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.     

DSM-IV criteria for borderline personality disorder: A critical evaluation

The present article critically examines the diagnostic criteria for borderline personality disorder (BPD) recently proposed by the DSM-IV Axis II work group (Gunderson, J. G., et al., Journal of Personality Disorders, 5, 340–352, 1991). It is concluded that some of the revisions are trivial and there is insufficient justification for others. The revisions are likely to increase the overlap between BPD and other disorders and represent an attempt to retain a categorical classification in the face of evidence that a dimensional model is more appropriate. Evidence suggests that many borderline traits are manifestations of extreme neuroticism.     

Patterns of emotional availability between mothers and young children: Associations with risk factors for borderline personality disorder

Emotional availability (EA) characterizes a warm, close relationship between caregiver and child. We compared patterns (clusters) of EA on risk factors, including those for borderline personality disorder (BPD). We sampled 70 children aged 4 to 7 years from low socio‐economic backgrounds: 51% of whose mothers had BPD. We coded filmed interactions for EA: mothers' sensitivity, structuring, non‐intrusiveness, non‐hostility, and children's responsiveness to, and involvement of, mothers. We additionally coded children's over‐responsiveness and over‐involvement. Using person‐centred analyses, we identified four clusters: high functioning, low functioning, asynchronous (mothers above average on two of four dimensions and children below), and below average. Mothers in the low‐functioning cluster had lower income, less social support, more of the borderline feature of negative relationships, and more depression than did mothers in the high‐functioning cluster. The children in the low‐functioning group had more risk factors for BPD (physical abuse, neglect, and separation from, or loss of caregivers, and negative narrative representations of the mother–child relationship in their stories) than did children in the high‐functioning group. The asynchronous group included older girls who were over‐responsive and over‐involving with their mothers in an apparent role reversal. Interventions targeting emotional availability may provide a buffer for children facing cumulative risks and help prevent psychopathology.

Highlights

• This paper investigated how mother‐child emotional availability (warmth and closeness) relates to risk factors for borderline personality disorder, including mother‐child role reversal.
• In filmed mother‐child interactions, low emotional availability was associated with risk for borderline personality disorder and role reversal was more likely for older girls.
• Findings support the cumulative risk hypothesis and may inform interventions to improve mother‐child emotional availability to prevent the development of psychopathology.

     

Emotional dysfunction in avoidant compared to borderline personality disorder: A study of affect consciousness

Knowledge of emotional dysfunction in patients with avoidant personality disorder (APD) is much needed. The present study examined affect consciousness (AC) in patients with APD compared to borderline personality disorder (BPD). AC, defined as capacity to perceive, reflect on, tolerate, and express emotional experiences, is assumed to be central to structure‐building in personality. The study tested the hypotheses that patients with APD have lower general AC and lower AC for pleasant affects compared to BPD. Fifty‐nine patients, 26 with APD and 33 with BPD were rated on several aspects of AC using the specialized AC interview. The structured interview SCID‐II was applied for diagnostic evaluations. The APD group had significantly lower levels of global AC and conceptual expressivity compared to the BPD group. Among 11 specific affects the APD group had significantly lower AC for interest and contempt. Emotional dysfunction is an important feature of APD and the findings indicate that psychotherapies for APD patients should focus on emotional experiences, aiming to improve emotional awareness, tolerance, and expressivity. The notion of a general avoidance of positive emotions in APD needs further exploration, including a possible dysfunction in the evolutionary based neuro‐affective Seeking system.     

