Affect in early memories of borderline patients

Psychoanalytically oriented observers using the framework of object relations theory noted that patients with borderline personality organization manifest serious pathology in their capacity to use internalized imagery to cope with the vicissitudes of separation-individuation. This study examined one source of such imagery, the affect associated with a specific sample of early memories, including the earliest recollections of parents. Patients with borderline personality disorder were compared with paranoid schizophrenics and patients with neurotic character pathology. Forty-five outpatients, 15 in each group, participated in the study. It was found that borderline patients had significantly fewer positively toned early memories than neurotics or paranoid schizophrenics. Only the neurotic group, had a majority of affectively positive memories. The results are generally consistent with object relations theories of borderline psychopathology.     

Emotions as wishes and beliefs

Emotions can be assessed by means of different diagnostic methods, for example, by self-report instruments, ratings of facial expressions, or by projective techniques. This study presents an alternative approach: a computerized investigation of verbally expressed emotions by means of the Affective Dictionary Ulm (ADU; Dahl, H?lzer, & Berry, 1992), which was applied to responses in the Holtzman Inkblot Technique (HIT; Holtzman, 1988; Holtzman, Thorpe, Swartz, & Herron, 1961). A normal group (n = 30), patients with neurotic disorders (n = 30), borderline patients (n = 30), acute schizophrenics (n = 25), and chronic schizophrenics (n = 25) were compared in regard to verbally expressed emotions. According to the results, patients with neurotic disorders did not differ from the normal group in regard to verbally expressed emotions. Borderline patients expressed fear and emotions in general significantly more frequently than all other diagnostic groups. Furthermore, borderline patients differed in regard to specific emotions from patients with neurotic disorders, acute schizophrenics, and chronic schizophrenics. Acute schizophrenics did not differ from the normal group in regard to the expression of emotions, whereas chronic schizophrenics expressed anger, fear, anxiety, and emotions in general significantly less frequently than normals. By a discriminant analysis using verbally expressed emotions as predictors of the diagnosis, hit rates between 87% and 100% could be achieved. Furthermore, hypotheses about correlations between emotions on the one hand and internalized primitive object relations and bizarre-idiosyncratic thinking were tested empirically. Significant correlations could be demonstrated. These results support the validity of assessing emotions through a lexical content analysis of the HIT by use of the ADU.     

The relationship between traumatic experiences, dissociation, and borderline personality pathology among male forensic patients and prisoners

In the present study the relationship between traumatic experiences, dissociation, and borderline personality disorder pathology is examined in a group of 39 male forensic patients and 192 male prisoners. Sexual and emotional abuse are significantly more common among forensic patients than among prisoners. Patients also report a broader range of different kinds of traumas. Prisoners report significantly more dissociative symptoms. Analyses of the relationship of type of trauma on the one hand and dissociation and borderline personality pathology on the other show that sexual abuse is significantly associated with borderline personality pathology but not with dissociation among the patients. In the prison sample these associations are found only for familial but not extrafamilial sexual abuse. When the subjects are grouped on account of presence or absence of a borderline personality disorder, highly significant differences on dissociation are found between both groups. The results from this study lend support to the hypothesis that sexual abuse is not related to dissociative symptoms but merely to borderline personality pathology. Because most subjects in this study are not patients, these findings are not likely to be confounded by false memories of traumatic events that are recovered by psychotherapy. Furthermore, dissociative symptoms are found to be related to borderline personality pathology and not to the experience of traumatic events.     

Internalization of the therapeutic process: differences between borderline and neurotic patients

Intersession process in psychotherapy refers to the thoughts, memories, and feelings about each other and about their therapy sessions that participants experience during the intervals between sessions. This study compared the intersession process experienced by patients who had been diagnosed with severe borderline personality disorders (BPD) with others who had not. A total of 76 patients with neurotic disturbances and 20 patients with BPD were treated in a therapeutic day clinic and completed the Intersession Experience Questionnaire (IEQ) before sessions of individual psychotherapy and the Session Questionnaire (Stundenbogen) after those sessions. Comparison of the two groups on these measures of intersession process and postsession outcome showed markedly different patterns in patients' evaluations and internalizations of in-session therapeutic experiences: most prominently, that BPD patients internalize therapy sessions with much more negative and contradictory emotions.     

Transference Focused Psychotherapy for Patients with Comorbid Narcissistic and Borderline Personality Disorder

Clinical experience involving the treatment of patients with comorbid borderline and narcissistic personality disorders suggests that this patient population is among the more difficult to treat within the personality disorder spectrum. In this article, we present refinements of Transference Focused Psychotherapy (TFP) based on our clinical experience with and research data on patients with comorbid narcissistic personality disorder/borderline personality disorder (NPD/BPD). We briefly review object relations formulations of severe narcissistic pathology, as well as recent research in attachment and the allied concept of mentalization, which have provided a new lens through which to view narcissistic disorders. The research findings from two randomized clinical trials demonstrating the efficacy and effectiveness of TFP are presented. The data from the two Randomized Clinical Trials (RCT) allowed for the study of the characteristics of the subgroup of borderline personality disorder patients who have comorbid NPD/BPD. Findings on comorbidity, attachment status, capacity for mentalization, and level of personality organization of borderline patients with comorbid NPD/BPD, compared with borderline patients without comorbid narcissistic pathology (BPD), are presented. Clinical implications of the observed group differences are discussed, with a focus on refinements in the technique of TFP. Clinical case material is presented to illustrate the specific challenges posed by narcissistic patients to carrying out TFP in each phase of treatment.     

