Managing persons with multiple personality disorder in a heterogeneous inpatient group

Experts advise against referring persons with multiple personality disorder to diagnostically heterogeneous groups. As more multiples are admitted to inpatient units this presents a problem. Excluding persons of a particular diagnosis from groups makes it difficult to promote a cohesive therapeutic milieu. I have found that multiples can be managed successfully in mixed groups. The leader is advised to adhere to a reliable structure and pay close attention to boundary issues. Themes for discussion must be judiciously evaluated so that effectiveness is not undermined. Patients with different diagnoses can come to appreciate their similarities and benefit from groups.     

Memory and awareness in a patient with multiple personality disorder

We studied an individual with multiple personality disorder in whom each of several personalities claimed to have no direct awareness of the others and to be unable to consciously remember the experiences of other personalities. A broad selection of implicit and explicit memory tests was used to determine the extent to which one personality had access to knowledge acquired by another and the circumstances in which that knowledge would be expressed. The implicit assessment of memory was a necessary but not sufficient condition for demonstrating interpersonality access. The degree of compartmentalization of knowledge in this patient depended largely on whether the interpretation of presented information was likely to differ across personalities.     

Introject and identity: structural-interpersonal analysis and psychological assessment of multiple personality disorder.

Revisions of the diagnostic nomenclature have contributed to renewed interest in multiple personality disorder (MPD). Identity and self-organization in MPD are assessed using a sophisticated structural-interpersonal measurement system, Structural Analysis of Social Behavior (SASB). Two important features of the SASB model applied to MPD are the assessments of interpersonal perceptions of childhood initiators of abuse and of the introject or self-organization of host and secondary personalities. SASB findings from a clinical series of six cases of MPD are analyzed to illustrate the use of this assessment technique. Host personalities and abused secondary personalities differed in their identity and self-organization. Host personalities evidenced internalization of abuse dynamics related to self-destructive trends. Secondary personalities, despite having experienced abuse, did not manifest such dynamics. Implications for understanding personality processes in MPD and for further research are discussed.     

Autobiographical memory in a case of multiple personality disorder

Previous research on multiple personality disorder (MPD) has been concerned with between-personalities amnesia, and little attention has been paid to within-personality memory function. This study examined the autobiographical memory of a multiple personality patient, I.C., with cueing procedures that have proven useful in previous studies of normal and abnormal memory. Results indicated that I.C. was able to retrieve autobiographical episodes from the recent past, although her performance differed in several respects from that of matched controls. The study also revealed a striking deficit in I.C.'s autobiographical memory for childhood: She was unable to recall a single episode from prior to the age of 10 in response to various retrieval cues, whereas control subjects had no difficulty recalling numerous childhood episodes. This phenomenon of extended childhood amnesia has not been reported previously in studies of MPD.     

Interviews of female patients with borderline personality disorder who dropped out of group psychotherapy

Premature termination from group psychotherapy continues to be a serious problem in the treatment of patients with borderline personality disorder (BPD). Qualitative research is regarded as an important means to shed light upon the complex dynamics leading to dropout. We conducted an interview study with patients having a diagnosis of BPD (n = 8) who dropped out from long-term group psychotherapy as a continuation therapy following intensive day treatment. The group therapists for these patients were interviewed as well (n = 12). The findings suggest the operation of many processes that contribute to dropout. Most significant appeared to be experiences of separation and loss of the day hospital that were not worked through and a failure of the group to regulate and contain the patients' affects. To integrate patients at risk of premature termination it seems necessary to pay attention to the strong negative emotions that they experience in the group. A higher treatment intensity than weekly group sessions may help to promote more beneficial group processes.     

Homogeneous group therapy of borderline personality disorder

The authors maintained a time-limited, diagnostically homogeneous psychotherapy group of borderline patients for one year. The group progressed through prototypical stages of group development, but each phase was marked by variations of the aggressive drive and defenses against aggression that are characteristic of this disorder. The group provided a well-suited forum for the exploration of suicidal and homicidal impulses and the development of an observing ego. Despite the limits on generalizability from this group, it appears that group psychotherapy can be a valuable adjunctive modality for some borderline patients.Paper presented at the American Psychiatric Association Conference, Montreal, May, 1988.     

