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Advances in Transference-Focused Psychotherapy Derived from the Study of Borderline Personality Disorder: Clinical Insights With a Focus on Mechanism
Abstract
The most current conceptualization of personality pathology emphasizes the assessment of the severity of selected domains of functioning involving lack of accurate perceptions of self and others that are common across the personality disorder categories. Advances in our understanding of personality pathology have stimulated further development of Transference-Focused Psychotherapy (TFP) for patients with borderline personality disorder, including treatment focus on both behavior and mental representations of self and others, the trajectory of change in TFP, and the extension of TFP principles to the entire domain of personality pathology.
... The ICD-11 levels of severity of personality disorder are congruent with personality organization in the psychodynamic approaches (1,(12)(13)(14)(15)(16)(17)(18). Waugh et al. (19) stated that the concept of "psycho-structural level" contained within the psychodynamic model (20) shows many parallels with the Level of Personality Functioning Scale-Self-Report (LPFS) as described in Criterion A of DSM-5 Alternative Model of Personality Disorder (AMPD) assessment, which refers to levels of personality functioning as assessed across the domains of self and interpersonal relatedness. ...
... The Structured Interview of Personality Organization (STIPO) (24) was developed from object relations theory as a dimensional assessment tool to assess severity of personality pathology. The STIPO organizes three levels for personality organization (PO) within a continuum of severity, from psychotic to borderline (with high and low levels) and neurotic, and from internalizing to externalizing (14,18). Clarkin et al. (25) provided a revised version (STIPO-R) to achieve a structural diagnosis by thoroughly evaluating the essential concepts of identity, object-relations (ORs), defenses (primitive and higher-level), aggression, moral values and narcissism (18,25). ...
... The STIPO organizes three levels for personality organization (PO) within a continuum of severity, from psychotic to borderline (with high and low levels) and neurotic, and from internalizing to externalizing (14,18). Clarkin et al. (25) provided a revised version (STIPO-R) to achieve a structural diagnosis by thoroughly evaluating the essential concepts of identity, object-relations (ORs), defenses (primitive and higher-level), aggression, moral values and narcissism (18,25). Among these critical concepts, identity (as the main definition of self) and aggression (as the principal part of interpersonal conflicts) have the main role in self and interpersonal aspects of personality; especially in personality disorder. ...
The current classification of personality disorder in ICD-11 includes a description of personality functioning, derived from a number of theoretical paradigms, but most notably consistent with the psychodynamic approach. Concurrently, an object-relations model of personality functioning in a dimensional assessment of severity is provided in the Structured Interview of Personality Organization-Revised (STIPO-R). To date, there are no published measures of International Classification of Diseases-11 (ICD-11) personality severity, though the construct is very comparable to the concepts assessed in the Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5) levels of personality functioning concept, which is measured by the Level of Personality Functioning Scale-Self-Report (LPFS-SR). This study examined the validity of ICD-11 personality functioning, as measured by the LPFS-SR, by evaluating its associations with the STIPO-R in Kurdistan region. The samples included 231 University students and 419 inpatient participants across four hospitals (267 with a diagnosed personality disorder). All the components of LPFS-SR and STIPO-R were positively and significantly intercorrelated. The components of each measure discriminated PD and non-PD patients from a University, non-clinical group adequately. Despite slightly better performance of the STIPO-R in this discrimination, the measures had a high congruence in predicting personality dysfunction. Overall, the findings of the present study support the validity of ICD-11 construct for evaluating personality functioning.
... Furthermore, D'Agostino et al. (2021) pointed to large positive associations between paranoid, schizotypal, and dependent PDs, and feelings of emptiness. As individuals with paranoid, schizoid and/or borderline PD are considered to present with a (lower) borderline or psychotic personality structure (Clarkin et al., 2018;Kernberg, 1984;Kernberg & Caligor, 2005), their reality testing and identity may be compromised, resulting in blurred boundaries between self and others, and a fragmented self (De Meulemeester et al., 2021;Jørgensen & Bøye, 2021;Miller et al., 2021). ...
... Finally, scores on obsessive-compulsive PD were unrelated to lack of identity and demonstrated moderate associations with disturbed identity. Despite a lack of empirical support, theory suggests that individuals with obsessive-compulsive PD manifest a neurotic level of functioning, characterized by intact reality testing and coherent conceptions of self and others (Clarkin et al., 2018). Nonetheless, the AMPD criteria for obsessive-compulsive PD feature a "sense of self derived predominantly from work or productivity, and difficulty with completing tasks and realizing goals" (APA, 2013). ...
As developmental and clinical research on identity has largely developed in disconnect, scholars recommend adopting a developmental psychopathology perspective on identity, which considers adaptive and pathological identity functioning. Such a perspective has also been introduced in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) Alternative Model for Personality Disorders (AMPD), which suggests that all personality disorders (PDs) are marked by moderate to extreme deficits in self-functioning (i.e., identity and self-direction). The present study aims to validate the Dutch Self-Concept and Identity Measure (SCIM), a 27-item self-report questionnaire that assesses consolidated identity, disturbed identity, and lack of identity, in 153 psychiatric inpatients with PDs (75.2% female; Mage = 31.73). We investigated the factor structure and reliability of the SCIM, and examined associations of SCIM scales with typical identity processes, AMPD domains of self-functioning, and symptoms of all PDs. Results indicated that a 23-item Dutch SCIM produced valid and reliable scores among patients with PDs. Furthermore, SCIM scales were significantly and differentially related to identity commitment processes, ruminative identity exploration, domains of self-functioning, and symptoms of all PDs. Moreover, findings indicated that PDs varied regarding the severity of identity impairment.
... TFP is a manualized, evidence-based, and psychoanalytically-oriented systematic approach for patients diagnosed with BPD. It has the objective of changing symptoms and interpersonal difficulties through structured psychological care that leads to modifying internal representations of the self and others, which guides behavior [14][15][16][17] . Some important features include establishing a framework for treatment in the form of a verbal contract, a focus on disturbed interpersonal behaviors and associated intense affect both in the patient's life and in relation to the therapist, use of the process of interpretation (clarification, confrontation, and interpretation) to modify internal relationships, and real-world changes in work and interpersonal relations 14,17 . ...
... It has the objective of changing symptoms and interpersonal difficulties through structured psychological care that leads to modifying internal representations of the self and others, which guides behavior [14][15][16][17] . Some important features include establishing a framework for treatment in the form of a verbal contract, a focus on disturbed interpersonal behaviors and associated intense affect both in the patient's life and in relation to the therapist, use of the process of interpretation (clarification, confrontation, and interpretation) to modify internal relationships, and real-world changes in work and interpersonal relations 14,17 . ...
Borderline personality disorder (BPD) is characterized by extreme sensitivity to perceived interpersonal conflicts, an unstable sense of self, intense and volatile emotions, impulsive behavior, and recurrent suicidality. This report presents a woman in her early 20s diagnosed with BPD who underwent treatment with transference-focused psychotherapy (TFP) using a videoconference platform. There is no manualized strategy to incorporate videoconferencing with TFP, so we adapted the therapeutic contract to telepsychiatry standards and discussed difficulties during the psychotherapeutic process. This case study can also be used to develop more detailed and structured studies on TFP using a telepsychiatric framework.
... Despite the relative stability of identity-related characteristics, dysfunctional identity may be modifiable in response to experiences, contexts, and interventions (Marcia & Josselson, 2013). Severe identity dysfunction is regarded as a core feature of personality pathology, such as borderline personality disorder, which is the subject of evidencebased treatments that focus expressly on resolving identity conflicts and deficits (Clarkin et al., 2018). Treatment models that focus on individuals' values and self-compassion may help to strengthen self-regulatory abilities (Luoma & Platt, 2015). ...
This study was developed to examine sexual risk behavior among patients seeking community-based mental health services, including associations with psychological distress, identity dysfunction, and childhood emotional neglect. A mediation model was examined regarding identity dysfunction mediating the link between emotional neglect and sexual risk behavior. A total of 245 outpatients completed questionnaires regarding perceived risky sexual behavior, psychological distress, identity dysfunction, and emotional neglect. Sexual risk behavior was found to be a prevalent issue among individuals seeking outpatient mental health services, with 13% reporting engagement in unsafe sexual practices at least some of the time. Mediation analysis revealed that childhood emotional neglect was indirectly linked with sexual risk behavior through the mediating effect of identity dysfunction. Thus, findings suggest a pathway to sexual risk behaviors through perceived childhood emotional neglect and identity dysfunction. Clinical attention to identity-related vulnerability among this population may be warranted in aiming to mitigate risk-taking associated with sexual practices.
... Then, by maintaining a non-judgmental and neutral subject, provide a space to tolerate their representations and communications or attachment patterns. The key features of this contemporary treatment model of object relations are: (a) Determining the treatment framework by setting an oral contract, (b) Focusing on disturbed interpersonal behaviors both in patients' lives and in their relationship with the therapist, (c) Using the process of interpretation to correct internal representations of oneself and others, and (d) causing real-world changes in interpersonal behaviors, especially in the field of work and close/romantic relationships (Clarkin, Cain & Lenzenweger, 2018). ...
