Borderline functioning, work, and outcome in intensive evening group treatment.

Cluster analysis was used to identify subgroups of a sample of 40 patients with borderline personality disorder (BPD). The BPD patients were part of a larger sample that had participated in an intensive, group-oriented Evening Treatment Program. A set of pretherapy outcome measures was used to represent patient "attributes" for the cluster analysis. Eight clusters were identified. Two, each defined by a single patient with pronounced pathology, were deleted from further analyses. In a discriminant-function analysis, four dimensions emerged that differentiated the six remaining clusters. Significant relationships among the four dimensions and measures of therapeutic work and treatment outcome were identified. The relationships reflected the impact of behavioral characteristics associated with BPD on participation in and benefit from intensive group-oriented evening treatment. Implications of these exploratory findings for the understanding and treatment of BPD are discussed.     

Group Treatment in Psychotherapy by Robert G. Hinckley and Lydia Hermann

A recently completed clinical trial that investigated the effectiveness of a group-oriented, day treatment program provided an opportunity to pursue a multidimensional approach to the prediction of treatment outcome. The sample consisted of 99 psychiatric outpatients, most of whom had received diagnoses of affective and personality disorders. The predictor variables included a patient personality characteristic (psychological mindedness), a group process variable (patient work), and their interaction. Univariate analyses revealed significant direct relationships between psychological mindedness and both work and favorable outcome, and between work and favorable outcome. Multivariate analyses indicated that psychological mindedness and work had independent significant relationships (additive or interactive) with several of the outcome variables. In combination they accounted for up to a quarter of the outcome variance. The results demonstrate the benefit of using a theoretically consistent multidimensional approach. The time-efficient nature of the predictor measures used in the study make them particularly amenable for use by clinicians and researchers.     

The effectiveness of dialectical behaviour therapy in routine public mental health settings: An Australian controlled trial

Randomised controlled studies in research environments have demonstrated dialectical behaviour therapy (DBT) to be more efficacious than treatment as usual in reducing suicidal behaviour in patients with borderline personality disorder (BPD). Limited evidence exists for the effectiveness of DBT in the treatment of BPD within routine clinical settings. This study examines the clinical and cost effectiveness of providing DBT over treatment as usual in a routine Australian public mental health service. Forty-three adult patients with BPD were provided with outpatient DBT for six months with patient outcomes compared to those obtained from patients in a wait list group receiving treatment as usual (TAU) from the same service. After six months of treatment the DBT group showed significantly greater reductions in suicidal/non-suicidal self-injury, emergency department visits, psychiatric admissions and bed days. Self-report measures were administered to a reduced sample of patients. With this group, DBT patients demonstrated significantly improved depression, anxiety and general symptom severity scores compared to TAU at six months. Average treatment costs were significantly lower for those patients in DBT than those receiving TAU. Therapists who received intensive DBT training were shown to produce significantly greater improvements in patients’ suicidal and non-suicidal self-injury than therapists who received only 4 day basic training. Further clinical improvements were achieved in patients offered an additional six months of DBT. This study demonstrates that providing DBT to patients within routine public mental health settings can be both clinically effective and cost effective.     

Refining the borderline personality disorder phenotype through finite mixture modeling: implications for classification