Quality of life in patients with alcohol dependence disorder with personality disorders: relation to psychological adjustment and craving

The purpose of this study is to determine the self-perceived quality of life of abstinent patients with alcohol dependence disorder during the first month of treatment, and how the presence of personality disorders, psychological adjustment, and the level of craving affect this perception. For this purpose, a sample was used comprising 65 participants with mean age of 43.26 years, of whom 70.8% were male and 29.2% female, with a mean duration of addiction to alcohol consumption of 11.83 years. The results show that quality of life is not related to the duration of abstinence or the course of the addiction. Moreover, the patients who present a personality disorder perceive poorer quality of life in areas such as health status, mood, and social relations. Self-perception of quality of life is affected by psychological adjustment and beliefs about craving. These data should be taken into account when considering quality of life as a measurement of the effectiveness of a treatment for drug addicts with personality disorders.     

Similarities between near-death experiences and multiple personality disorder

In this paper I compare the phenomenology of near-death experiences to that of multiple personality disorder. The comparison reveals a number of similarities, including out-of-body experiences, the transcendental environment, encounter with the higher self, possible temporal lobe involvement, and antecedent child abuse. Rather than being disparate and unrelated experiences, I suggest that the near-death experience and multiple personality disorder may be variants of the same basic phenomenological pattern.     

Alexithymia in patients with major depressive disorder and comorbid cluster C personality disorders: a 6-month follow-up study.

The authors examined the association between alexithymia, cluster C personality disorders (CPD), and severity of depression among 121 outpatients with major depressive disorder (MDD) in a 6-month, follow-up study. Diagnosis of depression and CPD was confirmed by means of the Structured Clinical Interviews for DSM-III-R (SCID I and SCID II). Alexithymia was screened using the 20-item version of the Toronto Alexithymia Scale and severity of depression was assessed using the 21-item Beck Depression Inventory. Results indicated that alexithymic features are common in patients with MDD but often alleviated during recovery from depression. Moreover, comorbid CPD and severity of depression seemed to be associated with poorer recovery from alexithymia. The implications of these findings are discussed.     

Six-year follow-up of three treatment programs to personality disorder

Previous studies of long-term outcome for personality disorder (PD) were either retrospective in design or did not include a control condition. In this paper we report results for three PD cohorts (N = 111) treated in two different specialist psychosocial programs (step-down and long-term inpatient) and in general psychiatric treatment as usual (TAU), which were prospectively followed up for 72-months after intake. The three PD samples were compared on symptom severity, social adjustment, global functioning and other clinical indicators (self-mutilation, parasuicide and readmission rates) at intake, 6, 12, 24, and 72 months. Results indicated that a specialist step-down model showed significantly greater change than a purely inpatient model and TAU in most key dimensions of functioning, a difference maintained at 72-months follow-up. Improvement in the samples was not associated with amount of intercurrent treatment received in the year prior to the follow-up assessment. This study confirms that a step-down program retains significant improvement associated with a specialist psychosocial approach for PD. However, this conclusion should be qualified by design limitations. The samples were not randomly allocated to the three conditions and the naturalistic geographical allocation used in the study created a potential for a number of confounds. Whilst we used extensive statistical controls, the possibility that the differences found between the groups may be due to population differences cannot be discounted.     

Assessment of ego functioning in multiple personality disorder

The dissociative disorder known as multiple personality disorder (MPD) presents a diagnostic challenge to psychological assessment techniques. A case example is presented in which a new self-report, multifactorial measure of ego functioning discriminated distinct profiles for four personalities within one multiple personality organization. Interpretations of characteristics of the primary and secondary personalities based on the Bell Object Relations Reality Testing Inventory (BORRTI) are presented. The relationship between these findings and other approaches to psychological testing for dissociation and MPD are discussed. It is suggested that this approach will facilitate the clinical assessment of suspected MPD subjects and contribute to affording appropriate treatment to this population.     

