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.     

Posttraumatic stress disorder, traumatic brain injury, and suicide attempt history among veterans receiving mental health services

History of posttraumatic stress disorder (PTSD) or traumatic brain injury (TBI) has been found to increase risk of suicidal behavior. The association between suicide attempt history among veterans with PTSD and/or TBI was explored. Cases (N = 81) and 2:1 matched controls (N = 160) were randomly selected from a Veterans Affairs Medical Center clinical database. PTSD history was associated with an increased risk for a suicide attempt (OR = 2.8; 95% CI: 1.5, 5.1). This increased risk was present for those with and without a history of TBI. Results support incorporating PTSD history when assessing suicide risk among veterans with and without TBI.     

Wrapping community-based mental health services around children with a severe behavioral disorder: An evaluation of project wraparound

During the past two decades there has been a significant increase in community-based mental health and educational services for children and youth with serious emotional and behavioral problems and their families. However, in the vast majority of programs there are no reliable longitudinal data on the adjustment of the children that are served. Project Wraparound was a community-based individualized treatment program which served children and youth with severely maladjusted behavior and their families by providing intensive home and school-based services. The purpose of this paper is to provide a longitudinal analysis of client and family adjustment data. Data on client adjustment within the home and characteristics of the home environment were obtained at intervals of 3 months, 6 months, and 1 year. Data on client adjustment in school was obtained at four points over a period of 2 years. The results from 19 cases indicate that substantial change occurred on measures of the home environment and client adjustment in the home with no significant change in adjustment in the school. Implications of the findings are discussed.     

Healthcare's greatest challenge: providing services for people with severe mental illness in managed care

The delivery of services for people with severe mental illness (SMI) is described as healthcare's most difficult challenge because SMI patients suffer from the combined effects of conditions that have 1) a chronic course, 2) disabling consequences, and 3) a high risk of poverty. The fundamental advantages of managed care for persons with chronic, disabling conditions are discussed along with an examination of how well these assumptions hold in actual practice for persons with SMI. The legal risks assumed by clinicians in managed care are reviewed, including the inherent risk of discriminating against high cost enrollees, such as patients with SMI. Finally, recommendations are made regarding the measures that might be taken to increase the "match" between the principles of managed care and the specialized needs of people with severe mental illness.     

Caregivers, young people with complex needs, and multiple service providers: a study of triangulated relationships

Five patterns of service provider-caregiver-adolescent interaction are discussed using qualitative interviews and file review data from 44 youth with complex needs who were clients of more than one psychosocial service (child welfare, mental health, addictions, juvenile justice, and special education). Findings show that young people and their families become triangulated with service providers, either engaging with, or resisting, interventions. For young people with complex needs involved with multiple service providers, both positive and negative patterns of interaction contribute to the complexity of caregiver-child interactions. According to young people themselves, the most functional of these patterns, empowerment, was experienced as protective when it helped them to meet their personal needs and enhance communication. In contrast, four problematic patterns produced triangulations described as conflictual or unsupportive. The implications of these patterns for family therapy are discussed with an emphasis on the therapist as both clinician and advocate for better services from multiple providers.     

Improving partnerships with families and carers in in‐patient mental health services for older people: a staff training programme and family liaison service

In spite of policies advocating the involvement of families in the care of mental health service users in the UK, there are few examples of initiatives to develop staff confidence and skills in partnership working. This article describes a whole team training initiative and family liaison service to promote family inclusive working on in‐patient wards for older people in Somerset, UK. A three‐day staff‐training programme is described and training outcomes are reported. Staff report a substantial increase in confidence and family meetings held. A pre‐and post‐ training case note audit shows increased consideration of the needs of families. To further increase face to face meetings with families a family liaison service has been established, whereby a staff member with systemic family therapy training joins ward staff to hold family meetings as part of the assessment/admission process. Evaluation of this service has shown it to be effective with positive feedback from families and staff.     