Borderline personality disorder (BPD) is characterized by considerable heterogeneity. Prior approaches to resolving heterogeneity in BPD pathology have used factor and cluster analytic as well as latent class analysis strategies. These prior studies have been atheoretical in nature, but provide an initial empirical corpus for further sub-typing efforts in BPD. A model-based taxonomy for BPD that is supported by evidence from an advanced statistical methodology would enhance investigations of BPD etiology, pathophysiology, and treatment. This study applied finite mixture modeling analysis, in a model-guided fashion, to selected dimensions of pathology within a group of well-characterized BPD patients to determine if latent groups are harbored within the disorder. Subjects with BPD (N = 90) were examined on a variety of model-relevant psychopathology dimensions. We applied finite mixture modeling to these dimensions. We then evaluated the validity of the obtained solution by reference to a variety of external measures not included in the initial mixture modeling. Three phenotypically distinct groups reside within the overall BPD category. Group-1 is characterized by low levels of antisocial, paranoid, and aggressive features. Group-2 is characterized by elevated paranoid features, whereas Group-3 is characterized by elevated antisocial and aggressive features. External correlates reveal a pattern of differences consistent with the validity of this proposed grouping structure. A theory-guided finite mixture modeling analysis supports a parsing of the BPD category into three subgroups. This proposed BPD taxonomy represents an approach to reducing heterogeneity observed among BPD patients and it may prove useful in studies seeking to understand etiologic and pathophysiologic factors as well as treatment response in BPD.     

Cluster Analysis of the Yale Global Tic Severity Scale (YGTSS): Symptom Dimensions and Clinical Correlates in an Outpatient Youth Sample

Tic disorders are heterogeneous, with symptoms varying widely both within and across patients. Exploration of symptom clusters may aid in the identification of symptom dimensions of empirical and treatment import. This article presents the results of two studies investigating tic symptom clusters using a sample of 99 youth (M age = 10.7, 81% male, 77% Caucasian) diagnosed with a primary tic disorder (Tourette’s disorder or chronic tic disorder), across two university-based outpatient clinics specializing in tic and related disorders. In Study 1, a cluster analysis of the Yale Global Tic Severity Scale (YGTSS) identified four symptom dimensions: predominantly complex tics; simple head/face tics; simple body tics; and simple vocal/facial tics. In Study 2, these clusters were shown to be differentially associated with demographic and clinical characteristics. Findings lend support to prior research on tic phenomenology, help to organize treatment goals, and suggest symptom dimensions of tic disorders for further evaluation.     

Client,Treatment, and Therapist Variables Related To Outcome in Brief,Systems-Oriented Family Therapy

Client, therapist, and treatment characteristics were examined with respect to how much of the variance they could account for in a variety of outcome measures. Multiple regression analyses were used to examine relationships among each of the client, therapist, and treatment characteristics studied and the various outcome measures. For the 219 families that were treated with brief family therapy, only a relatively low amount of variance in any of the outcome measures could be accounted for. The amount of explained variance, however, varied considerably from one outcome measure to the other. When the more homogeneous groups of clients (single parents or adolescent identified patients) were considered, the amount of explained variance generally showed an increase. Different sets of client, therapist, and treatment variables accounted for the variance in these outcome measures across client groups, demonstrating both the complexities of the relationships and the relative independence of various outcome measures. New variables are suggested for future research.     

Patient activity and outcome in group psychotherapy: new findings

The relation of patient verbal activity to pretherapy symptom status and outcome was examined for ninety patients in time-limited group psychotherapy. For each half-hour segment the most verbally active member, or main actor (MA), was identified. Verbal activity was measured by counting the number of times each patient was MA during the course of the group. Outcome was assessed by administering a battery of instruments pre- and posttherapy and by obtaining direct ratings of patient benefit from the patient, therapist, and an independent rater: the number of times MA was found to be significantly correlated with four pretherapy measures, indicating that the most disturbed patients were most active in these groups; the number of times MA was also correlated with patient and therapist benefit ratings, indicating that therapists and patients themselves agreed that those who spoke the most benefited the most. However, partial correlations between number of times MA and other outcome measures did not produce any significant relationships. Thus, it does not appear that patient verbal activity is related to outcome, as measured by objective instruments.     