Objective: This study aimed to compare the effectiveness of Transference-focused Psychotherapy (TFP) and Acceptance and Commitment Therapy (ACT) on promoting the mental health and psychological capital of staff working in hospitals covered by social security in Tehran Province. Methods: The present study was a quasi-experimental research with pre-test and post-test. The statistical population of the present study was the personnel working in hospitals covered by social security in Tehran Province. A total of 120 personnel from three hospitals were randomly divided into two experimental groups and one control group (40 people in each group). All three groups answered the Mental Health Questionnaire (Symptom Checklist-90-R (SCL-90-R)) and Psychological Capital Questionnaire (PCQ) as a pre-test. Then, the transfer-oriented treatment group and the acceptance and commitment treatment group (during eight sessions) received the experimental intervention and the control group did not receive any kind of intervention. At the end of the sessions, all three groups answered the questions of the SCL-90-R and PCQ again. Multivariate analysis of covariance was used to analyze the collected data. Results: The results of the present study showed that both TFP and ACT were effective in promoting the mental health of staff working in hospitals covered by social security. There was also a difference between the effectiveness of TFP and ACT in promoting the mental health of staff working in hospitals covered by social security. Thus, in the TFP group, the components of anxiety, morbid fear, psychosis, and paranoia gained significantly lower scores compared to the ACT group. Regarding the components of psychological capital, the ACT group scored significantly lower than the TFP group. Conclusion: Both methods can be used by counselors and therapists to promote the mental health of staff working in hospitals covered by social security.
... Treatments TFP is a manualized, structured, twice-weekly psychodynamic treatment for borderline personality disorder that has a treatment duration of 1 year or more and that focuses on the immediate interaction and transference between the patient and therapist (41)(42)(43). The treatment targets the affectively charged, unintegrated, and polarized representations of self and significant others that underlie the affective dysregulation, symptomatology, and deficits in self-and interpersonal functioning that characterize PDs. ...
Objective:
The aim of this article was to construct an empirical bridge between object relations theory and attachment theory by investigating how researchers in both traditions have contributed to understanding and assessing identity diffusion (a keystone of personality pathology) and object relations in patients with borderline personality disorder during 1 year of transference-focused psychotherapy (TFP).
Methods:
The Adult Attachment Interview (AAI) and the Structured Interview of Personality Organization (STIPO) were administered to patients (N=104, all women) before and after 1 year of treatment. This study was part of a randomized controlled trial in which 104 patients with borderline personality disorder were randomly assigned to receive either TFP (a manualized, structured psychodynamic treatment approach) or treatment by experienced community psychotherapists. Changes on the AAI in attachment representations, narrative coherence, and reflective function were examined for their associations with changes on the STIPO in identity, object relations, and aggression.
Results:
Patients who shifted from disorganized (unresolved) to organized attachment on the AAI after 1 year of TFP (but not treatment by experienced community psychotherapists) showed hypothesized improvements in domains of personality organization on the STIPO, including identity, object relations, and aggression. Those who did not change from disorganized (unresolved) to organized attachment improved only in the domain of aggression.
Conclusions:
These findings highlight the centrality of identity diffusion to borderline personality disorder pathology and the importance of targeting it in treatment. Furthermore, the results suggest that identity may be indexed by measures of attachment security, narrative coherence, and personality organization.
... Drust, 2018;Krischer et al., 2017). Die Rolle des Therapeuten besteht in der ständigen Reflexion der Übertragungs-und Gegenübertragungsprozesse in der jeweiligen Situation (Krischer et al., 2017), welche mittels Techniken der Klärung, Konfrontation und Deutung dem Jugendlichen gespiegelt werden (Clarkin, Cain, Lenzenweger, 2018). Dabei stimmen die Prinzipien der TFP-A zu großen Teilen mit der Behandlung Erwachsener überein. ...
This study examines whether transference-focused psychotherapy for adolescents (TFP-A) in a dayclinic setting increases the capability to regulate affects and decreases self-destructive behavior in adolescents with borderline personality organization in comparison to treatment as usual (TAU). A total of 120 adolescents consecutively presenting to the dayclinic were allocated to either TFP-A or TAU. They were assessed for aggression, irritability, depression, self-harm, internalizing behavior and pathological personality traits at baseline and after twelve weeks. TFP-A was more effective than TAU in reducing self-harm. Aggression and irritability was improved within the treatment group. These results can be explained by an improvement in affect regulation through a treatment with TFP-A in a dayclinic setting. Further research is necessary in order to assess whether TFP-A reduces self-harm, aggressive behavior and irritability from a long-term perspective and whether these exploratory results can be replicated in independent samples.
... SFT focuses on sudden shifts between schema modes of thought, behavior, and emotions that reflect a person's emotional state or behavior at any given moment. MBT emphasizes a shift in the mentalization process towards an effective mentalization process [16]. ...
Borderline Personality Disorder (BPD) is a condition that is currently commonly found in daily psychiatric practice, and causes serious psychiatric disorders because it has an impact on the emergence of various other comorbid psychiatric disorders. The management of BPD is a challenge, because it is quite difficult and complex. Psychotherapy is an effective first-line therapy for BPD. Transference Focused Psychotherapy (TFP) is psychodynamic based psychotherapy that is specifically designed for BPD and is considered effective based on the specific psychopathology of BPD, namely the lack of identity integration. TFP focuses on the relationship between patient and therapist in sessions which have the aim of facilitating better behavioral control and increasing reflection and influencing regulation so as to produce identity integration that leads to a more coherent identity, better regulatory abilities, less self-destructive behavior. forming a more balanced and constant relationship, and increasing overall functioning.Keywords : Borderline Personality Disorder, Psychodynamic Psychotherapy, Transference Focused Psychotherapy.
... These range from minor scratches, knocking the head on the wall, burning with cigarettes, up to high doses of drugs, and self-laceration with a knife. [4] Today, after the failure of the de-institutionalization movement, family has always taken the major role in responsibilities of patient care. [5] Families are the most important social support for these patients in society. ...
Background:
Social stigma is the most common and challenging burden of care on the family of people with Borderline Personality Disorder (BPD) In Iran, despite the cultural and social influences, this issue has been less studied. Therefore, present study was conducted to determine the lived experiences of caregivers of patients with BPD of social stigma.
Materials and methods:
This qualitative study was performed at Ibn Sina hospital in Mashhad, Iran from 2017 to 2019. Participants were selected by purposive and snowball sampling method. Data were collected through semi-structured interviews. Data saturation was achieved after 16 interviews. Finally, the data were analyzed by the method proposed by Diekelmann (1989).
Results:
In data analysis, one main theme and two sub-themes emerged. The main themes include Black shadow. Two sub-themes consisted of society dagger and secrecy. The sub-theme of society dagger included the two common meanings (inner turmoil in response to the stigma of others and weakening of family status among relatives and acquaintances). The sub-theme of secrecy comprised of the three common meanings (concealment of disease, hide hospitalization, and seclusion).
Conclusions:
An understanding of the experience of family stigma can lead to the development of supportive strategies to manage this problem among caregivers of patients with BPD. Nurses can support caregivers by offering them opportunities to discuss how stigma is disrupting their caregiving roles. They can also support the caregivers in negotiating the experienced social and emotional distress and when necessary, refer them to the other members of healthcare teams.
... 25,26 Some authors discussed the association of BPD and affected neural areas includes regions involved in understanding the mental state of others and themselves, 27,28 circuits mediating pain experience, 29 reward systems, and a limbic system with circuits regulating emotions and behaviour. 30 First-line treatment of patients with BPD is psychotherapy, such as dialectical behavioural therapy (DBT), [31][32][33] transference-oriented psychotherapy (TFP), [34][35][36] mentalisation-based therapy (MBT) [37][38][39] and schema therapy (ST). [40][41][42] DBT focuses on treating BPD's observable symptoms while MBT, TFP, and ST focus on improving the patient's understanding of their motives, feelings, and experiences. ...
Objective
Both sleep disorders and BPD are prevalent in the population, and one is often a comorbidity of the other. This narrative review aims to assess contemporary literature and scientific databases to provide the current state of knowledge about sleep disorders in patients with borderline personality disorder (BPD) and clinical suggestions for managing sleep disorders in BPD patients and future research direction.
Methods
Articles were acquired via PubMed and Web of Science, and papers published between January 1980 and October 2020 were extracted. Authors made a series of literature searches using the keywords: Sleep problems, Insomnia, Nightmares, Obstructive sleep apnea, Borderline personality disorder. The inclusion criteria were: published in peer-reviewed journals; studies in humans; or reviews on the related topic; English language. The exclusion criteria were: abstracts from conferences; commentaries; subjects younger than 18 years. After an inspection of the full texts, 42 papers from 101 were selected. Secondary documents from the reference lists of the primary designated papers were searched, assessed for suitability, and included. In total, 71 papers were included in the review process.
Results
Sleep disturbance is common among patients with BPD. Nevertheless, the number of investigations is limited, and the prevalence differs between 5–45%. Studies assessing objective changes in sleep architecture in BPD show inconsistent results. Some of them identify REM sleep changes and a decrease in slow-wave sleep, while other studies found no objective sleep architecture changes. There is also a higher prevalence of nightmares in patients with BPD. Untreated insomnia can worsen BPD symptoms via interference with emotional regulation. BPD itself seems to influence the subjective quality of sleep significantly. Proper diagnosis and treatment of sleep disorders in patients with BPD could lead to better results in therapy. Psychotherapeutic approaches can improve both sleep disorders and BPD symptoms.
Conclusion
Recognising and managing sleep disorders in patients with BPD may help alleviate the disorder’s symptoms. Treatment of people with BPD may be more effective if the treatment plan explicitly addresses sleep problems. Further research is needed to reach reliable conclusions.
... Quatro grandes organizações estruturais compõem o modelo: a Normal, a Neurótica, a Borderline e a Psicótica. Destas, a primeira está relacionada à capacidade de adaptação e flexibilidade, enquanto as demais apresentam algum grau de patologia da personalidade e são caracterizadas por uma rigidez no funcionamento psicológico 5,7 . ...
