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.     

Eating Disorders,Impaired Mentalization,and Attachment: Implications for Child and Adolescent Family Treatment

ABSTRACT

This article reviews the attachment and neuroscience model of Mentalization Based Treatment (MBT) (Allen, Fonagy, & Bateman, 2008) and its application for understanding and treating eating disorders (Skarderud & Fonagy, 2012). Mentalization, or mentalizing, refers to the capacity to apprehend one’s own and others’ behavior in terms of underlying mental states (needs, emotions, desires, beliefs, goals, reasons, and thoughts). Evidence from prospective studies suggests that insecure attachment and poor mentalizing difficulties may be risk factors for the development of eating pathology (Jewell et al., 2015; Rothschild-Yakar, Levy-Shiff, Fridman-Balaban, Gur, & Stein, 2010; Rothschild-Yakar & Stein, 2013). Preliminary research on the use of MBT for treating eating disorders, with nonsuicidal self-injury co-morbidity, suggests some promise for this model (Robinson et al., 2015). The theoretical rationale and key interventions of the MBT eating disorder model (MBT-ED) used in a multicenter research and treatment project are discussed (Skarderud & Fonagy, 2012; Robinson et al., 2015). Modifications of MBT-ED’s structure and techniques are proposed for family treatment of adolescent and child patients with eating disorders. Case example illustrates the impact of problems in the family system with mentalizing capacities on family cohesion, the therapeutic process, and the family’s ability to help the child recover.     

Distress tolerance but not impulsivity predicts outcome in concurrent treatment for posttraumatic stress disorder and substance use disorder

Posttraumatic stress disorder (PTSD) and substance use disorder (SUD) commonly co-occur. Emerging research suggests that both distress tolerance and impulsivity may underlie this comorbidity. However, to our knowledge no studies have examined whether these 2 constructs predict outcome in PTSD-SUD treatment. The current study investigated whether pretreatment distress tolerance and impulsivity predicted posttreatment PTSD and cravings severity in a sample of 70 Veterans receiving concurrent treatment for PTSD and SUD in a residential day treatment program. Veterans completed measures of symptom severity before and after treatment. Results demonstrated that pretreatment distress tolerance predicted posttreatment PTSD severity while controlling for pretreatment PTSD. By contrast, pretreatment impulsivity was not predictive of posttreatment PTSD while controlling for pretreatment values. Neither distress tolerance nor impulsivity predicted posttreatment cravings severity. The findings support the notion that distress tolerance may help to explain the co-occurrence of PTSD and SUD and suggest that targeting this construct in PTSD-SUD treatment may be important for successful outcomes.     

Mentalisierungsbasierte Psychotherapie bei schizophrenen Psychosen

Recently, there has been growing interest in new methods of psychotherapeutic interventions for schizophrenic patients. Social cognition, social functioning and quality of life are central objectives. Mentalization-based therapy (MBT) is a specific psychodynamic method developed from the fundament of attachment theory and empirical psychotherapy research for the treatment of borderline personality disorder, particularly focusing on attachment relationships, mentalizing capacity and affect regulation. Studies have shown that MBT is able to ameliorate interpersonal experience and social life. The latest neuroscientific findings support this view and encourage the application of a modified form of MBT in the treatment of schizophrenic patients. The authors present a concept for disorder-specific interventions in schizophrenia, including psychoeducational aspects and mentalizing exercises which step-by-step lead to a more reflective work in mentalization-based group psychotherapy.     

Treatment Outcome of 18-Month, Day Hospital Mentalization-Based Treatment (MBT) in Patients with Severe Borderline Personality Disorder in the Netherlands

Psychoanalytically oriented day hospital therapy, later manualized and named mentalization-based treatment (MBT), has proven to be a (cost-) effective treatment for patients with severe borderline personality disorder and a high degree of psychiatric comorbidity (BPD) in the United Kingdom (UK). As to yet it has not been shown whether manualized day hospital MBT would yield similar results when conducted by an independent institute outside the UK. We investigated the applicability and treatment outcome of 18-month, manualized day hospital MBT in the Netherlands by means of a prospective cohort study with 45 Dutch patients with severe BPD and a high degree of comorbid Axis I and Axis II disorders. Outcomes were assessed each six months. Symptom distress, social and interpersonal functioning, and personality pathology and functioning all improved significantly, with effect sizes between 0.7 and 1.7. Suicide attempts, acts of self-harm, and care consumption were also significantly reduced. The results indicate that MBT can effectively be implemented in an independent treatment institute outside the UK. This study also supports the clinical effectiveness of manualized day hospital MBT in patients with severe BPD and a high degree of psychiatric comorbidity.     

