Borderline personality characteristics and treatment outcome in cognitive-behavioral treatments for PTSD in female rape victims

Many studies report that comorbid borderline personality pathology is associated with poorer outcomes in the treatment of Axis I disorders. Given the high rates of comorbidity between borderline personality pathology and posttraumatic stress disorder (PTSD), it is essential to determine whether borderline symptomatology affects PTSD treatment outcome. This study examined the effects of borderline personality characteristics (BPC) on 131 female rape victims receiving cognitive-behavioral treatment for PTSD. Higher BPC scores were associated with greater pretreatment PTSD severity; however, individuals with higher levels of BPC were just as likely to complete treatment and also as likely to show significant treatment response on several outcome measures. There were no significant interactions between type of treatment and BPC on the outcome variables. Findings suggest that women with borderline pathology may be able to benefit significantly from cognitive-behavioral treatment for PTSD.     

A comparison of depressed patients with and without borderline personality disorder: implications for interpreting studies of the validity of the bipolar spectrum

The nosological status of borderline personality disorder as it relates to the bipolar disorder spectrum has been controversial. Studies have supported, in part, the validity of the bipolar spectrum by demonstrating that these patients, compared to patients with nonbipolar depression, are characterized by earlier age of onset of depression, recurrent depressive episodes, comorbid anxiety and substance use disorders and increased suicidality. However, all of these factors have likewise been found to distinguish depressed patients with and without borderline personality disorder. A family history of bipolar disorder is one of the few disorder specific validators. In the present study from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we compared the demographic and clinical characteristics of depressed patients with and without borderline personality disorder. We hypothesized that many of the factors used to validate the bipolar spectrum will also distinguish depressed patients with and without borderline personality disorder except, however, a family history of bipolar disorder. Two thousand nine hundred psychiatric outpatients at Rhode Island Hospital were evaluated with the Structured Clinical Interview for DSM-IV (SCID) and Structured Interview for DSM-IV Personality Disorders (SIDP-IV). Family history information regarding first-degree relatives was obtained from the patient using the Family History Research Diagnostic Criteria. One hundred and one patients with borderline personality disorder plus major depressive disorder were compared to 947 patients with major depressive disorder alone on the prevalence of bipolar disorder validators. Compared to depressed patients without borderline personality disorder, depressed patients with borderline personality disorder had a younger age of onset, more depressive episodes, a greater likelihood of experiencing atypical symptoms and had a higher prevalence of comorbid anxiety disorders, substance use disorders, and number of previous suicide attempts. The depressed patients with borderline personality disorder did not significantly differ from the patients without borderline personality disorder on morbid risk for bipolar disorder in first degree relatives. In addition, patients with a diagnosis of bipolar disorder had a significantly higher morbid risk of bipolar disorder in first degree relatives than the borderline personality disorder group. The findings indicate that many factors used to validate the bipolar spectrum are not disorder specific. These results raise questions about studies of the validity of the broad bipolar spectrum that do not assess borderline personality disorder. Our results do not support inclusion of borderline personality disorder as part of the bipolar spectrum.     

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.     

Are personality disorders associated with social welfare burden in the United States?

This study examined the association between personality disorders and use of major social welfare services in a nationally representative sample of U.S. adults (N = 43,093). Social welfare services received and diagnoses of personality, substance use, mood, and anxiety disorders were assessed with the Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-IV-version. Analyses quantified the association between personality disorders and forms of public assistance while controlling for numerous confounds. Logistic regression analyses revealed dependent personality disorder, paranoid personality disorder, antisocial personality disorder, and avoidant personality disorder were significantly associated with increased odds of receiving public assistance. In contrast, persons diagnosed with histrionic, schizoid, and obsessive-personality disorder were not significantly more likely to receive any public welfare service. Development of effective prevention and treatment of personality disorders would likely lead to reductions in overall social welfare burden.     

Heterogeneity of borderline personality disorder: do the number of criteria met make a difference?