The Personality Disorders Institute/Borderline Personality Disorder Research Foundation randomized control trial for borderline personality disorder: rationale, methods, and patient characteristics

The Personality Disorder Institute/Borderline Personality Disorder Research Foundation randomized control trial (PDI/BPDRF RCT) is a controlled outcome study for borderline personality disorder (BPD), in which 90 participants were randomized to one of three manualized and monitored, active psychosocial treatment conditions. These treatments are: (a) Transference-Focused Psychotherapy (TFP; Clarkin, Yeomans, & Kernberg, 1999), a treatment for BPD based on object-relational and psychoanalytic principles first applied to BPD by Kernberg (1996), notable for its particular emphasis on interpretation of object relations activated in the ongoing therapeutic relationship; (b) Dialectical Behavior Therapy (DBT; Linehan, 1993), a popular treatment for BPD, with evidence of efficacy (Linehan, Armstrong, Suarez, Allmon, & Heard, 1991) that emphasizes a balance between acceptance and change in its combination of cognitive-behavioral and Zen principles; and (c) supportive psychotherapy (Rockland, 1992), another object-relational and psychoanalytically based treatment for BPD which, in contrast to TFP, eschews transference interpretation and places primary emphasis on development of a collaborative engagement with the patient to foster identity development. Patients received medication, if clearly indicated, according to the treatment algorithm developed by Soloff (2000). This article describes the significance and rationale of the study and the overall design, methods, plan of analysis, and demographic characteristics of the recruited sample of patients.     

Group Psychotherapy in the Treatment of Some Neurodermatoses

The relation of patient verbal activity to pretherapy symptom status and outcome was examined for ninety patients in time-limited group psychotherapy. For each half-hour segment the most verbally active member, or main actor (MA), was identified. Verbal activity was measured by counting the number of times each patient was MA during the course of the group. Outcome was assessed by administering a battery of instruments pre- and posttherapy and by obtaining direct ratings of patient benefit from the patient, therapist, and an independent rater: the number of times MA was found to be significantly correlated with four pretherapy measures, indicating that the most disturbed patients were most active in these group; the number of times MA was also correlated with patient and therapist benefit ratings, indicating that therapists and patients themselves agreed that those who spoke the most benefited the most. However, partial correlations between number of times MA and other outcome measures did not produce any significant relationships. Thus, it does not appear that patient verbal activity is related to outcome, as measured by objective instruments.     

Improving Service Evaluation in Clinical Genetics: Identifying Effects of Genetic Diseases on Individuals and Families

Outcome measurement in clinical genetics is challenging. Outcome attributes used currently have been developed by service providers or adapted from measures used in other areas of healthcare. Many of the ‘patients’ in clinical genetics are healthy but at risk of developing or transmitting a condition. Usually no pharmacological or surgical treatment is offered, although information-giving is an objective of most consultations. We argue that services should be evaluated on the basis of how well they alleviate the effects of disease, from a patient perspective. This paper describes a qualitative study using seven focus groups with health professionals, patients and patient representatives. Social and emotional effects of genetics diseases were identified. Some differences emerged between the effects identified by health professionals and those identified by patients. These findings will be used to inform the evaluation of existing outcome measures and develop robust measures of outcome for clinical genetics services.     

The relationship between impulsivity, aggression, and impulsive-aggression in borderline personality disorder: an empirical analysis of self-report measures

Impulsivity has been repeatedly identified as a key construct in BPD; however, its precise definition seems to vary especially regarding the overlap with aggression. The term impulsive-aggression , also generally seen as central to an understanding of BPD, seems to address itself to the interface between the two, but has itself been used inconsistently in the literature, sometimes having reference to a unitary phenotypic dimension, and at other times suggesting some combination of distinct traits. This study examined the relationship between multiple measures of impulsivity, aggression, and impulsive-aggression in a BPD sample ( N = 92) in order to clarify the relationship between these measured constructs in this clinical population. Results show little relationship between measures of aggression and impulsivity in BPD, with measures of impulsive-aggression correlating strongly with measures of aggression only. Implications of the present results for future research and clinical work with BPD are discussed.     