Gender-sensitive training for substance use disorder treatment: Results and implications of a pilot health professionals needs assessment

This study explored mental health practitioner training needs in gender-sensitive substance use disorder (SUD) counselling genderqueer populations. Informants were health professionals in SUD practices and from the Eastern Cape, South Africa (females = 75%; black = 90%, 10% = white, clinical and counselling psychologists = 10%, social workers = 65%, auxiliary health workers = 25%). They completed focus group interviews regarding their needs for gender-sensitive (GS) training in SUD treatment. Thematic analysis of the data indicated training needs in how to deal with their own bias and prejudice beliefs about the genderqueer population. Furthermore, results indicated that they needed training on how to manage the treatment setting once genderqueer clients were integrated in treatment with cisgender clients. Training for SUD treatment and care with genderqueer clients should prioritise gender sensitisation. Health professionals’ need gender equality awareness training for health care equity with the genderqueer community.     

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.     

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.     

The development of borderline personality disorder--a mentalizing model

This paper describes a mentalization-based model of the development of borderline personality disorder (BPD). The model takes into account constitutional vulnerability and is rooted in attachment theory and its elaboration by contemporary developmental psychologists. The model suggests that disruption of the attachment relationship early in development in combination with later traumatic experiences in an attachment context interacts with neurobiological development. The combination leads to hyper-responsiveness of the attachment system which makes mentalizing, the capacity to make sense of ourselves and others in terms of mental states, unstable during emotional arousal. The emergence of earlier modes of psychological function at these times accounts for the symptoms of BPD. The model has clinical implications and suggests that the aim of treatment is not only to encourage development of mentalizing but also to facilitate its maintenance when the attachment system is stimulated.     

Relations between cyclothymic temperament and borderline personality disorder traits in non-clinical adolescents

ObjectivesThe aim of the present study was to examine the relation between cyclothymic temperament and borderline personality disorder traits in adolescents and to identify a typology of adolescents based on temperamental traits (cyclothymic temperament and BPD traits).Participants and methodsA sample of 312 adolescents completed several questionnaires assessing cyclothymic temperament, borderline personality disorder traits, depressive symptoms, suicidal ideation, antisocial behaviors and frequency of cannabis use.ResultsThe Cyclothymic-Hypersensitive Temperament (CHT) questionnaire and the Borderline Personality Features Scale for Children (BPFS-C) were highly correlated which suggests that these scales may measure the same construct. Factor analyses of the pooled items of both scales yielded two factors, ‘anger–impulsivity’ and ‘affective instability’, both composed half of items from both scales. The relation between these traits and suicidal ideation was fully mediated by depressive symptomatology. Cluster analysis showed that these traits may occur independently and that adolescents with both traits had the highest levels of depressive symptoms, suicidal ideations and antisocial behaviors.DiscussionThe CHT questionnaire and the BPFS-C may measure the same construct which appeared relevant for defining a subgroup of adolescents with high levels of depressive symptoms, suicidal ideations and antisocial behaviors.     

Effectiveness of dialectical behaviour therapy for borderline personality disorder in an inpatient setting

This study evaluates the effectiveness of dialectical behaviour therapy (DBT) for borderline personality disorder (BPD) in an unselected, comorbid population seeking 3-month inpatient treatment. We studied 50 consecutively admitted individuals (44 women, six men) with BPD as defined by DSM-IV at three time points (at admission, at discharge, and at the 15-month follow-up). For the clinical diagnoses, we used the Structured Clinical Interview for DSM-IV (SCID) and compared the frequencies of comorbid axis I and axis II disorders at admission and at the 15-month follow-up. Overall, participants showed a high degree of comorbidity. Psychopathology was significantly reduced at post-treatment and at follow-up. Effect sizes for outcome measures were within the range of those of previous studies. Our findings support the notion that the results of the DBT efficacy research can be generalized to an inpatient setting and to patients with BPD disorder with high comorbidity.     

Conscious knowledge influences decision‐making differently in substance abusers with and without co‐morbid antisocial personality disorder

Decision‐making impairment, as measured by the Iowa Gambling Task (IGT), is a consistent finding among individuals with substance use disorder (SUD). We studied how this impairment is influenced by co‐morbid antisocial personality disorder (ASPD) and conscious knowledge of the task. Three groups were investigated: SUD individuals without co‐morbid ASPD (n = 30), SUD individuals with co‐morbid ASPD (n = 16), and healthy controls (n = 17). Both SUD and SUD+ASPD participants had poor overall IGT performance. A block‐by‐block analysis revealed that SUD participants exhibited slow but steady improvement across the IGT, whereas SUD+ASPD participants exhibited initial normal improvement, but dropped off during the last 40 trials. Conscious knowledge of the task was significantly correlated to performance for controls and SUD participants, but not for SUD+ASPD participants. Our findings suggest that decision‐making proceeds differently in SUD and SUD+ASPD individuals due to differences in acquisition and application of conscious knowledge.     