Este é um estudo quantitativo realizado entre 2014 a 2015 nas cidades de Erechim, Canoas e Porto Alegre com pacientes em tratamento psicoterápico e/ou psiquiátrico (amostra clínica) e estudantes da modalidade Ensino de Jovens e Adultos e de cursos superiores (amostra não clínica), com o objetivo de examinar a capacidade do Inventário de Organização de Personalidade – Brasil em discriminar pessoas com diferentes níveis de organização da personalidade. Participaram 180 indivíduos, sendo 69% pacientes em atendimento psiquiátrico ou psicológico e 31% estudantes. As médias do grupo clínico foram maiores em todas as escalas do que as médias do grupo não clínico (d variou de 0,60 a 1,30). Quando comparados os grupos de participantes de acordo com seus níveis de organização da personalidade, os escores não discriminaram todos os grupos, tendo sido observado um padrão de três níveis: normal; prejuízo leve; e, prejuízo grave. Os escores tenderam a diferenciar esses três grupos. Com isso, entende-se que há evidências de validade, baseadas em critérios externos, de que os escores são capazes de identificar níveis de prejuízo no funcionamento da personalidade.
... Lack of identity scale scores were a stronger positive predictor of variance in paranoid, schizotypal, and borderline PD symptoms than disturbed identity scale scores. Individuals bearing symptoms of Cluster A PDs (such as paranoid and schizotypal PDs) commonly experience difficulties with reality-testing and cognitive organization (Clarkin, Cain, & Lenzenweger, 2018;Kernberg, 1984Kernberg, , 2006McWilliams, 1994). These symptoms may contribute to their experience of severe identity diffusion or even a lack of identity. ...
Section III of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders includes an alternative model for personality disorders (PDs), in which identity impairment is considered an essential criterion of all PDs. This alternative approach has stimulated researchers to characterize identity across PDs. In the present study, we examined associations between identity and PD symptomatology among 242 Flemish community adults (49.2% female; Mage = 42.76, SD = 14.42). Participants completed the Self-Concept and Identity Measure (Kaufman, Cundiff, & Crowell, 2015) to assess identity functioning (with subscales measuring consolidated identity, disturbed identity, and lack of identity) and the Assessment of DSM-IV Personality Disorders (Schotte, De Doncker, Vankerckhoven, Vertommen, & Cosyns, 1998) to assess dimensionally measured PDs. Bivariate correlational analyses and hierarchical regression analyses were performed to investigate associations. Additionally, to test if the standardized beta weights for the disturbed identity and lack of identity scales were significantly different from one another, we estimated their corresponding 95% confidence intervals via bias corrected bootstrap. Bivariate correlational analyses yielded negative associations between the consolidated identity subscale and all PDs, whereas scores on disturbed identity and lack of identity scales were positively related to PDs. Hierarchical regression analyses indicated that the consolidated identity scale negatively predicted variance in borderline PD. Disturbed identity and lack of identity scales positively predicted variance in all PDs, with lack of identity being the stronger predictor of paranoid, schizoid, schizotypal, borderline, and avoidant PDs. These findings generally support identity impairment as a central dysfunction among all PDs in a Flemish community sample.
... Lack of identity scale scores were a stronger positive predictor of variance in paranoid, schizotypal, and borderline PD symptoms than disturbed identity scale scores. Individuals bearing symptoms of Cluster A PDs (such as paranoid and schizotypal PDs) commonly experience difficulties with reality-testing and cognitive organization (Clarkin, Cain, & Lenzenweger, 2018;Kernberg, 1984Kernberg, , 2006McWilliams, 1994). These symptoms may contribute to their experience of severe identity diffusion or even a lack of identity. ...
Aims. Section III of DSM-5 offers an alternative model for diagnosing personality disorders (PDs) in which identity impairment is considered a potential criterion of all PDs. The present studies examined associations between identity and PDs in Belgian community adults and in-patients with borderline personality disorder (BPD).
Methods. Study 1 investigated relations between identity and PD symptomatology among 555 Belgian community adults [62.9% female; Mage = 35.36]. Study 2 replicated Study 1 in a sample of approximately 75 in-patients with BPD. All participants completed the Self-Concept and Identity Measure (SCIM) to assess dimensions of identity functioning and the Assessment of DSM-IV Personality Disorders (ADP-IV) to assess dimensionally measured PDs. Correlational and hierarchical regression analyses were performed to examine associations. Additionally, to test if the standardized beta weights for the disturbed identity and lack of identity scales were significantly different from one another, we estimated their corresponding 95% confidence intervals via bias corrected bootstrap.
Results. In Study 1, correlational analyses indicated negative associations between consolidated identity and PDs, whereas disturbed identity and lack of identity were positively associated with PDs. Hierarchical regression analyses indicated that consolidated identity negatively predicted variance in schizoid and antisocial PDs. Disturbed identity and lack of identity positively predicted variance in all PDs. Interestingly, lack of identity was a stronger predictor of variance in paranoid, schizoid, schizotypal, antisocial, borderline, histrionic, avoidant, and obsessive-compulsive PDs. Clinical data for Study 2 are currently being collected and will be analyzed in time for the congress.
Conclusion. Identity impairment appears to be an essential commonality among personality disorders.
... Lack of identity scale scores were a stronger positive predictor of variance in paranoid, schizotypal, and borderline PD symptoms than disturbed identity scale scores. Individuals bearing symptoms of Cluster A PDs (such as paranoid and schizotypal PDs) commonly experience difficulties with reality-testing and cognitive organization (Clarkin, Cain, & Lenzenweger, 2018;Kernberg, 1984Kernberg, , 2006McWilliams, 1994). These symptoms may contribute to their experience of severe identity diffusion or even a lack of identity. ...
Section III of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) includes an alternative model for diagnosing personality disorders (PDs). This model highlights identity impairment as a potential criterion of all PDs, which has stimulated researchers to characterize identity functioning across PD presentations. Accordingly, the present study examined associations between dimensions of identity functioning and PD symptomatology among 242 Flemish community adults (49.2% female; Mage = 42.76, SD = 14.42). Participants completed the Self-Concept and Identity Measure (Kaufman, Cundiff, & Crowell, 2015) to assess identity functioning and the Assessment of DSM-IV Personality Disorders (Schotte, De Doncker, Vankerckhoven, Vertommen, & Cosyns, 1998) to assess dimensionally measured PDs. A correlational analysis yielded negative associations between the consolidated identity subscale and all PDs, whereas scores on both disturbed identity and lack of identity scales were positively associated with PDs. A multivariate regression analysis indicated that the consolidated identity scale did not account for unique variance in PD dimensions. Disturbed identity and lack of identity scale scores positively predicted variance in all PDs, with the lack of identity scale being the stronger predictor of symptoms of paranoid, schizotypal, and borderline PDs. Study findings generally support identity impairment as a central dimension in PD symptomatology in a Flemish community sample.
... Finally, it has been suggested that psychedelics facilitate experiences of transference (Goldsmith, 2007) and enhance therapeutic alliance (e.g., Dolder et al., 2016;Mithoefer et al., 2011), which are essential components of MBT and TFP. Moreover, the altered sense of self (for a discussion, see Nour & Carhart-Harris, 2017) and relation to others (Bershad et al., 2019;Carhart-Harris, Erritzoe et al., 2018) induced by psychedelics and the emphasis on targeting the patient's representation of the self and others within TFP (Clarkin, Cain, & Lenzenweger, 2018), may benefit from one another. Accordingly, compared with either treatment alone, utilizing psychedelics alongside evidence-based interventions and their techniques, such as DBT (e.g., mindfulness, radical acceptance), MBT (e.g., 'validation of the transference,' 'mentalizing the transference'), and TFP (e.g., 'working with transference,' clarification, confrontation), may have positive synergistic effects for the treatment of BPD (see Fig. 1). ...
Borderline Personality Disorder (BPD) is a severe psychiatric disorder characterized by behavioral dysregulation, emotion dysregulation, disturbances in self-identity, and social functioning. Despite the existence of evidence-based psychotherapeutic interventions for BPD, these interventions have important limitations (e.g., limited treatment efficacy). Furthermore, little evidence exists for the efficaciousness of pharmacological interventions for BPD. Thus, a strong need for improving current interventions for BPD exists. Although research incorporating psychedelics within interventions for a wide range of psychiatric disorders has shown promise, research has not yet explored the utility of incorporating psychedelics within interventions for BPD. Therefore, this paper reviews the impact of psychedelics on treatment targets in interventions for BPD (i.e., behavioral dysregulation, emotion dysregulation, disturbances in self-identity, and social functioning), as well as purported overlapping mechanisms of change between interventions for BPD and psychedelics (i.e., emotion dysregulation, mindfulness, and self-compassion). Finally, safety concerns, clinical recommendations, and proposed next research steps related to the administration of psychedelics to individuals with BPD are discussed. This paper aims to explore the case for conducting research on, and the potential clinical utility surrounding, incorporating psychedelics within interventions for BPD.
... For example, the Diagnostic and Statistical Manual of Mental Disorders (currently 5th ed.; DSM-5) explains that histrionic PD is associated with "roleplaying" in interpersonal relationships without being aware of doing so (e.g., playing the role of a high-status person to appear desirable) [1]. This viewpoint also has influenced PD treatment approaches, as psychotherapy protocols such as transference-focused psychotherapy conceptualize identify disturbance as core to personality pathology and seek to facilitate awareness of the self and others in treatment [2,3]. ...