Differential effects of the menstrual cycle on reactive and proactive aggression in borderline personality disorder

Borderline personality disorder (BPD) is characterized by rapidly shifting symptoms, including intense anger and aggressive behavior. Understanding how fluctuations in ovarian hormones across the menstrual cycle may contribute to symptom instability is key for accurate assessment of BPD symptoms and effective interventions. Reactive and proactive aggression, as well as anger-in and anger-out, were assessed daily in 15 physically healthy, unmedicated naturally cycling female individuals meeting criteria for BPD across 35 days. Urine luteinizing hormone surge and salivary progesterone were used to confirm ovulation and verify the cycle phase. Multilevel models evaluated cyclical differences of symptoms between cycle phases. Both forms of aggressive behavior demonstrated marked cycle effects, with reactive aggression highest during the midluteal cycle phase, co-occurring with initial increases in anger and irritability and followed by perimenstrual peaks in anger and anger-in. In contrast, highest levels of proactive aggression were observed during the follicular and ovulatory phases, when emotional symptoms and anger were otherwise at lowest levels. These findings highlight the importance of identifying the function of aggression when considering potential psychological and biological influences. Naturally cycling individuals with BPD may be at elevated risk for luteal worsening of a range of interpersonally reactive symptoms, including reactive aggression, whereas proactive aggression may occur more in phases characterized by less emotional and cognitive vulnerability and greater reward sensitivity. Research on aggression in this population should consider cycle effects. Cycling individuals with BPD attempting to reduce aggressive behavior may benefit from cycle-tracking to increase awareness of these effects and to develop appropriate strategies.     

Examining the relationship between emotion regulation deficits and borderline personality disorder features: A daily diary study

This study used a six-day daily diary methodology to precisely specify the nature of emotion regulation deficits associated with borderline personality disorder (BPD) features. Three possibilities were explored: that BPD features are associated with (1) the overall underuse of emotion regulation strategies; (2) the overuse of dysfunctional and the underuse of functional strategies; and (3) the lower perceived effectiveness of emotion regulation strategies. One hundred and fifty-four undergraduate participants completed self-report measures of BPD feature severity, and then reported their daily negative emotional intensity, whether or not they used various emotion regulation strategies, and whether or not the strategies that they used were effective across a six-day period. Higher BPD features were associated with (a) higher total frequency use of emotion regulation strategies; (b) higher frequency use of dysfunctional and functional emotion regulation strategies; and (c) less self-reported effectiveness of functional strategies. BPD features may be characterized by increased attempts to regulate emotions, without corresponding increases in perceived effectiveness.     

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.     

Clients with borderline personality disorder: Exploring their experiences of dialectical behaviour therapy

This study explores clients’ experiences of Dialectical Behavioural Therapy (DBT). Five participants, all with a diagnosis of borderline personality disorder, were interviewed following a semi‐structured format about their experiences of an NHS regional DBT programme. The interviews were transcribed and analysed using Interpretative Phenomenological Analysis (IPA). Three superordinate themes were identified consisting of a number of sub themes: joining a DBT Programme (external and internal factors); experience of DBT (specific and non specific factors); and evaluation of DBT (change, evaluation and role of the past and future). The study provides an insight into clients’ experiences of DBT. The results are discussed in relation to clinical practice and future research.     

Changes in schemas of patients with severe borderline personality disorder: The Oulu BPD study

Borderline personality disorder (BPD) is a relatively common and severe psychiatric disorder that can impair quality of life in many ways. The aim of this study was to determine whether a combined treatment model for BPD patients, utilising major principles from schema‐focused therapy (SFT) and dialectical behavioral therapy (DBT), could be more effective in relieving early maladaptive schemas of BPD patients, compared to treatment as usual (TAU). This study is a part of the Oulu BPD study conducted at mental health care services run by Oulu city social and health care services. The study is a multisite, randomized controlled trial conducted over a one year period, involving two groups of patients with severe BPD: (1) Community Treatment By Experts (CTBE) patients (n = 18) receiving the combined treatment model, and 2) TAU patients (n = 27). The patients' schemas were assessed using the Young Schema Questionnaire (YSQ‐L3a) before and after one year of treatment. The results reveal that CTBE patients who attended the combined treatment model showed a statistically significant reduction in eight out of 18 early maladaptive schemas, while patients receiving treatment as usual did not demonstrate any significant changes in schemas. The cognitive therapeutic treatment model can be applied for clinical use in public mental health settings using existing professionals, and appears to produce positive changes in patients with BPD.     