High-lethality status in patients with borderline personality disorder

Recurrent suicidal behaviors in patients with Borderline Personality Disorder (BPD) are often considered communicative gestures; however, 10% complete suicide. This study seeks to identify risk factors for suicide within a BPD sample by comparing patients with High- and Low-Lethality attempts. BPD attempters (n = 113) were assessed on demographic, diagnostic, and personality variables: clinical symptoms, suicidal behaviors; childhood, family, and treatment histories; social adjustment; and recent life events. Forty-four High-Lethality attempters, defined by a score of 4 or more on Beck's Medical Lethality Scale, were compared to 69 Low-Lethality attempters. Discriminating variables were entered in a multivariate logistic regression model to define predictors of High-Lethality status. High-Lethality attempters were older, with children, less education, and lower socioeconomic class (SES) than Low-Lethality attempters. They were more likely to have Major Depressive Disorder (MDD), co-morbid Antisocial Personality Disorder (ASPD), and family histories of substance abuse. They reported greater intent to die, more lifetime attempts, hospitalizations, and time in the hospital. High-Lethality status was best predicted by low SES, co-morbid ASPD, extensive treatment histories, and greater intent to die. These characteristics resemble profiles of patients who complete suicide, are not specific for BPD, and do not include impulsivity, aggression, or severity of BPD criteria.     

Gender differences in a clinical sample of patients with borderline personality disorder

The aim of the study was to investigate gender differences and similarities in patients with borderline personality disorder (BPD) with respect to Axis I comorbidity, Axis II comorbidity, general psychopathology (Symptom Checklist 90-Revised), and dimensional personality traits (NEO-Personality-Inventory Revised [NEO-PI-R] and the Dimensional Assessment of Personality Profile Basic questionnaire [DAPP-BQ]). Fifty-seven men and 114 women with BPD were included in the study. Regarding Axis I and II disorders in an exploratory analysis, men with BPD more often fulfilled the diagnostic criteria for binge eating disorder, antisocial personality disorder, narcissistic personality disorder, and conduct disorder in childhood, whereas women had higher frequencies of bulimia nervosa, posttraumatic stress disorder, and panic disorder with agoraphobia. After correcting for multiple tests, only the gender differences in narcissistic and antisocial personality disorder remained significant. In the SCL-90-R profile, no significant gender differences could be identified. In the exploratory analysis of the dimensional personality traits, women showed higher rates on the NEO-PI-R main factors (Neuroticism and Agreeableness) compared to men. In the DAPP-BQ profile, men reached higher sores on the main factor, Dissocial Behavior. When correcting for multiple tests, gender differences still existed for Neuroticism and Dissocial Behavior. Our results argue for gender differences in Axis I and II comorbidity and dimensional personality traits in BPD. However, in general, more similarities than differences were shown in this study.     

Historical reliability: a key to differentiating populations among patients presenting signs of multiple personality disorder.

The clinical value of inconsistencies in the historical data of patients presenting with signs of multiple personality disorder was assessed. Three major inconsistencies in historical data were identified in 23 patients who were admitted to a Dissociative Disorders Program with a diagnosis of Multiple Personality Disorder. This group showed psychological disturbance that was quite different from 23 patients with a similar discharge diagnosis but who did not exhibit inconsistencies in history. The former group reported less psychological disturbance and fewer dissociative experiences. Patients who are less credible by virtue of inconsistencies in their historical reports may belong to a different diagnostic group. The findings point to the need to chart history carefully in authenticating genuine cases.     

Empathy in families of women with borderline personality disorder, anorexia nervosa, and a control group

This is a study of empathy in the families of 27 women with borderline personality disorder (BPD), 28 women with restricting anorexia nervosa (AN), and 27 women without a clinical diagnosis (NC). The daughters and both parents responded to the Interpersonal Reactivity Index (IRI), an instrument for assessing four dimensions of empathy. In addition, they were personally interviewed, with the Family Interview for Protectiveness and Empathy (FIPE), about the extent of empathy expressed by the parents to their daughter during her development. On the IRI, women with BPD scored highest on the immature and lowest on the mature aspects of empathy, whereas scores of AN and NC women were all within normal limits. Parents of BPDs had the lowest IRI scores, while parents of AN and NC groups were similar to each other and to criterion group scores. IRI scores of AN daughters were positively correlated with their parents' scores whereas BPDs' scores were negatively correlated with those of their parents. There were no correlations between the IRI scores of NC subjects and their parents. On the FIPE, borderline daughters and parents agreed about the relative absence of empathic parenting, whereas AN and NC daughters and parents agreed as to the presence of empathic parenting. The theoretical and clinical implications of these contrasting findings are discussed.     