Purpose of review
The validity of self-ratings of personality pathology often is questioned because personality disorders (PD) historically have been viewed as being characterized by poor insight. However, recent research indicates that PD self-ratings are valid in many ways and have significant clinical utility. Building upon this growing literature, our goal here is to provide practical discussion of how incorporating dimensional PD ratings into assessment protocols can benefit diagnosis and treatment.
Recent findings
We first review evidence suggesting that PD self-ratings are particularly useful for assessing constructs related to individuals’ own subjective experiences (e.g., propensities for experiencing negative mood states). We then highlight research indicating that PD self-ratings (a) change positively with intervention and (b) meaningfully inform diagnosis, treatment planning, and treatment outcome. Finally, we illustrate how freely available, well-validated self-report PD measures can be used to efficiently obtain clinically useful information in a manner comprehensible to both practitioners and patients.
Summary
Self-ratings of personality pathology are valid and useful in many ways and can be efficiently incorporated into assessment protocols. Key future directions for advancing knowledge of self-report PD assessment include examining the extent to which self-ratings of antagonism—a core PD trait—are accurate across contexts.
... For example, the Diagnostic and Statistical Manual of Mental Disorders (currently 5 th ed.; DSM-5) explains that histrionic PD is associated with "roleplaying" in interpersonal relationships without being aware of doing so (e.g., playing the role of a high-status person to appear desirable) [1]. This viewpoint also has influenced PD treatment approaches, as psychotherapy protocols such as transference focused psychotherapy conceptualize identify disturbance as core to personality pathology and seek to facilitate awareness of the self and others in treatment [2,3]. ...
Purpose of Review: The validity of self-ratings of personality pathology often are questioned because personality disorders (PD) historically have been viewed as being characterized by poor insight. However, recent research indicates that PD self-ratings are valid in many ways and have significant clinical utility. Building upon this growing literature, our goal here is to provide practical discussion of how incorporating dimensional PD ratings into assessment protocols can benefit diagnosis and treatment. Recent findings: We first review evidence suggesting that PD self-ratings are particularly useful for assessing constructs related to individuals’ own subjective experiences (e.g., propensities for experiencing negative mood states). We then highlight research indicating that PD self-ratings (a) change positively with intervention and (b) meaningfully inform diagnosis, treatment planning, and treatment outcome. Finally, we illustrate how freely available, well-validated self-report PD measures can be used to efficiently obtain clinically useful information in a manner comprehensible to both practitioners and patients. Summary: Self-ratings of personality pathology are valid and useful in many ways and can be efficiently incorporated into assessment protocols. Key future directions for advancing knowledge of self-report PD assessment include examining the extent to which self-ratings of antagonism—a core PD trait—are accurate across contexts.
... A Content-Focused Psychodynamic Treatment -Transference Focused Psychotherapy TFP was developed by Frank Yeomans, John Clarkin, and Otto Kernberg (Yeomans et al., 2015) and is associated with a new conceptual idea of identity formation and personality organization. The aim of treatment is to decrease the symptomatic burden and interpersonal problems in patients with BPD by changing patients' mental representations of others and self that underlies their behavior (Clarkin, Cain, & Lenzenweger, 2018), to meaningfully improve functioning in the domains of work, studies and profession, and intimate relations (Yeomans et al., 2015). ...
Borderline Personality Disorder (BPD) is a serious health issue associated with a high burden for the individual and society. Among the “Big Four” of evidence-based treatments for patients with BPD are two psychodynamic therapies that have evolved from classic psychoanalytic treatment with a change of setting and change of focus: Transference-Focused Psychotherapy (TFP) and Mentalization-Based Treatment (MBT).
This overview provides a comparison of the two treatments in terms of stance, clinical concepts, costs and key interventions. Furthermore, the current literature on the efficacy of both treatments is reviewed.
While TFP focuses on the content of disintegrated representations of self and other, MBT focuses on the processing of mental states. Both treatments diverge in their clinical concepts and interventions for the treatment of BPD.
Although both treatments are regarded as effective in treating BPD, no direct comparison of both treatments has been made so far. Future studies are needed to investigate mechanisms of change and derive recommendations for a differential indication.
Specialized therapies for BPD have favorable drop-out rates and outcome compared to non-specialized ones.
MBT and TFP have very diverse clinical concepts and interventions for the treatment of BPD.
Both, MBT and TFP show efficacy in RCTs.
No trial has directly compared MBT and TFP; there is no evidence base for differential indication.
Specialized therapies for BPD have favorable drop-out rates and outcome compared to non-specialized ones.
MBT and TFP have very diverse clinical concepts and interventions for the treatment of BPD.
Both, MBT and TFP show efficacy in RCTs.
No trial has directly compared MBT and TFP; there is no evidence base for differential indication.
... Lack of identity scale scores were a stronger positive predictor of variance in paranoid, schizotypal, and borderline PD symptoms than disturbed identity scale scores. Individuals bearing symptoms of Cluster A PDs (such as paranoid and schizotypal PDs) commonly experience difficulties with reality-testing and cognitive organization (Clarkin, Cain, & Lenzenweger, 2018;Kernberg, 1984Kernberg, , 2006McWilliams, 1994). These symptoms may contribute to their experience of severe identity diffusion or even a lack of identity. ...
Section III of the DSM-5 includes an alternative model for personality disorders (PDs), in which identity impairment is considered a key symptom of personality pathology. The present study examined associations between identity functioning and PD symptomatology among 242 community adults. Bivariate correlational analyses demonstrated negative associations between consolidated identity and all PDs, whereas scores on both disturbed identity and lack of identity were positively associated with all PDs. Multiple hierarchical regression analyses indicated that consolidated identity negatively predicted BPD. Disturbed identity and lack of identity positively predicted all PDs, with lack of identity being the stronger predictor of paranoid, schizoid, schizotypal, borderline, and avoidant PDs.
... From this perspective, BPO includes some of the most severe personality disorders and allows the assessment of the severity of the personality pathology and affiliation (introversion vs. extraversion). In sum, structural personality organization model combines a dimensional perspective of the severity and allows a categorical classification of the personality pathology (Kernberg, & Caligor, 2005;Clarkin, Cain, & Lenzenweger, 2017;Esguevillas, Díaz-Caneja, Arango, del Rey-Mejías, Bernardo, Delgado,... & Carrasco, 2017). The fact that we observed that BPD comorbid with Schizotypal and Antisocial pathology predicts SDE is consistent with the structural personality model in which, patients with diagnosis of BPD with schizotypal characteristics would present the highest severity of personality pathology on the side of the introversion, and patients with diagnosis of BPD with antisocial characteristics would show the highest severity of personality pathology on the side of the extraversion, and therefore, more identity alterations, use of primitive defenses and manifestations of ego weakness and consequently, higher dissociative experience. ...
The objective of this study was to identify personality disorders comorbid to BPD that confer greater risk for the presence of severe dissociative experiences. Three hundred and one outpatients with a primary diagnosis of BPD were evaluated using the Structured Clinical Interview for DSM-IV Axis II personality disorders (SCID-II), the Borderline Evaluation of Severity Over Time (BEST) and the Dissociative Experiences Scale (DES). Our results show that the most frequent personality disorders comorbid to BPD were paranoid (83.2%, n = 263) and depressive (81.3%, n = 257). On average, the patients scored with 43.3 points and 28.6 points in the BEST and DES scales respectively. We categorized the sample into patients with and without severe dissociative experiences (41% were positive). A logistic regression model revealed that Schizotypal, Obsessive-compulsive and Antisocial personality disorders conferred greater risk for the presence of severe dissociative experiences. The results suggest that a large proportion of patients with BPD present a high rate of severe dissociative experiences and that some clinical factors such as personality comorbidity confer greater risk for dissociation, which is related to greater dysfunction and suffering, as well as a worse progression of the BPD.
... GPM is an easily learned and applied treatment with a focus on psycho-education and improvement of functionality and quality of life. Beyond the specific characteristics of these various methods and the knowledge that all efficacious treatments for BPD include a careful reflection of and investment in the therapeutic alliance, all evidence-based psychotherapies aim to improve patients' emotion regulation capacity [7][8][9]. In addition, treatment targets have recently been extended to foster more coherent self-identity and sense of agency and to increase the capability to mentalize others' mental states [10]. ...
Emotion dysregulation is a hallmark of borderline personality disorder (BPD). Most interventions for patients with BPD, therefore, aim at the improvement of emotion regulation. In the current paper, we provide an overview of studies investigating the effects of psychotherapeutic or pharmacological interventions on neurobiological correlates of various aspects of emotion regulation. In fact, studies suggest that the prefrontal-limbic circuit may play a major role in mediating effects of clinically efficacious psychotherapeutic treatments, i.e., they lead to clinical improvement via modulating the function and structure of the amygdala, the insula, and the dorsal anterior cingulate cortex, as well as prefrontal areas involved in the cognitive regulation of emotions, and enhancing the coupling of limbic and prefrontal areas. Oxytocin as a promising pharmacological approach to emotion dysregulation in BPD was shown to dampen amygdala activity in response to emotional stimuli. Understanding the brain mechanisms that mediate treatment effects will harness further development of targeted mechanism-based interventions for patients with BPD.
We propose to critically evaluate and strengthen the level of clinical evidence in psychoanalysis, using a strategy of triangulating clinical phenomena from different perspectives and increasing contextual knowledge. Insufficient discussion of alternative hypotheses and limited contextual information are two Achilles heels of psychoanalytic case presentations. We analyze the case of a patient treated with transference-focused psychotherapy (TFP), making explicit the theoretical-clinical agreements and disagreements between the authors. We discuss the strengths and limitations of triangulation and contextualization, concluding that they make clinical work and psychoanalytic writing more reliable, transparent, auditable and replicable.