Treating infants and mothers in psychic distress: A mental health program for infancy

Our purpose is to outline a program of mental health for mothers and infants up to the age of 3. The theoretical background of the program refers to the psychoanalytical genetic point of view developed by French and American authors. The therapeutic objectives consist of promoting the infant's self-development and the mother's reflective self-capacity to improve the infant's resiliency. These objectives aim to have preventive purposes. The program has clinical, research and training activities and a multidisciplinary staff. The clinical population is referred by medical services, from families with a middle-low socioeconomic status. With the data collected during the assessment phase, we establish a diagnosis based on a psychodynamic analysis of the pathological process and the evaluation of the risk and protective factors. Our multidisciplinary approach combines individual therapeutic modalities focused on mothers, child or mother-child relationship, with family interventions in our Unit or in the community. An evaluation of our intervention based on Parent-Infant Relationship-Global Assessment Scale (PIR-GAS) is presented. © 1997 Michigan Association for Infant Mental Health     

Evaluation of the SCID-II personality disorder traits for DSM-IV: coherence, discrimination, relations with general personality traits, and functional impairment

The utility of the DSM personality disorder (PD) system remains a concern. The strategy employed represents one approach designed to evaluate and improve the diagnostic efficiency of the SCID-II PDs. Using a sample of 203 patients, SCID-II PD items-based on the criterion sets of the 10 DSM-IV PDs-were evaluated with respect to (a) convergent validity; (b) divergent validity; (c) relation to general personality traits; and (d) association with functional impairment. Only Borderline PD items were satisfactory on all four evaluation criteria. Histrionic and Obsessive-Compulsive PD items met criteria for convergent and divergent validity and relation to personality dimensions of the Five-Factor Model of Personality (FFM) but were not related to functional impairment, suggesting they might be reconsidered as disorders. Schizotypal PD items met three of the four criteria but showed no relation to FFM dimensions, suggesting that it may be a candidate for reassignment to Axis I.     

Externalizing pathology and the five-factor model: a meta-analysis of personality traits associated with antisocial personality disorder, substance use disorder, and their co-occurrence

In this meta-analysis we examined Five-Factor Model of personality (FFM) characteristics of externalizing disorders. Two pathologies, Antisocial Personality Disorder (APD) and Substance Use Disorder (SUD), have significant levels of co-occurrence that may be due to shared personality traits. Results from 63 samples (N = 15,331) were analyzed in order to summarize and compare five-factor results for APD, SUD, and co-occurring APD/SUD. Shared and unique personality features were identified at both the domain and the facet level of the FFM. Moderation analyses indicated that sample source (clinical versus community) and diagnosis (psychopathy versus DSM-based APD) accounted for some of the variability at the domain level. Results are discussed with respect to personality and externalizing disorders.     

The family roles of siblings of people diagnosed with a mental disorder: Heroes and lost children

In order to cope with the diagnosis of mental illness in a family member, siblings may be forced to adjust their roles in the family. Taking into account the crucial role that some siblings play in caregiving for the mentally ill especially when the parents are no longer available, it is imperative to develop awareness of their unique needs and address them. Thirty‐three adult siblings of people diagnosed with a mental disorder completed the Role Behaviour Inventory (RBI) and a general questionnaire including open‐ended questions regarding the roles they played in their families of origin. Findings from the inventory and general questionnaire suggest that the well siblings score higher on two roles, the Hero and Lost Child, and lower on the Mascot and Scapegoat roles relative to a comparison group (N = 33). Being a sibling caregiver emerged as a risk factor to assume certain dysfunctional roles in the family. Implications for future research and therapy are discussed.     

Hypervigilance in patients with borderline personality disorder: specificity, automaticity, and predictors

According to cognitive theory, an important factor in borderline personality disorder (BPD) is hypervigilance. The aim of the present study was to test whether BPD patients show schema-related biases, and to explore relations with childhood trauma, schemas, and BPD symptoms. Sixteen BPD patients were compared with 18 patients with a cluster C personality disorder, 16 patients with an axis I disorder, and 16 normal controls. An emotional Stroop task was applied with schema-related and unrelated, negative and positive, supra- and subliminal person-related stimuli. BPD patients showed hypervigilance for both negative and positive cues, but were specifically biased towards schema-related negative cues. Predictors were BPD schemas, childhood sexual traumas, and BPD anxiety symptoms. Both BPD and axis I disorder patients showed a trend for a bias for negative schema-related subliminal stimuli. More attention to hypervigilance in BPD is recommended for clinical practice.     