Borderline personality disorder and laboratory-induced cold pressor pain: Evidence of stress-induced analgesia

Behavioral neuroscience findings regarding stress-induced analgesia may be an appropriate model for the paradoxical effects of self-mutilative pain of patients with borderline personality disorder (BPD). We hypothesized that BPD patients would show an exaggerated antinociceptive effect from an uncontrollable cold pressor stress, compared to persons with other personality disorders or to a nonpsychiatric control group. This hypothesis was supported. Limitations of the study and directions for future research are discussed.     

No evidence for overgeneral memories in borderline personality disorder

The hypothesis that borderline personality disorder (BPD) is related to overgeneral memories was tested in a mixed sample of 39 patients. A memory test with emotional cue words and the instruction to produce specific autobiographical memories was used. Specificity was judged by an independent rater. Regression analyses indicated that age and major depressive disorder were related to the production of less specific memories, whereas educational level and presence of personality disorder were positivily related to number of specific memories. Borderline personality disorder, anxiety disorders and childhood traumas were not related to number of specific memories.     

The HoST programme: A pilot evaluation of modified dialectical behaviour therapy with female offenders diagnosed with borderline personality disorder

The Holloway skills therapy programme (HoST) at Her Majesty’s Prison and Young Offenders’ Institution Holloway is provided to women who, because of problematic behaviour associated with borderline personality disorder, are often excluded from treatment in prison and in the community. HoST addresses issues of offending behaviour, self-harm, suicidality and indiscipline, through a modified evidence-based treatment modality, dialectical behaviour therapy (DBT), which is a form of cognitive behaviour psychotherapy. This paper will outline the possibility of a modified DBT approach to working with female offenders in the prison setting. A pilot evaluation of female prisoners who received the treatment is also presented through a range of quantitative measures. In turn, positive outcomes with regard to reduction in time spent on the assessment and care in custody teamwork process, reduction in adjudications and improved overall mental health are presented. These findings are discussed along with the implications for clinical practice in the prison setting. The need for future structured research is also discussed.     

The social problem-solving abilities of people with borderline personality disorder

Interventions for people suffering from borderline personality disorder (BPD), such as dialectical behaviour therapy, often include a problem-solving component. However, there is an absence of published studies examining the problem-solving abilities of this client group. In this study, the social problem-solving (SPS) abilities of three groups of participants were assessed: a BPD group (n=25), a clinical control (CC) group (n=25) procedure and a non-clinical control (NCC) group (n=25). SPS ability was assessed using the means-end problem-solving (MEPS) procedure and the Social Problem-Solving Inventory-Revised (SPSI-R). The BPD group exhibited deficits in their SPS abilities, however the majority of these deficits were not specific to the BPD group but were also found in the CC group, indicating that a common factor between these two groups, such as negative affect, may account for these observed deficits. Specific SPS deficits were identified in the BPD group: they provided less specific solutions on the MEPS and reported higher levels of negative problem orientation and a more impulsive/carelessness style towards solving social problems. The results of this study provide empirical support for the use of problem-solving interventions with people suffering from BPD.     

Borderline personality disorder,complex trauma,and problems with self and identity: A social-communicative approach

Borderline personality disorder (BPD) is a relatively highly prevalent psychiatric disorder that is associated with very high personal and socioeconomic costs. This paper provides a state-of-the-art review of the relationship between complex trauma and key features of BPD, with a focus on problems with self-coherence and self-continuity. We first review evidence for the high prevalence of complex trauma in BPD patients. This is followed by a discussion of emerging knowledge concerning the biobehavioral mechanisms involved in problems related to self and identity in BPD. We emphasize three biobehavioral systems that are affected by complex trauma and are centrally implicated in identify diffusion in BPD: the attachment system, mentalizing or social cognition, and the capacity for epistemic trust—that is, an openness to the reception of social communication that is personally relevant and of generalizable significance. We formulate a new approach to personality and severe personality disorders, and to problems with self and identity in these disorders, rooted in a social-communicative understanding of the foundations of selfhood. We also discuss how extant evidence-based treatments address the above-mentioned biobehavioral systems involved in identity diffusion in BPD and related disorders, and the supporting evidence. We close the paper with recommendations for future research.     