ABSTRACT
We propose to critically evaluate and strengthen the level of clinical evidence in psychoanalysis, using a strategy of triangulating clinical phenomena from different perspectives and increasing contextual knowledge. Insufficient discussion of alternative hypotheses and limited contextual information are two Achilles heels of psychoanalytic case presentations. We examine the concept and quality standards of clinical evidence in psychoanalysis and related disciplines, with particular attention to the contribution of the Three-Level Model (3-LM). We analyze the case of a patient treated with transference-focused psychotherapy (TFP), making explicit the theoretical-clinical agreements and disagreements of the authors. We discuss the strengths and limitations of triangulation and contextualization, concluding that they make clinical work and psychoanalytic writing more reliable, transparent, auditable and replicable.
Background:
Due to the structural separation of child and adolescent psychiatric treatment and adult psychiatric treatment, a switch between these two systems upon the age of 18 is necessary. Considering the importance of an organized transition, patients from an age of 17 were asked about their transition needs and aspects of their identity development. Thus future improvements in the treatment structures in this sensitive phase should derive.
Methods:
With the help of the Transition Readiness and Appropriateness Measure (TRAM), the transition-specific needs of 17 to 24-year-old patients (N = 42) at the Clinic for Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy in Hall in Tirol were surveyed. In addition, the connection between identity development and transition was examined using the Assessment of Identity Development in Adolescence (AIDA).
Results:
Almost 80% of the patients stated that they needed further care. 'Patient-related factors' and 'family support' were described as barriers to the willingness to transition. A significant connection was found between identity development and the willingness or need for transition (r = 0.431, p < 0.01), although this was more pronounced in relation to the need for transition (r = 0.821 p < 0.01). In addition, those affected stated that they were frequently and severely burdened by stress, 45% reported self-injurious behavior, 48% suicidal thoughts or behavior in the last six months. In terms of psychopathology, anxiety and depression were among the most common symptoms. In terms of functional impairment, the 'relationships' area was the most affected.
Conclusions:
The study provides initial insights into the transition-specific characteristics and needs of patients in transition age. The integration of standardized measuring instruments in institutional care systems, which individually record the transition-related needs, the willingness and need of young people in transition age, can facilitate targeted and needs-based treatment or transition. Interdisciplinary cooperation between child and adolescent psychiatry and adult psychiatry as well as a continuous transfer of the therapeutic relationships in the transition process should also be guaranteed.
This chapter provides an overview of the major theories of behavior and their applications, beginning with the first mention of mental illness in Egyptian records in 1550 BC (see Fig. 5.1). In the following decades and centuries, mentions of depression and mental illness began to increase, creating a rich lode for further developments as societies became more advanced and could utilize more resources for healthcare. By 1879, the first experimental psychology laboratory was founded. The beginning of the twentieth century bore witness to great conceptual progress through Freud’s radical innovations regarding the unconscious mind and psychotherapy. In the 1920s, Piaget developed the first systematic account of developmental psychology. Freud and Piaget were followed by a myriad of other psychological theories, including behaviorism, classical conditioning, Gestalt psychology, and attachment theory. The second half of the twentieth century had three major waves of new psychotherapies and psychosocial interventions. The first wave consisted of behavioral therapies that evolved to promote a more scientific approach to therapy grounded in experimental behavioral science. A second wave focused on cognitive distortions as a driver of pathology, leading to the development of cognitive behavioral therapy (CBT). The third wave of therapies has emerged in the last two decades partly in response to the concern that – though CBT techniques are fairly well validated – the link between cognitive therapy and cognitive science continues to be weak. Mindfulness-based interventions, for example, rather than challenge the validity of automatic thoughts, seek to help the patient achieve a state of present focus and to acknowledge and accept the flow of sensations, emotions, and thoughts without avoidance or negative judgment. In the more recent decades, other therapeutic modalities, such as interpersonal psychotherapy, dialectical behavioral therapy, and behavioral activation, have gained prominence.
Introduction: Although self-disturbance is considered as an essential aspect of borderline personality disorder, there is little knowledge about its nature in affected individuals.
Aim: The present study aimed to determine the patterns of self in women with borderline personality disorder.
Method: This study was a basic research with a qualitative approach. The statistical population consisted of women with borderline personality disorder in Mashhad and psychologists and psychiatrists in Mashhad and Tehran, Iran, in 2021. Fifteen women with borderline personality disorder were selected by convenience sampling using Leichsenring's Borderline Questionnaire (1999) from Ibn Sina Hospital in Mashhad, and eight specialists were selected through purposive sampling. Data was collected through semi-structured interviews and coded through thematic analysis.
Results: In the data analysis, five main themes, including self-knowledge, self-agency, loneliness, self and injury, and self and emotions, were identified. The self-knowledge theme has two sub-themes, namely, lack of self-awareness and instability. Self-agency included two external and internal themes. Loneliness was also divided into three themes of rejection, being misunderstood, and avoidance. Self and injury contained the themes of self pathology and self-harm, and finally, the main theme of self and emotions was divided into positive and negative emotions.
Conclusion: In women with borderline personality disorder, under the influence of adverse and harmful experiences from early relationships and due to the accumulation of unprocessed emotions that cause impulsive behaviors, the self is incoherent, unstable with low self-awareness, and weak agency in facing life difficulties. Therefore; the extracted themes can provide a more comprehensive understanding of these individuals.
Résumé
Objectifs
Étudier l’état des connaissances et des représentations au sujet du trouble de personnalité borderline d’un groupe de soignants francophones intéressés par ces patients.
Méthodes
Entre 2019 et 2020, nous avons au début d’une formation aux approches psychothérapeutiques du trouble de personnalité borderline fait passer à 126 soignants francophones de diverses obédiences professionnelles deux questionnaires concernant les connaissances et les représentations au sujet de ce trouble.
Résultats
Les résultats montrent un important déficit de connaissances parmi les professionnels, en particulier non médicaux, souhaitant prendre en charge les patients avec un trouble de personnalité borderline. Concernant les représentations des soignants, il existe une reconnaissance de leur détresse ainsi qu’une demande de formations dédiées, mâtinées toutefois de pessimisme pronostique ainsi que de craintes à les prendre en charge.
Conclusions
Les stigmas et la méconnaissance persistent autour des patients souffrant d’un trouble de personnalité borderline. Les cursus de formation actuels ne permettent pas aux soignants qui sont en première ligne (en particulier les professions infirmières) et désireux de se former d’acquérir suffisamment de connaissances et d’outils nécessaires à la prise en charge des patients souffrant de ce trouble. Ceci appelle à une amélioration de la formation ainsi qu’à une réflexion autour d’approches les plus ajustées possibles aux divers publics cibles.
Purpose of Review
The concept of personality functioning (Alternative DSM-5 Model of Personality Disorders) has led to increased interest in dimensional personality disorder diagnosis. While differing markedly from the current categorical classification, it is closely related to the psychodynamic concepts of personality structure and personality organization. In this review, the three dimensional approaches, their underlying models, and common instruments are introduced, and empirical studies on similarities and differences between the concepts and the categorical classification are summarized. Additionally, a case example illustrates the clinical application.
Recent Findings
Numerous studies demonstrate the broad empirical basis, validated assessment instruments and clinical usefulness of the dimensional concepts. Their advantages compared to the categorical approach, but also the respective differences, have been demonstrated empirically, in line with clinical observations.
Summary
Evidence supports the three dimensional concepts, which share conceptual overlap, but also entail unique aspects of personality pathology, respectively.
Objectives: The concept of narcissism contains a yet unresolved paradox: Its grandiose facet depicts the psychopathological core but is often associated with life-satisfaction and overall functioning, whereas its vulnerable facet is associated with psychological distress, but still not included in the international classification systems. Our goal was to investigate the relationship between the two facets of narcissism expecting underlying defense mechanisms to be core elements. First, we aimed to identify defense mechanisms specific to grandiose and vulnerable narcissism. Second, we explored how both facets are differentially associated with psychological distress, assuming that grandiose narcissism would be associated with less psychological distress than vulnerable narcissism. Third, we investigated the mediating role of defense mechanisms between narcissism and psychological distress.
Methods: In a non-clinical sample of N = 254 individuals, the Pathological Narcissism Inventory was used for the assessment of grandiose and vulnerable facets of narcissism, the Defense Style Questionnaire for defense mechanisms, and the Brief Symptom Inventory for psychological distress. Structural equation modeling was employed to identify distinct factors of grandiose and vulnerable narcissism. Associations between specific defense mechanisms and both facets were calculated. Furthermore, the direct association between both facets and psychological distress was examined. We finally explored whether defense mechanisms mediate the association between distress and both grandiose and vulnerable narcissism.
Results: A distinct pattern of defense mechanisms for each facet of narcissism could be extracted: Both facets showed significant positive correlations with specific intermediate and all maladaptive defense mechanisms. Only grandiose narcissism showed significant positive correlations with adaptive defenses. Vulnerable narcissism showed negative correlations with all adaptive defenses. Specifically, grandiose narcissism was significantly related to anticipation, pseudo-altruism, rationalization, and dissociation, whereas vulnerable narcissism was negatively related to all these defense mechanisms. While grandiose narcissism was not related to psychological distress, vulnerable narcissism showed high correlations with psychological distress. Intriguingly, mediator analysis found that grandiose narcissism was related to psychological distress when mediated by maladaptive defense mechanisms.
Discussion: The role of defense mechanisms is central for a differentiated understanding of the two different faces of narcissism. The relevance of assessing defense mechanisms in clinical settings, and related empirical findings are discussed.