An empirical study of object relations and defensive operations in antisocial personality disorder

This study assessed the object relations, defensive operations, and level of psychopathy and narcissism in a group of antisocial personality disordered offenders. The Rorschach protocols of 33 subjects who met the Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev. [DSM-III-R], American Psychiatric Association, 1987) criteria for antisocial personality disorder were analyzed utilizing Kwawer's (1980) criteria for borderline object relations categories (borderline phenomena), the Lerner and Lerner (1980) Defense Scale, and a number of experimental criteria including Cooper and Arnow's (1986) defense criteria. Level of narcissism was assessed utilizing Exner's (1973) Self-Focus Sentence Completion Test. Hare's Psychopathy Checklist was used as an independent variable to determine a subject's level of psychopathy. Those subjects scoring 30 or more on the psychopathy checklist were compared to subjects scoring less than 30. The level of narcissism or proportion of defenses did not differ significantly between the severe psychopaths (greater than or equal to 30) and the moderate psychopaths (less than 30). The severe psychopaths produced a significantly greater number of borderline object relations. I conclude that antisocial individuals tend to be highly egocentric, and that narcissism is one component of psychopathy. Severe psychopaths, as a group, tend to be more borderline in their functioning than those exhibiting moderate levels of psychopathic disturbance. I also conclude that individuals who are incarcerated for felony offenses and also meet the DSM-III-R criteria for antisocial personality disorder exhibit degrees of borderline personality organization.     

An Empirical Study of Object Relations and Defensive Operations in Antisocial Personality Disorder

This study assessed the object relations, defensive operations, and level of psychopathy and narcissism in a group of antisocial personality disordered offenders. The Rorschach protocols of 33 subjects who met the Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev. [DSM-111-R], American Psychiatric Association, 1987) criteria for antisocial personality disorder were analyzed utilizing Kwawer's (1980) criteria for borderline object relations categories (borderline phenomena), the Lerner and Lerner (1980) Defense Scale, and a number of experimental criteria including Cooper and Arnow's (1986) defense criteria. Level of narcissism was assessed utilizing Exner's (1973) Self-Focus Sentence Completion Test. Hare's Psychopathy Checklist was used as an independent variable to determine a subject's level of psychopathy. Those subjects scoring 30 or more on the psychopathy checklist were compared to subjects scoring less than 30. The level of narcissism or proportion of defenses did not differ significantly between the severe psychopaths (230) and the moderate psychopaths (< 30). The severe psychopaths produced a significantly greater number of borderline object relations. I conclude that antisocial individuals tend to be highly egocentric, and that narcissism is one component of psychopathy. Severe psychopaths, as a group, tend to be more borderline in their functioning than those exhibiting moderate levels of psychopathic disturbance. I also conclude that individuals who are incarcerated for felony offenses and also meet the DSM-111-R criteria for antisocial personality disorder exhibit degrees of borderline personality organization.     

Angstzustände bei Patienten mit schweren Persönlichkeitsstörungen

States of anxiety are very common problems in patients with severe personality disorders. All phenomena of anxiety can be observed. In this connection a continuum of the severity of impairment of structural personality organisation can be postulated. In many cases proper anxiety disorders exist as comorbid disorders. Anxiety is esteemed to be the central affective problem of borderline patients. In spite of these relations, states of anxiety in patients with personality disorders are often underdiagnosed or misdiagnosed. For the treatment of neurotic anxiety disorders (for example panic disorders), there exist disorder-specific therapy manuals that proceed from behavioural as well as psychodynamic perspectives. Nevertheless, for the treatment of anxiety states in personality disordered patients, the techniques that focus heavily on symptomatology appear often contraindicated. In our opinion, treatment of these typically severe anxieties must be contained within a therapeutic framework, which essentially takes into account the personality organisation of this group of patients. Such treatment makes special demands on the therapist for working with transference and countertransference processes. From a disorder-specific psychodynamic perspective recommendations are given for psychotherapy.     

Borderline manifestations in the Rorschachs of male transsexuals

It was hypothesized that male transsexuals manifest a character structure consistent with Kernberg's criteria for borderline personality organization. Exploring this hypothesis, Kernberg's criteria for borderline personality organization were operationalized using Rorschach measures. The following variables were examined: aggression (Holt System Aggressive Content Section), object relations (Urist's Mutuality of Autonomy Scale), reality testing (Exner System X + %), and self/object differentiation (Exner System Special Scorings). A group of male college students, a group of male borderlines, and a group of male transsexuals were compared on the above variables. Compared to the normals, the transsexuals and borderlines displayed significantly more intense levels of aggression, a lower level of object relations, poorer reality testing, and impaired boundary differentiation. The transsexuals and borderlines did not differ significantly. The results were taken as suggesting that male gender dysphorics may be a sub-group of the wider borderline diagnostic category.     