Many studies have compared the demographic and clinical characteristics of patients with and without borderline personality disorder (BPD), but there is limited knowledge on differences within the population of borderline patients. One potential index of heterogeneity is disorder severity. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we examined whether the severity of borderline personality disorder, as measured by the number of criteria present, is associated with co-morbidity of Axis I and Axis II diagnoses, as well as demographic factors and psychosocial functioning. Two thousand three hundred psychiatric outpatients were interviewed with the Structured Interview for DSM-IV Personality (SIDP-IV). Approximately ten percent (n = 237) of the patients were diagnosed with BPD, and they were divided into four groups based on the number of DSM-IV criteria met, 5 (n = 89), 6 (n = 70), 7 (n = 46), and 8 or 9 (n = 32). There were greater rates of drug use disorders and comorbid Axis II disorders, as well as a greater number of suicidal gestures, in patients meeting seven or more BPD criteria. There were no significant differences between the groups in the number and specific rates of other co-morbid Axis I disorders, other measures of psychosocial functioning, or demographic correlates. Sub-typing of borderline patients by the number of criteria met provides a limited explanation for heterogeneity within BPD patients.     

Comorbid anxiety and mood disorders among persons with social anxiety disorder.

Axis I comorbidity is associated with greater severity of social anxiety disorder. However, the differential effects of comorbid mood and anxiety disorders on symptom severity or treatment outcome have not been investigated. We evaluated 69 persons with uncomplicated social anxiety disorder, 39 persons with an additional anxiety disorder, and 33 persons with an additional mood disorder (with or without additional anxiety disorders). Those with comorbid mood disorders reported greater duration of social anxiety than those with uncomplicated social anxiety disorder. They were also judged, before and after 12 weeks of cognitive-behavioral group treatment and at follow-up, to be more severely impaired than those with no comorbid diagnosis. In contrast, persons with comorbid anxiety disorders were rated as more impaired than those with no comorbid diagnosis on only a single measure. Type of comorbid diagnosis did not result in differential rates of improvement of social anxiety disorder.     

A preliminary report on defenses and conflicts associated with borderline personality disorder

The authors present preliminary psychodynamic findings from a naturalistic study of borderline personality disorder compared to antisocial personality disorder and bipolar type II (depression with hypomania) affective disorder. An independent psychodynamic interview of each subject was videotaped from which ratings were made of the presence of 22 defense mechanisms and 11 psychodynamic conflicts. A factor analysis of ratings from 81 subjects supported the separation of borderline (splitting, projective identification) from narcissistic defenses (devaluation, omnipotence, idealization, mood-incongruent denial). While certain groups of defenses were associated with each diagnosis, defense ratings did not significantly discriminate the three diagnostic groups, suggesting a limit to their diagnostic value. Among 27 subjects rated, borderline personality was strongly associated with two conflicts: separation-abandonment, and a global conflict over the experience and expression of emotional needs and anger. Antisocial personality was psychodynamically distinct and more heterogeneous. Bipolar type II was associated with two hypothesized depressive conflicts: dominant other and dominant goal. Chronic depression, which was more common in both personality disorder groups than in bipolar type II, was associated with a third depressive conflict, overall gratification inhibition. Overall, conflicts were powerful discriminators of the three diagnostic groups. The heuristic value of these findings is discussed.     

Neurochemistry in the comorbidity of conduct disorder with other disorders of childhood and adolescence: Implications for counselling

Conduct disorder (CD) is comorbid with other child and adolescent disorders with a frequency that is significantly greater than chance. Findings of studies on neurochemical abnormalities and treatment provide tentative empirical evidence for a neurochemical diathesis in children and adolescents with CD with others disorders. Counsellors of children and adolescents with CD and comorbid conditions with a greater appreciation of the medical and psychosocial aspects of comorbidity are likely to be more effective.     

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.     

Associations in the course of personality disorders and Axis I disorders over time

In this study, the authors examined time-varying associations between schizotypal (STPD), borderline (BPD), avoidant (AVPD), or obsessive-compulsive (OCPD) personality disorders and co-occurring Axis I disorders in 544 adult participants from the Collaborative Longitudinal Personality Disorders Study. The authors tested predictions of specific longitudinal associations derived from a model of crosscutting psychobiological dimensions (L. J. Siever & K. L. Davis, 1991) with participants with the relevant Axis I disorders. The authors assessed participants at baseline and at 6-, 12-, and 24-month follow-up evaluations. BPD showed significant longitudinal associations with major depressive disorder and posttraumatic stress disorder. AVPD was significantly associated with anxiety disorders (specifically social phobia and obsessive-compulsive disorder). Two of the four personality disorders under examination (STPD and OCPD) showed little or no association with Axis I disorders.     