Transference-focused psychotherapy (TFP) is an empirically validated psychodynamic psychotherapy for borderline personality disorder (BPD), based on object relations theory, that has clinical utility for individuals with narcissistic personality disorder (NPD). Given the effectiveness of TFP for patients with BPD, including a number of patients with comorbid NPD, we have adapted the tactics and techniques of TFP with specific modifications for patients with NPD or narcissistic traits. TFP for NPD (TFP-N) retains core elements of the treatment, including a contracting phase and an interpretive process designed to identify and modify maladaptive mental representations of self and others that underlie the affect and behavioral dysregulation in those with personality disorders including NPD. The major goal of TFP-N is the focus on disturbed interpersonal patterns of relating in the here-and-now of the therapeutic interaction as a vehicle to effect enduring changes in personality organization and real-world changes in the areas of love and work.
This article demonstrates the utility of a theory-guided psychodynamic approach to the assessment of personality and personality pathology based on the object relations model developed by Kernberg (1984). We describe a clinical interview, the Structural Interview (SI; Kernberg, 1984), and also a semistructured approach, the Structured Interview of Personality Organization (STIPO; Clarkin, Caligor, Stern, & Kernberg, 2004) based on this theoretical model. Both interviews focus on the assessment of consolidated identity versus identity disturbance, the use of adaptive versus lower level defensive operations, and intact versus loss of reality testing. In the context of a more clinically oriented assessment, the SI makes use of tactful confrontation of discrepancies and contradictions in the patient's narrative, and also takes into account transference and countertransference phenomena, whereas the more structured approach of the STIPO incorporates clinical judgment informed by clinical theory into a well-guided interaction with the patient. Both interviews have good interrater reliability and are coherent with the alternative model for personality disorder diagnosis proposed by the Diagnostic and Statistical Manual of Mental Disorders (5th ed.), Section III. Finally, they provide the clinician with specific implications for prognosis and treatment planning and can rationally guide clinical decision making.
In this article we first contextualize and then outline a model of TFP adapted for working with adolescents with Borderline Personality Disorders. We discuss how to take the normal developmental challenges of adolescence, such as separation-individuation in consideration, and how to support this in the context of the therapeutic work, while at the same time stimulating curiosity through clarification and confronting the adolescent with self-defeating and destructive patterns and dangerous behavior. Furthermore, we give examples of working with split-off parts of self and other representations through clarification to increase self-awareness and confrontations with contradictions within the adolescents communication and nonverbal behavior, with the aim of facilitating the integration of identity.
Les troubles de la personnalité sont courants et leur effet est débilitant, mais il existe des dissensions au sujet de la définition, de l’évaluation et du traitement de ces conditions. Cette revue examine les principales démarches de conceptualisation des troubles de la personnalité, aussi récentes que celle qui figure dans la section III du DSM–5 et que l’initiative des critères de volets de recherche du National Institute of Mental Health. Trois modèles connus pour expliquer ces troubles (fonctionnement neural, modèle interpersonnel et modèle du système de traitement cognitif-affectif) sont examinés selon leurs fondements empiriques pertinents. Les répercussions pour la recherche future en psychopathologie, sur les traitements et la pratique sont présentées.
The antecedents and risk factors and for developing borderline personality disorder (BPD) are now
well documented, but there is a paucity of developmental models to understand the key processes
through which they impact on the development of BPD in adolescents. In this article, we present a
developmental psychopathology model of BPD in adolescence and link the difficulties adolescents
with BPD have with impulsivity and self regulation, with risk factors such as genetic vulnerability,
parenting and trauma.We propose a number of psychological processes through which these risk factors
undermine personal and interpersonal functioning, and makes it particularly difficult to engage
with the challenges of adolescence. These key psychological processes undermine the integration of
the self, with extreme unintegrated affects and extreme representations of self and others, undermining
the capacity to mentalize. We then make links to possible neurobiological underpinnings of the
disturbances in affect, Theory of Mind and interpersonal difficulties in adolescents with BPD.
This study aims at investigating factors associated with early dropout in dual diagnosis patients, considering socio-demographic, diagnostic and personality structure variables. We hypothesized that the personality structure of the patient will show stronger associations with dropout, as compared to descriptive variables. Forty-seven patients consecutively admitted in a dual diagnosis residential treatment unit were administered the Structured Interview of Personality Organization (STIPO), the Structured Clinical Interview for Axis II Disorders (SCID II), the Response Evaluation Measure 71 (REM71), the Symptom Check List 90–R (SCL90-R), and the Borderline Personality Disorder Check List (BPDCL). Significant differences emerged between the dropout and no-dropout group: Investments and self-coherence problems (STIPO) were higher among dropouts; moreover, in the dropout group a significantly higher number of patients showed a borderline personality organization (88.9 %). Results support the use of structural interviews in the assessment of dual diagnosis patients; implications regarding research and clinical practice are discussed.
Recent editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013) conceptualize personality disorders (PDs) as categorical constructs, but high PD co-occurrence suggests underlying latent dimensions. Moreover, several borderline PD criteria resemble Criterion A of the new DSM-5 Section III general criteria for personality pathology (i.e., self and interpersonal dysfunction). We evaluated a bifactor model of PD pathology in which a general factor and several specific factors of personality pathology (PD 'g' and 's' factors, respectively) account for the covariance among PD criteria. In particular, we examined the extent to which the borderline PD criteria would load exclusively onto the g-factor versus on both the g- and one or more s-factors. A large (N = 966) sample of inpatients were interviewed for six DSM-IV (American Psychiatric Association, 1994) PDs using the (Structured Clinical Interview for Personality Disorders (SCID-II; First, Spitzer, Gibbon, Williams, & Benjamin, 1994) with no skip-outs. We ran a series of confirmatory, exploratory, and bifactor exploratory factor analyses on the rated PD criteria. The confirmatory analysis largely replicated the DSM PDs, but with high factor correlations. The "standard" exploratory analysis replicated four of the DSM PDs fairly well, but nearly half the criteria cross-loaded. In the bifactor analysis, borderline PD criteria loaded only on the general factor; the remaining PDs loaded either on both the general and a specific factor or largely only on a specific factor. Results are interpreted in the context of several possibilities to define the nature of the general factor. (PsycINFO Database Record (c) 2015 APA, all rights reserved).
We investigated attachment representations and the capacity for mentalization in a sample of adult female borderline patients with and without comorbid narcissistic personality disorder (NPD). Participants were 22 borderline patients diagnosed with comorbid NPD (NPD/BPD) and 129 BPD patients without NPD (BPD) from 2 randomized clinical trials. Attachment and mentalization were assessed on the Adult Attachment Interview (AAI; George, Kaplan, & Main, 1996). Results showed that as expected, compared with the BPD group, the NPD/BPD group was significantly more likely to be categorized as either dismissing or cannot classify on the AAI, whereas the BPD group was more likely to be classified as either preoccupied or unresolved for loss and abuse than was the NPD/BPD group. Both groups of patients scored low on mentalizing, and there were no significant differences between the groups, indicating that both NPD/BPD and BPD individuals showed deficits in this capacity. The clinical implications of the group differences in AAI classification are discussed with a focus on how understanding the attachment representations of NPD/BPD patients helps to illuminate their complex, contradictory mental states. (PsycINFO Database Record (c) 2014 APA, all rights reserved).
The assessment of personality organization and its observable behavioral manifestations, i.e. personality functioning, has a long tradition in psychodynamic psychiatry. Recently, the DSM-5 Levels of Personality Functioning Scale has moved it into the focus of psychiatric diagnostics. Based on Kernberg's concept of personality organization the Structured Interview of Personality Organization (STIPO) was developed for diagnosing personality functioning. The STIPO covers seven dimensions: (1) identity, (2) object relations, (3) primitive defenses, (4) coping/rigidity, (5) aggression, (6) moral values, and (7) reality testing and perceptual distortions. The English version of the STIPO has previously revealed satisfying psychometric properties.
Validity and reliability of the German version of the 100-item instrument have been evaluated in 122 psychiatric patients. All patients were diagnosed according to the Diagnostic and Statistical Manual for Mental Disorders (DSM-IV) and were assessed by means of the STIPO. Moreover, all patients completed eight questionnaires that served as criteria for external validity of the STIPO.
Interrater reliability varied between intraclass correlations of .89 and 1.0, Crohnbach's alpha for the seven dimensions was .69 to .93. All a priori selected questionnaire scales correlated significantly with the corresponding STIPO dimensions. Patients with PD revealed significantly higher STIPO scores (i.e. worse personality functioning) than patients without PD; patients cluster B PD showed significantly higher STIPO scores than patients with cluster C PD.
Interrater reliability, Crohnbach's alpha, concurrent validity, and differential validity of the STIPO are satisfying. The STIPO represents an appropriate instrument for the assessment of personality functioning in clinical and research settings.