Evaluation of early relational disturbance in high-risk populations: Borderline personality disorder features,maternal mental state,and observed interaction

Despite the longstanding theoretical association in the attachment literature between maternal trauma history and disturbances in the mother–infant interaction, few studies have investigated mechanisms of transmission of traumatogenic relational patterns in high-risk mother–infant dyads. This study investigated interrelationships among maternal trauma history, distorted maternal representations (DMRs, i.e. disturbed thoughts and feelings about the infant and self-as-parent), maternal mentalisation (i.e. capacity to conceive of self and other's intentions in terms of mental states including thoughts, feelings, and desires), and quality of interaction in a clinical sample of mothers with Borderline Personality Disorder (BPD) features and their infants (N = 61). Measures used included the Childhood Trauma Questionnaire, Parent Development Interview, Mother–Infant Relationship Scale, Borderline Symptom Checklist-23, and the Emotional Availability Scales. The results indicated BPD features mediated the relationship between maternal trauma history and DMRs predicting disturbance in interaction. In addition, analyses showed that maternal mentalisation had a buffering effect between DMRs and maternal non-hostility and yet the severity of BPD features moderated the relationship between mentalisation and DMRs. The findings suggest postpartum borderline pathology may adversely impact the experience of being a parent for women with a relational trauma history including deficits in mentalisation (i.e. hypermentalising) and disturbances in the mother–infant interaction. Implications for research and clinical practice are discussed.     

Perspectives of people with mental health problems at hot spots: Attitudes and perceptions of safety,crime, and the police

People who live in places with high levels of crime and disorder are more likely to experience mental illness compared with those who do not live in these types of place (Weisburd et al., 2018; Weisburd & White, 2019). The increased police presence on high crime streets may also increase the likelihood that these individuals will encounter law enforcement. There is a strong body of literature focused on the relationship between neighborhoods and the physical and mental health of residents (e.g. Arcaya et al., 2016; Duncan & Kawachi, 2018; Leventhal & Brooks‐Gunn, 2003), but there are very few studies that look at the perceptions of people with mental illness directly, particularly as they relate to the environment of the street on which they live and attitudes toward the police. In turn, existing studies generally look at the most serious mental health problems (e.g. schizophrenia), ignoring more common mental health concerns such as post‐traumatic stress disorder (PTSD) and depression. This paper uses self‐report data from a large in‐person survey of people who live on crime hot spot and non‐hot spot streets in order to assess attitudes among a broader group of persons with mental health problems. Furthermore, we examine the interaction between living in crime hot spots and non‐hot spots and perceptions of these residents. Our findings in this broader sample confirm earlier studies that identify greater fear and less trust of the police among persons with mental illnesses. At the same time, our findings suggest that fear of crime and perceptions of police are moderated by living in a crime hot spot.     

Deliverance,demonic possession,and mental illness: some considerations for mental health professionals

This paper outlines an unconventional treatment for mental illness, the exorcism or deliverance ritual used by Pentecostals and some other charismatic Christians. Deliverance beliefs and practices are based on the assumption that both mental and physical ills result from possession of the sufferer by demons, and are to be treated by the expulsion of those demons. Deliverance practitioners claim to treat schizophrenia, ADHD, and Reactive Attachment Disorder, and believe that these problems are related to sins either of the person in treatment or of an ancestor. Clinicians and counsellors dealing with clients who partially or completely espouse deliverance beliefs may need to understand their worldviews and to discuss their belief system before managing to engage them in conventional mental health treatments. Unusual ethical problems may also be met in the course of such work.