An atypical anxious‐impulsive pattern of social anxiety disorder in an adult clinical population

An atypical subgroup of Social Anxiety Disorder (SAD) with impulsive rather than inhibited traits has recently been reported. The current study examined whether such an atypical subgroup could be identified in a clinical population of 84 adults with SAD. The temperament dimensions harm avoidance and novelty seeking of the Temperament and Character Inventory, and the Liebowitz Social Anxiety Scale were used in cluster analyses. The identified clusters were compared on depressive symptoms, the character dimension self‐directedness, and treatment outcome. Among the six identified clusters, 24% of the sample had atypical characteristics, demonstrating mainly generalized SAD in combination with coexisting traits of inhibition and impulsivity. As additional signs of severity, this group showed low self‐directedness and high levels of depressive symptoms. We also identified a typically inhibited subgroup comprising generalized SAD with high levels of harm avoidance and low levels of novelty seeking, with a similar clinical severity as the atypical subgroup. Thus, higher levels of harm avoidance and social anxiety in combination with higher or lower levels of novelty seeking and low self‐directedness seem to contribute to a more severe clinical picture. Post hoc examination of the treatment outcome in these subgroups showed that only 20 to 30% achieved clinically significant change.     

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.     

A preliminary, randomized trial of psychoeducation for women with borderline personality disorder

The main objective of this study was to determine whether being taught the latest information concerning borderline personality disorder (BPD) leads to a decline in core BPD symptoms and an improvement in psychosocial functioning. Fifty-five late adolescent women participated in a rigorous diagnostic assessment and 50 met DIB-R and DSM-IV criteria for BPD. All 50 were informed that they met criteria for BPD. Then 30 were randomized to a psychoeducation workshop that took place within a week of diagnostic disclosure. The other 20 were assigned to a waitlist and participated in the workshop at the end of this 12-week study. The two primary outcome measures were readministered each week of the trial: the Zanarini Rating Scale for DSM-IV Borderline Personality Disorder (ZAN-BPD) and the Sheehan Disability Scale (SDS). Immediate psychoeducation concerning the BPD diagnosis was associated with a significantly greater decline in general impulsivity and the storminess of close relationships. However, it did not result in significantly improved psychosocial functioning. Taken together, the results of this study suggest that informing patients about BPD soon after diagnostic disclosure may help to alleviate the severity of two of the core elements of borderline psychopathology-general impulsivity and unstable relationships. They also suggest that such instruction may prove to be a useful and cost-efficient form of pre-treatment.     

Reliability and validity of the borderline personality disorder severity index

The psychometric properties and validity of the Borderline Personality Disorder Severity Index (BPDSI), a semistructured interview assessing the frequency and severity of manifestations of Borderline Personality Disorder (BPD) during a circumscribed period, were investigated in two studies. In study 1, patients with BPD (n = 15), with other personality disorders (PD; n = 18), and without Axis II disorders (but with Axis I disorders; n = 10) assessed with the SCID were interviewed with the BPDSI (1-yr. version). Patients also filled out a number of questionnaires. A second rater judged taped BPDSI interviews. The BPDSI appeared to yield highly reliable (ICC = .93) and internally consistent (Cronbach's alpha = .85) scores. The BPDSI strongly discriminated BPD patients from other patients, and was not related to other Axis II pathology. Concurrent and construct validity was excellent. In study 2, a version of the BPDSI suitable for use in treatment outcome research was investigated (3-month version) in a sample of 64 BPD patients, 23 Cluster C PD patients, and 20 nonpsychiatric controls. Again, reliability coefficients were excellent (ICC = 0.97; Cronbach's alpha = 0.93), and validity indices were good. Clinical norms were also derived. In a sample of 28 BPD patients, the instrument detected improvement during 6 months of psychotherapy.     