Sustained efficacy of dialectical behaviour therapy for borderline personality disorder

Dialectical Behaviour Therapy (DBT) is considered one of the most promising treatments for borderline personality disorder (BPD). Recently, we reported significantly positive effects of 12 months DBT on parasuicidal behaviour and impulsivity in a mixed group of female BPD patients with and without substance abuse. Fifty-eight women with BPD were randomly assigned to either 52 weeks of DBT or treatment as usual (TAU). Follow-up assessment took place at 78 weeks, i.e., 6 months after discontinuation of DBT. Participants were clinical referrals from addiction treatment and psychiatric services. Outcome measures included parasuicidal behaviour, impulsivity and substance abuse. Six months after treatment discontinuation, the benefits of DBT over TAU in terms of lower levels of parasuicidal and impulsive behaviours, and in alcohol use, sustained. No differences between the treatment conditions were found for drug abuse. In conclusion, DBT seems to have a sustained effect on some of the core symptoms of BPD and on alcohol problems in a mixed population of female borderline patients with and without substance abuse problems.     

Structural models of psychotherapy groups and their effect on inpatients with borderline personality disorders: Patients' perceptions

This research compares the way in which various group structural models affect self-understanding, interpersonal relationships and catharsis in hospitalized patients with borderline personality disorders. Each of the models is characterized by a different combination of group focus and leadership style. Three psychotherapy groups were chosen as paradigms: the dynamic psychotherapy group; the therapeutic games group, and psychodrama group. Sixty three inpatients with borderline personality disorders participated in the study. The one-way ANOVA yielded significant differences between the group models. Results of the post-hoc t-test showed that the dynamic and the games groups were perceived by the patients as more beneficial than psychodrama.     

‘Seeing beyond the battled body’ – An insight into selfhood and identity from women's accounts who self‐harm with a diagnosis of borderline personality disorder

Background: Self‐harm (self poisoning and self‐injury) is broadly characterised as any act intended to harm one's own body, without a conscious intent to die. Research indicates that when practitioners encounter self‐harm they often remain anxious, fearful, frustrated, and challenged about such individuals, principally because they are constrained to understand and respond to self‐harm almost exclusively within a problematised discourse (Walker, 2006). That is, a problem that must be diagnosed and contained. Women who self‐harm with a diagnosis of BPD are often portrayed as being risky, chaotic and their identity can be unstable. The aim of this study was to examine and explore the subjective experiences of women who self‐harm with a diagnosis of BPD. Participants: Four women who had a history of self‐harming behaviour with the diagnosis of BPD volunteered for the study. Method: Face‐to‐face, in‐depth narrative interviews were undertaken and were analysed within a framework which drew upon aspects of the ‘performance’ (Langellier, 1989; 2001) and ‘narrative thematic’ approaches (Reissman, 1993). Findings: Two of the participant's accounts illustrate how their self‐harming appeared to have affected their selfhood and sense of agency. They discuss how the external signs of self‐harm may take over their identity and how others communicate and interact with them. Despite the problematic nature of self‐harm implications for practice are highlighted which practitioners may draw upon in their work around self‐harm.     

A comparison of three personality disorder assessment approaches

Three approaches to the assessment of DSM-III personality disorders are compared by examining the manner in which interrelationships between disorders are portrayed by the different techniques. Although a fair degree of convergence was noted among the three techniques, several differences were also observed. These comparisons, particularly the noted contrasts, have implications for future researchers using these techniques.