Factor-analytic evidence has led most psychologists to describe affect as a set of dimensions, such as displeasure, distress, depression, excitement, and so on, with each dimension varying independently of the others. However, there is other evidence that rather than being independent, these affective dimensions are interrelated in a highly systematic fashion. The evidence suggests that these interrelationships can be represented by a spatial model in which affective concepts fall in a circle in the following order: pleasure (0), excitement (45), arousal (90), distress (135), displeasure (180), depression (225), sleepiness (270), and relaxation (315). This model was offered both as a way psychologists can represent the structure of affective experience, as assessed through self-report, and as a representation of the cognitive structure that laymen utilize in conceptualizing affect. Supportive evidence was obtained by scaling 28 emotion-denoting adjectives in 4 different ways: R. T. Ross's (1938) technique for a circular ordering of variables, a multidimensional scaling procedure based on perceived similarity among the terms, a unidimensional scaling on hypothesized pleasure–displeasure and degree-of-arousal dimensions, and a principal-components analysis of 343 Ss' self-reports of their current affective states. (70 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
The current Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnostic system for Axis II disorders continues to be characterized by considerable heterogeneity and poor discriminant validity. Such problems impede accurate personality disorder (PD) diagnosis. As a result, alternative assessment tools are often used in conjunction with the DSM. One popular framework is the object relational model developed by Kernberg and his colleagues (J. F. Clarkin, M. F. Lenzenweger, F. Yeomans, K. N. Levy, & O. F. Kernberg, 2007, An object relations model of borderline pathology, Journal of Personality Disorders, Vol. 21, pp. 474-499; O. F. Kernberg, 1984, Severe Personality Disorders, New Haven, CT: Yale University Press; O. F. Kernberg & E. Caligor, 2005, A psychoanalytic theory of personality disorders, in M. F. Lenzenweger & J. F. Clarkin, Eds., Major Theories of Personality Disorder, New York, NY: Guilford Press). Drawing on this model and empirical studies thereof, the current study attempted to clarify Kernberg's (1984) PD taxonomy and identify subtypes within a sample with varying levels of personality pathology using finite mixture modeling. Subjects (N = 141) were recruited to represent a wide range of pathology. The finite mixture modeling results indicated that 3 components were harbored within the variables analyzed. Group 1 was characterized by low levels of antisocial, paranoid, and aggressive features, and Group 2 was characterized by elevated paranoid features. Group 3 revealed the highest levels across the 3 variables. The validity of the obtained solution was then evaluated by reference to a variety of external measures that supported the validity of the identified grouping structure. Findings generally appear congruent with previous research, which argued that a PD taxonomy based on paranoid, aggressive, and antisocial features is a viable supplement to current diagnostic systems. Our study suggests that Kernberg's object relational model offers a plausible substantive aid in refining PD classification. (PsycINFO Database Record (c) 2012 APA, all rights reserved).
Borderline personality disorder (BPD) is a heterogeneous disorder, and previous analyses have parsed its phenotype in terms of subtypes or underlying traits. We refined the BPD construct by testing a range of latent variable models to ascertain whether BPD is composed of traits, latent classes, or both. We also tested whether subtypes of BPD could be distinguished by anger, aggressiveness, antisocial behavior, and mis-trustfulness, additional putative indicators drawn from Kernberg's (1967, 1975) theory of BPD. In a mixed clinical and nonclinical sample (N = 362), a factor mixture model consisting of two latent classes (symptomatic and asymptomatic) and a single severity dimension fit the BPD criteria, as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), data better than latent class or factor analytic approaches. In the second analytic phase, finite mixture modeling of the symptomatic latent class (n = 100) revealed four BPD subtypes: angry/aggressive, angry/mistrustful, poor identity/low anger, and prototypical. Our results support a hybrid categorical-dimensional model of the BPD DSM-IV criteria. The BPD subtypes emerging from this model have important implications for treatment and etiological research.
What changes and how quickly these changes occur as a result of therapy in borderline personality disorder (BPD) is an important ongoing question. The features of BPD patients that are most predictive of rates of change in such patients remain largely unknown. Using the Cornell Personality Disorders Institute (CPDI) randomized controlled trial data, we sought to determine (a) the number and nature of broad domains underlying a large number of rate of change (slope) measures across many psychological, psychiatric, and psychosocial indexes, and (b) which baseline individual difference psychological features of the BPD patients correlated with these rate of change domains. We examined the latent structure of slope (rate of change) measures gleaned from individual growth curves for each subject, studied in multiwave perspective, on separate measures of anger, aggression, impulsivity, depression, global functioning, and social adjustment. Three broad domains of change rate could be discerned. These domains were reflected in factors that are described as (a) anger/aggression change ("aggressive dyscontrol"), (b) global functioning/social adjustment change ("social adjustment/self-acceptance"), and (c) anxiety/depression/impulsivity change ("conflict tolerance/behavioral control"). Factor scores were computed for each change domain and baseline measures of personality and psychodynamic features, selected a priori, were correlated with these factor scores. Multiple regression analyses revealed (a) baseline negative affectivity and aggression predicted the aggressive dyscontrol change domain, (b) baseline identity diffusion predicted the social adjustment/self-acceptance change domain, and (c) baseline social potency predicted the conflict tolerance/behavioral control change domain. These baseline predictors suggest potential research foci for understanding those aspects of BPD that change at comparable rates over time.
Clinicians routinely note the challenges involved in psychotherapy with individuals with BPD, yet little research exists on the therapeutic alliance with this population. An important question is, what patient factors contribute to a disturbed alliance with individuals with BPD? Executive attention has been identified as a mechanism of BPD, and mental state vacillations (e.g., idealization/denigration, incoherence in self-concept) are a hallmark of the disorder. The goals of this study were to examine the link between executive attention and the alliance and assess mental state vacillations as a mediator. Thirty-nine participants diagnosed with BPD, participating in a randomized clinical trial, were administered the Attentional Network Task (ANT). Early psychotherapy sessions were coded using the Working Alliance Inventory (WAI). In addition, six items were generated and coded representing in-session vacillations in mental states. Performance on the ANT was related to the alliance (r =.34, p =.035), as were in-session mental state vacillations (r =.59, p <.001). A model was supported in which in-session mental state vacillations mediated the relationship between executive attention and alliance. Executive attention was related to therapeutic alliance, and this relationship was found to be mediated by in-session mental state vacillations. These findings emphasize the importance of executive attention in the disorder and uncover a link between poor executive attention and mental state vacillations. Mental state vacillations as a mediator suggests a path in which poor executive attention leads to greater vacillations, which leads to poorer working alliance.
Transference-focused psychotherapy is a manualised treatment for borderline personality disorder.
To compare transference-focused psychotherapy with treatment by experienced community psychotherapists.
In a randomised controlled trial (NCT00714311) 104 female out-patients were treated for 1 year with either transference-focused psychotherapy or by an experienced community psychotherapist.
Significantly fewer participants dropped out of the transference-focused psychotherapy group (38.5% v. 67.3%) and also significantly fewer attempted suicide (d = 0.8, P = 0.009). Transference-focused psychotherapy was significantly superior in the domains of borderline symptomatology (d = 1.6, P = 0.001), psychosocial functioning (d = 1.0, P = 0.002), personality organisation (d = 1.0, P = 0.001) and psychiatric in-patient admissions (d = 0.5, P = 0.001). Both groups improved significantly in the domains of depression and anxiety and the transference-focused psychotherapy group in general psychopathology, all without significant group differences (d = 0.3-0.5). Self-harming behaviour did not change in either group.
Transference-focused psychotherapy is more efficacious than treatment by experienced community psychotherapists in the domains of borderline symptomatology, psychosocial functioning, and personality organisation. Moreover, there is preliminary evidence for a superiority in the reduction of suicidality and need for psychiatric in-patient treatment.
In this article, we describe the development and preliminary psychometric properties of the Structured Interview of Personality Organization (STIPO), a semistructured interview designed for the dimensional assessment of identity, primitive defenses, and reality testing, the three primary content domains in the model of personality health and disorder elaborated by Kernberg (1984; Kernberg & Caligor, 2005). Results of this investigation, conducted in a clinical sample representing a broad range of personality pathology, indicate that identity and primitive defenses as operationalized in the STIPO are internally consistent and that interrater reliability for all 3 content domains is adequate. Validity findings suggest that the assessment of one's sense of self and significant others (Identity) is predictive of measures of positive and negative affect, whereas the maladaptive ways in which the subject uses his or her objects for purposes of regulating one's self experience (Primitive Defenses) is predictive of measures of aggression and personality disorder traits associated with cluster B personality disorders. We discuss implications of these findings in terms of the theory-driven and trait-based assessment of personality pathology.
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.
Changes in attachment organization and reflective function (RF) were assessed as putative mechanisms of change in 1 of 3 year-long psychotherapy treatments for patients with borderline personality disorder (BPD). Ninety patients reliably diagnosed with BPD were randomized to transference-focused psychotherapy (TFP), dialectical behavior therapy, or a modified psychodynamic supportive psychotherapy. Attachment organization was assessed with the Adult Attachment Interview and the RF coding scale. After 12 months of treatment, participants showed a significant increase in the number classified secure with respect to attachment state of mind for TFP but not for the other 2 treatments. Significant changes in narrative coherence and RF were found as a function of treatment, with TFP showing increases in both constructs during treatment. No changes in resolution of loss or trauma were observed across treatments. Findings suggest that 1 year of intensive TFP can increase patients' narrative coherence and RF. Future research should establish the relationship between these 2 constructs and relevant psychopathology, identify treatment components responsible for effecting these changes, and examine the long-term outcome of these changes.
The authors examined three yearlong outpatient treatments for borderline personality disorder: dialectical behavior therapy, transference-focused psychotherapy, and a dynamic supportive treatment.
Ninety patients who were diagnosed with borderline personality disorder were randomly assigned to transference-focused psychotherapy, dialectical behavior therapy, or supportive treatment and received medication when indicated. Prior to treatment and at 4-month intervals during a 1-year period, blind raters assessed the domains of suicidal behavior, aggression, impulsivity, anxiety, depression, and social adjustment in a multiwave study design.