An integrated model of social psychological and personality psychological perspectives on personality and wellbeing

This article uses multi-rater data from 458 triads (students, mother, father, total N = 1374) to examine the relationship of personality ratings with wellbeing ratings, using a multi-method approach to separate accurate perceptions (shared across raters) from biased perceptions of the self (rater-specific variance). The social-psychological perspective predicts effects of halo bias in self-ratings on wellbeing, whereas the personality-psychological perspective predicts effects of personality traits on wellbeing. Results are more consistent with the personality perspective in that neuroticism (negative), extraversion, agreeableness, and to a lesser extent conscientiousness predicted wellbeing, whereas positive illusions about the self were only weakly and not significantly related to wellbeing. These results cast doubt on the hypothesis that self-enhancement is beneficial for wellbeing.     

Childhood abuse in Chinese patients with borderline personality disorder

This study examined (1) the relative prevalence of childhood abuse and other pathological childhood experiences in China reported by outpatients with borderline personality disorder (BPD), with other personality disorders, and without personality disorders; and, (2) whether the primary predictors of BPD in North America are associated with the development of BPD in China. The childhood experiences of 203 outpatients with BPD, 109 outpatients with other personality disorders, and 70 outpatients without Axis II diagnoses were assessed with the Chinese version of the Childhood Experience of Care and Abuse Questionnaire (CECA.Q). Patients with BPD reported significantly more physical, emotional, and sexual abuse than either comparison group. Four types of childhood experiences were significant predictors of BPD: maternal neglect, paternal antipathy, sexual abuse, and maternal physical abuse. The findings suggest that maternal physical abuse is as strong a predictor of BPD in China as sexual abuse, a finding not replicated in North America.     

Experiential avoidance in adolescents with borderline personality disorder: comparison with a non-BPD psychiatric group and healthy controls

ABSTRACT

Previous research has identified experiential avoidance (EA) as related to a host of adolescent internalizing and externalizing problems, as well as borderline personality disorder, suggesting that it is a crosscutting factor for adolescent psychopathology. It remains unclear whether EA differs among adolescents with BPD compared to adolescents with other psychiatric disorders and healthy adolescents. The aims of this study were to 1) examine EA in adolescents with BPD compared to non-BPD inpatient adolescents and healthy adolescents, and 2) to evaluate whether EA has a unique relationship to borderline pathology over and above internalizing and externalizing. Self-report measures of BPD features, EA, and psychopathology were completed by 692 adolescents (64.5% female, M_age= 15.20). This sample included a group of psychiatric inpatient youth (n = 197 BPD; n = 403 non-BPD) and a group of healthy adolescents (n = 92). Results revealed that EA differed significantly across all three groups, with the highest level of EA evidenced in adolescents who had BPD. Furthermore, there was a significant, unique association between BPD symptoms and EA over afnd above internalizing and externalizing pathology. These findings pinpoint EA as an important risk marker and possible target of prevention or intervention for adolescent BPD.     

The course of adult experiences of abuse in patients with borderline personality disorder and Axis II comparison subjects: a 10-year follow-up study

The first objective of this study was to assess the rates of adult experiences of verbal, emotional, physical, and sexual abuse reported by borderline patients and Axis II comparison subjects over 10 years of prospective follow-up. The second objective was to determine time-to-cessation, recurrence, and new onset of each type of abuse. The Abuse History Interview (AHI) was administered to 290 borderline patients and 72 Axis II comparison subjects at baseline. The AHI Follow-up Version (AHI-FUV) was administered at five contiguous follow-up waves. Over 10 years of follow-up, the rates of all four types of abuse declined significantly for borderline patients. For borderline patients, rates of cessation were high for all types of abuse (>90%). However, recurrences and new onsets of verbal and emotional abuse were relatively common (>60%). Contrastingly, they were relatively uncommon for physical and sexual abuse (<30%), suggesting that verbal and emotional abuse represent more stable forms of abuse.