy (DBT) has received strong empirical support and is practiced widely as a treatment for borderline personality disorder (BPD) and BPD with comorbid substance use disorders (BPD-SUD). Therapeutic success in DBT requires that individuals generalize newly acquired skills to their natural environment. However, there have been only a limited number of options available to achieve this end. The primary goal of this research was to develop and test the feasibility of the DBT Coach, a software application for a smartphone, designed specifically to enhance generalization of a specific DBT skill (opposite action) among individuals with BPD-SUD. We conducted a quasiexperimental study in which 22 individuals who were enrolled in DBT treatment programs received a smartphone with the DBT Coach for 10 to 14 days and were instructed to use it as needed. Participants used the DBT Coach an average of nearly 15 times and gave high ratings of helpfulness and usability. Results indicate that both emotion intensity and urges to use substances significantly decreased within each coaching session. Furthermore, over the trial period, participants reported a decrease in depression and general distress. Mobile technology offering in vivo skills coaching may be a useful tool for reducing urges to use substances and engage in other maladaptive behavior by directly teaching and coaching in alternative, adaptive coping behavior.