Individual growth curve analysis revealed that patients in all three treatment groups showed significant positive change in depression, anxiety, global functioning, and social adjustment across 1 year of treatment. Both transference-focused psychotherapy and dialectical behavior therapy were significantly associated with improvement in suicidality. Only transference-focused psychotherapy and supportive treatment were associated with improvement in anger. Transference-focused psychotherapy and supportive treatment were each associated with improvement in facets of impulsivity. Only transference-focused psychotherapy was significantly predictive of change in irritability and verbal and direct assault.
Patients with borderline personality disorder respond to structured treatments in an outpatient setting with change in multiple domains of outcome. A structured dynamic treatment, transference-focused psychotherapy was associated with change in multiple constructs across six domains; dialectical behavior therapy and supportive treatment were associated with fewer changes. Future research is needed to examine the specific mechanisms of change in these treatments beyond common structures.
The authors sought to test the hypothesis that in patients with borderline personality disorder, the ventromedial prefrontal cortex and associated regions would not be activated during a task requiring motor inhibition in the setting of negative emotion. Such a finding would provide a plausible neural basis for the difficulty borderline patients have in modulating their behavior during negative emotional states and a potential marker for treatment interventions.
A specifically designed functional magnetic resonance imaging (fMRI) activation probe was used, with statistical parametric mapping analyses, to test hypotheses concerning decreased prefrontal inhibitory function in the context of negative emotion in patients with borderline personality disorder (N=16) and healthy comparison subjects (N=14). 3-T fMRI scanning was used to study brain activity while participants performed an emotional linguistic go/no-go task.
Analyses confirmed that under conditions associated with the interaction of behavioral inhibition and negative emotion, borderline patients showed relatively decreased ventromedial prefrontal activity (including medial orbitofrontal and subgenual anterior cingulate) compared with healthy subjects. In borderline patients, under conditions of behavioral inhibition in the context of negative emotion, decreasing ventromedial prefrontal and increasing extended amygdalar-ventral striatal activity correlated highly with measures of decreased constraint and increased negative emotion, respectively.
These findings suggest specific frontolimbic neural substrates associated with core clinical features of emotional and behavioral dyscontrol in borderline personality disorder.
There can be little question that we need better treatments for mental disorders. The recent Global Burden of Disease Study1 demonstrates how neuropsychiatric disorders are a leading source of medical disability in the United States, increasing since 1990 despite a concomitant increase in pharmacologic treatments.2 Although there have been many commercially successful medications for anxiety, depression, and psychosis, few compounds have shown truly new mechanisms of action, and even fewer represent true breakthroughs in efficacy.3 For many of our most serious clinical challenges, such as anorexia nervosa, posttraumatic stress disorder, the core symptoms of autism, and the cognitive deficits of schizophrenia, to name a few, we lack effective medications altogether.
Advances in our understanding of complex psychopathology will likely benefit from approaches to mind, brain, and behavior that seek to (a) specify those general neurobehavioral processes underpinning pathology and (b) bridge to other process-based models of psychopathology at different levels of analysis. Well-defined neurobehavioral processes (e.g., positive emotionality, negative emotionality, nonaffective constraint, fear, affiliation) and their phenotypic indicators are firmly rooted in neural substrates (Depue & Lenzenweger, 2005). Furthermore, long-studied psychodynamic psychological processes, such as identity diffusion, primitive psychological defensive functioning, and reality-testing dimensions, are important to understanding personality pathology (Kernberg & Caligor, 2005). Both theoretical perspectives view the cardinal processes involved in the determination of personality disorders (PDs) as relevant across existing PD diagnostic entities. The authors examined relationships between psychometric indicators of these two sets of processes, the neurobehavioral and the psychodynamic, in a well-characterized sample of individuals with borderline personality disorder (BPD; N = 92). In bridging these two levels of analysis, the authors found that the alienation, aggression, and absorption constructs represent important linkages to the psychodynamic processes, especially primitive psychological defenses and reality-testing impairments. These results are discussed in terms of their potential for joining these two domains of analysis-a neurobehaviorally informed view of personality and the psychodynamic-in efforts to (a) foster a process-oriented approach, (b) resolve heterogeneity, and (c) facilitate identification of endophenotypes in BPD. The heuristic value of this approach for understanding other forms of psychopathology is also discussed.
Psychologists and nonpsychologists alike assume that people have distinct, enduring personalities. Ample evidence exists that individuals do differ reliably in what they do and think and feel in any given situation (e.g., Mischel, Shoda, & Ayduk, 2008). But, historically, it has remained surprisingly difficult to demonstrate the
consistency of such individual differences from one situation to another. Findings to date show that neither the research nor the intuition was wrong about the nature of individual differences in social behavior, although each had given an incomplete picture. It turned out that hidden in the seemingly random variation of individuals' behavior across situations is a pattern that is stable and distinctive for every individual (e.g., Shoda & LeeTiernan, 2002). The behavior itself varies, but there is stability in how each individual's behavior varies from one situation to another. These stable and distinctive
if ... then ... situation-behavior patterns form
behavioral signatures of personality (Shoda, Mischel, & Wright, 1994) and suggest the existence of a higher-order consistency on which the intuitive belief in personality may be based (Mischel & Shoda, 1995). To understand these stable intraindividual patterns of variability requires a theory and research paradigm that goes beyond the traditional investigation of personality and social situations. The findings yield both new answers and new questions about the nature of personality and the interactions of persons and situations. Happily, passionate debates in the search for the nature of personality are being replaced by findings and reconceptualizations that promise to resolve paradoxes and to overcome problems that have frustrated and divided the study of personality almost since its inception. This chapter focuses on the key implications of these developments in recent decades for building a unifying, cumulative personality theory and science, based on the findings from a century of theory-making and research in psychology and related fields. The question is: In light of advances in our science, is it possible to integrate, within a unitary framework, the dispositional (trait) and processing (social-cognitive-affective dynamic) approaches that have so long been split virtually into two separate fields (e.g., Mischel & Shoda, 1994, 1998)? (PsycINFO Database Record (c) 2012 APA, all rights reserved)
We hypothesized that affect dysregulation among individuals with borderline personality disorder (BPD) would involve greater persistence of negative affect between interpersonal events and heightened reactivity to stimuli indicating risk of rejection or disapproval, specifically perceptions of others' communal (agreeable-quarrelsome) behaviors. A total of 38 participants with BPD and 31 controls collected information about affect and perceptions of the interaction partner's behavior during interpersonal events for a 20-day period. Negative and positive affect persisted more across interpersonal events for individuals with BPD than for controls. In addition, individuals with BPD reported a greater increase in negative affect when they perceived less communal behavior and a smaller increase in positive affect when they perceived more communal behavior in others. Findings indicate the importance of interpersonal perceptions in the affect dysregulation of individuals with BPD.
There has been enormous progress in psychotherapy research. This has culminated in recognition of several treatments that have strong evidence in their behalf. Even so, after decades of psychotherapy research, we cannot provide an evidence-based explanation for how or why even our most well studied interventions produce change, that is, the mechanism(s) through which treatments operate. This chapter presents central requirements for demonstrating mediators and mechanisms of change and reviews current data-analytic and designs approaches and why they fall short of meeting these requirements. The role of the therapeutic alliance in psychotherapy and cognitive changes in cognitive therapy for depression are highlighted to illustrate key issues. Promising lines of work to identify mediators and mechanisms, ways of bringing to bear multiple types of evidence, recommendations to make progress in understanding how therapy works, and conceptual and research challenges in evaluating mediators and mechanisms are also presented.
A great deal has been written about the nature of borderline personality. We maintain that borderline psychopathology emanates from particular disturbances in mental representations-impairment in the ability to maintain and use benign and integrated internal images of self and others-and that these troubled ways of thinking drive the troubled interpersonal relations, affective instability, and impulsivity associated with borderline. Aspects of borderline self-other representational disturbances are present across a wide theoretical spectrum, and a number of research methodologies already exist to assess the phenomena. We conclude that borderline attributes exist on continua, and summarize important features as: (1) unstable mental images of self and others, often marked by self-loathing and attributions of malevolence to others; (2) interactions with others organized around a fundamental need for care that is felt to be necessary for basic functioning; (3) fear of others based on expectations of being mistreated and disappointed and/or terror of having one's identity subsumed by another person; (4) difficulty considering multiple and/or conflicting perspectives, with a tendency toward concrete, all-or-none, or black-and-white, thinking and distortion of reality; and (5) sadomasochistic interpersonal interactions in which a person alternatively inflicts suffering on others and suffers at the hands of others.
This paper explores the development of BPD as it might emerge in the child's early interpersonal reactions and how such reactions might evolve into the interpersonal pattern that typifies BPD. It begins to bridge the relevant bodies of clinical literature on the borderline's prototypic interpersonal problems with the concurrently expanding relevant literature on early child development. We will start by considering how a psychobiological disposition to BPD is likely to include a constitutional diathesis for relational reactivity, that is, for hypersensitivity to interpersonal stressors. Data relevant to this disposition's manifestations in adult clinical samples and to its heritability and neurobiology will be reviewed. We then consider how such a psychobiological disposition for interpersonal reactivity might contribute to the development of a disorganized-ambivalent form of attachment, noting especially the likely contributions of both the predisposed child and of parents who are themselves predisposed to maladaptive responses, leading to an escalation of problematic transactions. Evidence concerning both the genetics and the developmental pathways associated with disorganized attachments will be considered. Emerging links between such developmental pathways and adult BPD will be described, in particular the potential appearance by early- to middle-childhood of controlling-caregiving or controlling-punitive interpersonal strategies. Some implications from this gene-environment interactional theory for a better developmental understanding of BPD's etiology are discussed.