Remarks on aggression

This paper attempts to draw attention to the difference between the states of mind and inner worlds of neurotic, borderline and psychopathic patients, with reference to different types of destructiveness: anger in the neurotic patient; desperate vengeful hatred in the borderline paranoid; and a cold addiction to violence in the psychopath. Discussion focuses on technical issues and the need to meet the psychopathic patient where he really is, in the inner bleak emotional cemetery he may be inhabiting. Although most patients refuse to stay put in the neat schematic categories outlined, they do seem to appreciate and to need the therapist's recognition of the specific quality of these vastly different states of mind.     

Borderline personality traits in nonclinical young adults

The main purpose of this study was to explore the dimensionality of the borderline personality disorder in nonclinical young adults by means of the Borderline Personality Questionnaire (BPQ; Poreh et al., 2006). We also studied the phenotypic expression of the borderline personality traits as a function of participants' gender and age, and the relationship between BPQ subscales and measures of depressive symptoms, anxiety, stress, hallucinatory predisposition, and paranoid ideation. The sample comprised 809 young adults, 562 (69.5%) were women, with a mean age of 20.2 years (SD = 2.9). The results indicate that the BPQ self-report has adequate psychometric properties. The levels of internal consistency for the BPQ subscales ranged between .78 and .93. Analysis of the internal structure of the BPQ subscales yielded a one-dimensional solution. In contrast, second-order principal components analysis at the item level yielded a five-dimensional solution. Likewise, statistically significant differences in the mean scores of the borderline personality traits as a function of participants' gender and age were found. The BPQ subscales correlated significantly with measures of depression, anxiety, stress, paranoid ideation, and hallucinatory predisposition. These results help to improve our understanding of the dimensional structure of the borderline personality in the general population. Future research should continue to identify participants who are at risk for the development of borderline personality disorder and facilitating the development of early detection and prevention programs.     

Some comments on the role of cotherapists in group psychotherapy with borderline patients

This paper points out examples of patients in a psychotherapy group who meet DSM-III criteria for the diagnosis of borderline personality disorder and who are treated by cotherapists utilizing object relations theory. Interpretations of phenomena shown by borderline patients—splitting, projective identification and denial—are illustrated. How cotherapy lends itself to the recognition and management of the problems these patients bring to group psychotherapy is illustrated.Hope Aspell assisted in the editing of this paper.     

Projective identification as a communication its grammar in borderline psychotic children

This paper distinguishes between the grammar of wishes in neurotic patients and the grammar of imperative needs in borderline patients. The treatment of a borderline psychotic boy 30 years ago was uninformed by subsequent developments in technique arising from the theory of projective identification as a communication rather than as an attack or a defense. Issues that need addressing in borderline patients, especially those who are children, include (a) developmental delay, (b) the distinction between defenses and overcomings in the paranoid position, (c) rectification fantasies of vengeance, and (d) rectification fantasies of justice and other moral imperatives.     

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.     

Changes in the level and quality of object relations in psychoanalysis: followup of a longitudinal, prospective study

As part of a prospective, longitudinal study of suitability for and outcome of psychoanalysis, 22 patients were evaluated for changes in the level and quality of their object relations. These patients had been accepted for supervised analysis with candidates in training by senior analysts who had diagnosed them as neurotic. The majority of these patients reported difficulties in relationships as at least one of their reasons for originally seeking psychoanalytic treatment. Prior to beginning analysis, each patient was given a battery of psychological tests. One year after the termination of analysis, the test battery was readministered and a followup interview was conducted separately with each patient and analyst. Ratings of change based on patient and analyst interviews and comparisons of psychological tests before and after treatment all showed statistically significant improvement in the level and quality of object relations for this patient group. The results of this study support what is often observed in clinical practice, that psychoanalysis has a positive effect on the level and quality of a patient's object relations.     

On the nature of attachment in a borderline population: a preliminary investigation

Analyses of interpersonal behavior within a borderline population usually focus on object relations variables. In contrast, this preliminary research focuses on the nature of attachment styles and its relation to behavioral pathology. 24 hospitalized borderline patients were administered an Attachment Style Inventory and Millon Clinical Multiaxial Inventory. Analysis confirms predicted differences in attachment style between the borderline and normal control samples as well as indicates that a dependent style of attachment within this borderline sample is associated with less pathology than an avoidant, hostile, or resistant/ambivalent style. The implications of this preliminary work for full-scale research are addressed.     

Malevolent object representations in borderline personality disorder and major depression.

To study malevolent representations, earliest memories were reliably coded on scales of affect tone. Ss were diagnosed with borderline personality disorder: 31 without and 30 with concurrent major depression. Nonborderline comparison subjects had either major depressive disorder (n = 26) or no psychiatric diagnosis (n = 30). Borderline subjects were discriminated from comparison subjects by their more malevolent representations; they more frequently produced memories involving deliberate injury; and they portrayed potential helpers as less helpful. Results suggest the diagnostic significance of malevolent representations, which need to be explained by any theory of borderline personality disorder.