Psychodynamic counselling for the borderline personality disordered client: A case study

Psychodynamic counselling for clients with borderline personality disorder is difficult and challenging because there are problems with the validity of the concept, diagnosing the disorder, managing disturbed behaviour and maintaining the treatment to successful completion. Nevertheless, counsellors are frequently called upon to provide assessment, management and treatment for this group. This article explores the application of psychodynamic principles of counselling to clients with borderline personality disorder, examines the history of the concept, the diagnostic process, and employs a case presentation to help describe aspects of character structure and treatment.     

Lines of Advance in Treating People of Color with Borderline Personality Disorder: Alloying the “gold” of Vocational Rehabilitation with the “Copper” of Psychodynamic Psychotherapy

People of color with borderline personality disorder (PoCwBPD), in particular African-Americans and Latinxs in the inner city, present a special population at risk for unemployment and long-term impairment in psychiatric and psychosocial recovery. A growing literature points to the need for comprehensive care that addresses the symptoms of the borderline syndrome alongside social, vocational, and educational achievement. This article paints a picture of the individual, communal, and systemic complexities involved in aiding PoCwBPD achieve psychosocial recovery. After contextualizing the historical and systemic forces that impact recovery for PoCwBPD, I discuss principles of intervention to assist clinicians tailor treatment to this population. Drawing on insights from Transference-Focused Psychotherapy, an evidence-based psychodynamic therapy for BPD, I offer a theoretical cultural adaptation for people of color. This article provides clinical vignettes to illustrate the resulting model, and shows that helping the patient engage in productive activity provides the foundation for exploratory work, which in turn addresses intrapsychic obstacles to psychosocial success.     

Diagnostic profiles of offenders in substance abuse treatment programs

This study examined the association of Axis I and Axis II disorders among offenders who were in prison-based substance abuse treatment in a national multi-site study. Participants (N = 280) received a psychosocial assessment and a structured diagnostic interview in two separate sessions. Logistic regression models examined the association between lifetime mood and anxiety disorders with two personality disorders, and the relationship of Axis I and Axis II disorders (alone and in combination) to pre-treatment psychosocial functioning. Over two-thirds of the sample met criteria for at least one mental disorder. Borderline personality disorder was strongly associated with having a lifetime mood disorder (odds ratio = 7.5) or lifetime anxiety disorder (odds ratio = 8.7). Individuals with only an Axis II disorder, or who had both Axis I and Axis II disorders, had more severe problems in psychosocial functioning than those without any disorder. Clinical treatment approaches need to address this heterogeneity in diagnostic profiles, symptom severity, and psychosocial functioning.     

Personality-based clusters in bulimia nervosa: differences in clinical variables and ecological momentary assessment

The present study examined whether personality-based subgroups of bulimic individuals differed in eating disorder behavior, comorbid psychopathology, treatment history, and momentary assessments of mood and behavior. Participants completed an Ecological Momentary Assessment (EMA) protocol for a period of 2 weeks. Latent profile analysis on the Dimensional Assessment of Personality Pathology revealed 3 groupings of bulimic participants: Interpersonal-emotional, Stimulus seeking-hostile, and Low personality pathology. The personality-based groups differed in histories of mood, anxiety, substance use disorders, features of borderline personality disorder, treatment history, and several momentary measures. These findings suggest that personality variation within the bulimia nervosa diagnostic construct may be associated with meaningful conceptual and clinical differences, including daily experiences in the natural environment.     