Effects of the dialectical behavioral therapy-mindfulness module on attention in patients with borderline personality disorder

It is known that patients with borderline personality disorder (BPD) show attention deficits and impulsivity. The main aim of this study was to explore the effects of Dialectical Behavioral Therapy-Mindfulness training (DBT-M), used as an adjunct to general psychiatric management (GPM), on attention variables in patients diagnosed with BPD. A second objective was to assess the relation of mindfulness formal practice on clinical variables. A sample of 60 patients with BPD was recruited. Forty of them were allocated to GPM + DBT-M treatment and the other 20 received GPM alone. At the termination of the mindfulness training, DBT-M + GPM group showed a significant improvement on commissions, hit reaction time, detectability scores from the CPT-II neuropsychological test, and also on the composite scores of inattention and impulsivity. Further, the more minutes of mindfulness practice were correlated to greater improvement in general psychiatric symptoms and affective symptomatology, but not in CPT-II measures. This is probably the first study so far assessing the effects of this single DBT module in patients with BPD. The results suggest a positive effect of such intervention on attention and impulsivity variables.     

Dysfunctional beliefs and psychopathology in Borderline Personality Disorder

This study examined the factor structure of the Borderline Personality Disorder subscale of the Personality Beliefs Questionnaire (PBQ-BPD; Butler, Brown, Beck, & Grisham, 2002), and the relationships between the emergent factors and psychopathology. The sample comprised 184 patients diagnosed with borderline personality disorder (BPD). Exploratory factor analysis yielded three factors relating respectively to dependency, distrust, and the belief that one should act preemptively to avoid threat. Although the three factors were significantly associated with depression, only dependency and distrust significantly correlated with hopelessness. Distrust was the sole factor that correlated significantly with suicide ideation. These findings support the dimensional structure of the PBQ-BPD. Given its multidimensional structure, the scale can be used as a measure of belief profiles associated with BPD and as an aid to conceptualizing beliefs underlying a range of psychopathology associated with patients with BPD.     

Dimensions of Relationship Quality

Four studies examined the dimensions of relationship quality. In Study 1, based on a principal components analysis, four dimensions underlying the prototype of relationship quality were identified: intimacy, agreement, independence, and sexuality. The four–factorial structure was replicated both with a German sample (Study 2) and a Canadian sample (Study 3). Study 4 tested the validity of scales based on the four–factorial structure of relationship quality with German and Canadian samples. Relationship satisfaction was predicted well by the four scales, with intimacy contributing most, and sexuality least, to overall relationship satisfaction. The four scales correlated as predicted with other constructs relevant to close relationships, such as commitment, trust, love, and the like. Consequences for the measurement of relationship quality are discussed.     

Social networks in borderline personality disorder

The interpersonal dysfunction that characterizes borderline personality disorder (BPD) has generally been studied using broad global measures, leading to a lack of precision. We report on a novel methodology using social network analysis (SNA) to quantify interactions with others in the patient's social world. We assessed the social networks of 22 clinical patients, diagnosed with either BPD (N = 11) or no personality disorder (No PD; N = 11). The social networks of patients with BPD contained a greater number of former romantic partners, and a greater number of relationships that had been terminated. Mixed model analyses found that the No PD group reported higher levels of positive relationships (e.g., trust, social support) with more central members of their social networks, whereas the BPD group did not discriminate among members of their networks. Results suggest deficits in social cognition for positive relations, but not for negative relations such as interpersonal conflict.     

Psychoanalysis and the Family Neurosis by Martin Grotjahn

Abstract

This study examined the factor structure and validity of the Therapeutic Factors Inventory-Short Form (TFI-S), a measure originally developed to assess Yalom’s eleven conceptually derived therapeutic factors. Patients in a group-oriented day treatment program (n = 174) completed the TFI-S and other measures to assess concurrent and predictive validity. Four broad therapeutic factors were identified: Instillation of Hope, Secure Emotional Expression, Awareness of Interpersonal Impact, and Social Learning. Alpha coefficients ranged from .71 to .91. Significant correlations between the TFI-S factors and Group Climate Questionnaire subscales provided preliminary evidence for the concurrent validity of the TFI S. Significant relationships were also identified between the TFI-S factors and improvement in symptoms, quality of life, and interpersonal distress at the end of treatment, suggesting that the TFI-S may have predictive validity.