Autistic traits and neuropsychological performance in 6- to-10-year-old children: a population-based study

Clinical studies of children with autism spectrum disorder (ASD) provide evidence for poorer neuropsychological performance within specific domains compared to age, gender, and sometimes IQ-matched controls. Since recent evidence suggests that autistic symptoms form a spectrum that extends into the general population, it was our goal to evaluate the nature of the relationship between autistic traits and neuropsychological performance across the continuum in the general population. We examined neuropsychological performance across five different domains in 1019 6-to-10-year-old children participating in a population-based study of child development. Autistic traits were assessed when the children were 6 years of age using the Social Responsiveness Scale and ASD diagnoses were obtained via medical records. Neuropsychological functioning was measured using the NEPSY-II-NL and included the domains of attention and executive function, memory and learning, sensorimotor functioning, language, and visuospatial functioning. We found that children with higher autistic traits showed significantly lower neuropsychological performance in all domains investigated and that this association remained even after excluding children with the highest autistic traits or confirmed ASD. When comparing 41 children with confirmed ASD diagnosis to typically developing controls, children with ASD showed significantly lower neuropsychological performance across all domains. Taken together, our results suggest that children with both ASD and subclinical autistic traits have lower neuropsychological performance. Thus, this may provide an understanding of why some children without an ASD diagnosis may require some additional assistance within academic settings.     

Childhood abuse as a risk factor for suicidal behavior in borderline personality disorder

A childhood history of sexual or physical abuse is highly prevalent in borderline personality disorder (BPD) and is associated with self-destructive behavior in clinical and nonclinical samples. Viewing BPD as a "high risk" disorder, we asked if childhood abuse was a risk factor for adult suicidal behavior or if it was related to other known risk factors for suicide in BPD. A semistructured Abuse History was obtained in 61 criteria-defined BPD patients, who were characterized by structured interviews and self-reports for Axis I disorders, Suicide History, BPD severity, hopelessness, impulsivity, impulsive-aggression, and antisocial traits. Occurrence and severity of childhood sexual abuse, but not physical abuse, predicted adult suicidal behavior independent of other known risk factors. The odds of a sexually abused patient attempting suicide in adulthood was over 10 times that of a patient who was never sexually abused. Given a history of childhood sexual abuse, the risk of adult suicidal behavior in BPD was increased by antisocial traits, severity of BPD, hopelessness, or comorbid major depressive episode (MDE).     

A systematic review of the evidence-based psychosocial risk factors for understanding of borderline personality disorder

Borderline personality disorder (BPD) is a serious personality disorder characterized by affective instability, impulsivity and interpersonal disturbance. Currently, intensive research is being conducted concerning the aetiology of BPD, including research on neurobiological, temperamental, psychosocial and cultural risk factors. This study focuses on psychosocial risk factors while other risk factors are taken into account in the discussion of the development of BPD. To our knowledge, no systematic review of the evidence-based medicine literature concerning this theme has been made thus far. However, understanding psychosocial risk factors of BPD is important in order to develop psychotherapeutic treatment models and methods. We provide a systematic review of the literature focusing on psychosocial risk factors for BPD. Utilizing this knowledge, we discuss how these data may be used when studying the development of borderline personality disorder and the treatment of borderline personality disorder.     

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.     

The Relation between Mind‐mindedness in Mothers with Borderline Personality Disorder and Mental State Understanding in their Children

This study investigated relations between mind‐mindedness in mothers with borderline personality disorder (BPD) and mental state understanding in their children. Participants were 20 mothers with BPD and 19 mothers without personality disorder and their children, aged 39–61 months. Children's mental state understanding was examined via a battery of theory of mind and emotion labelling tasks. Maternal mind‐mindedness was assessed by mothers' use of mental state references to describe their children relative to other attributes. Maternal BPD was associated with fewer references to children's mental states as well as poorer levels of mental state understanding in their children. Findings lend some empirical support to recent theoretical suggestions that BPD is associated with a reduced capacity for mentalization, as well as reduced capacity for mental state understanding in children of mothers with BPD. Copyright © 2012 John Wiley & Sons, Ltd.     

Are the interpersonal and identity disturbances in the borderline personality disorder criteria linked to the traits of affective instability and impulsivity?

This study examines the degree to which two putative biologically influenced personality traits, affective instability and impulsive aggression, are associated with some of the interpersonal and intrapsychic disturbances of borderline personality disorder (BPD) and with choice of defense mechanism. In a sample of 152 personality disorder patients, affective instability and impulsive aggression were measured. Defense mechanisms were assessed in 140 of these patients using the Defensive Style Questionnaire (DSQ). The correlations between the traits of affective instability and impulsive aggression and the eight DSM-III-R criteria for borderline personality disorder and 20 DSQ defenses were examined. Affective instability was significantly correlated with the DSM-III-R criteria of identity disturbance, chronic emptiness or boredom, inappropriate anger, suicidality, and the affective instability criteria. It also was associated with the defenses of splitting, projection, acting out, passive aggression, undoing, and autistic fantasy. Impulsive aggression was related to unstable interpersonal relationships, inappropriate anger and impulsiveness and with the defense of acting out. It was negatively correlated with the defenses of suppression and reaction formation. A number of the interpersonal and experiential disturbances and defense mechanisms that are features of BPD are associated with the traits of affective instability and impulsive aggression among patients with personality disorders.     

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.