Impact of personality disorders on treatment outcome for female assault survivors with chronic posttraumatic stress disorder

This study examined the impact of comorbid personality disorders on the outcome of cognitive behavioral treatment for women with chronic posttraumatic stress disorder (PTSD). Seventy-five adult women with PTSD resulting from rape or nonsexual assault in adulthood or sexual abuse in childhood were treated with prolonged exposure with or without cognitive restructuring. Assessment of personality disorders found that 39% of participants met DSM-IV criteria for some personality disorder diagnosis. No difference was found between women with and without personality disorders on the prevalence of PTSD at the end of treatment. Participants with a personality disorder were less likely to attain good end-state functioning, but this may be attributable to the fact that they started off slightly worse than those without personality disorders. Finally, the comorbid patients treated by community therapists fared as well or better than those treated by cognitive behavioral treatment experts in posttreatment prevalence of PTSD and end-state functioning.     

Suicide Attempts in Major Depressed Patients with Personality Disorder

Suicide attempters who met criteria for borderline personality disorder (BPD) comorbid with major depressive disorder (MDD) were compared to both suicide attempters suffering from MDD alone and to attempters with comorbid MDD and other personality disorders (PD). Participants were 239 (158 patients with comorbid PD and 81 patients with MDD without comorbidity) inpatients consecutively admitted after a suicide attempt made in the last 24 hours. Suicide attempters with comorbid MDD and BPD had more frequent previous suicide attempts and were more likely to have a history of aggressive behaviors and alcohol and drug use disorders compared with patients suffering from MDD without Axis II comorbidity.     

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.     

Recent trends in the pharmacotherapy of personality disorders

This article reviews pharmacologic trials conducted between 2000 and 2003 directed at the treatment of borderline personality disorder, antisocial personality disorder, and schizotypal personality disorder. Atypical antipsychotics, antiepileptics, selective serotonin reuptake inhibitors, omega fatty acids, and opioid antagonists have all been studied in the treatment of borderline personality disorder with positive results. Atypical antipsychotics have been studied in both schizotypal personality disorder and antisocial personality disorder, again with encouraging outcome reports. Implications of personality changes in response to pharmacologic treatment are discussed. Based on the prevalence of these disorders and the burden they cause to afflicted individuals and society, further trials are unequivocally indicated.     

Alterations of social attention in mental disorders: Phenomenology,scope, and future directions for research

Mental disorders often involve changes in the way subjects attend to other people. However, the nature of these modifications and how they unfold in different pathologies are not sufficiently clear. This article addresses these issues from the perspective of phenomenological psychopathology. The primary goal of the article is to suggest a new way of assessing and distinguishing the alterations of social attention in subjects with mental disorders. The first part of the article characterizes the essential properties of a capacity for social attention based on multidisciplinary evidence. This model is then used to examine anomalies in social attention in autism, schizophrenia, borderline personality disorder, and social anxiety disorder. The analysis of alterations in the way subjects with different types of pathologies attend to and with others is followed by a threefold typology, which clarifies the phenomenal nature of impairments of social attention in mental disorders.     

Psychoanalytisch-orientierte Fokaltherapie der sozialen Phobie

Although psychodynamic therapy is one of the most frequently applied forms of psychotherapy to treat anxiety disorders in clinical practice, evidence for the efficacy of psychodynamic therapy in anxiety disorders is unsatisfactory. This is especially true with regard to randomized controlled trials of psychodynamic psychotherapy in anxiety disorders. Psychodynamically oriented treatment manuals for anxiety disorders presently exist for generalized anxiety disorder and panic disorder. For social phobia (or social anxiety disorder), however, no manual for psychodynamic treatment has yet been published. Social phobia is a very frequent mental disorder characterized by an early onset, a chronic course, severe psychosocial impairments and high socio-economic costs and at the same time in spite of these facts one of the mental disorders which are scarcely diagnosed and treated. In this article, a manual for a 30-session (5 exploratory and 25 therapy sessions) short-term psychodynamic treatment of social phobia is presented. The treatment is based on Luborsky’s supportive-expressive (SE) therapy. In the first part, the general principles of SE therapy are presented. In the second part, a manual specifically adapted to the treatment of social phobia is described. This manual includes specific additional treatment elements that have clinically proved to be useful in the therapy of social phobia. The treatment manual is presently used in a large-scale randomized controlled multi-center study comparing short-term psychodynamic psychotherapy and cognitive-behavioral therapy in the treatment of social phobia.