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Surprisingly few studies have investigated the accuracy of prognostic assessments of therapy outcome by clinicians. The objective of the present study was to investigate the relationship between clinicians' prognostic assessments and patient characteristics and treatment outcome. Seventy-one patients with a borderline personality disorder randomly allocated to schema-focused therapy (SFT) or transference focused psychotherapy (TFP) were assessed every 3 months for 3 years. Prognostic assessments proved to be unrelated to patients' biographical (i.e., age, gender, education level, and employment level) and clinical characteristics (i.e., number of Axis I and Axis II diagnoses, and severity of psychiatric symptoms or borderline personality pathology). Clinical assessors as well as therapists rated the probability of success for SFT to be higher than for TFP. Prospective assessments of assessors and therapists accurately predicted different indices of outcome above and independent of patient characteristics. The prediction of outcome in the TFP condition in particular proved to be valid. Identifying prognostic markers of treatment outcome as used by clinicians in their prognostic assessments may improve current prediction models and patient-treatment matching.

Mentalization is the process by which we implicitly and explicitly interpret the actions of ourselves and others as meaningful based on intentional mental states (e.g., desires, needs, feelings, beliefs, and reasons). This process is disrupted in individuals with comorbid antisocial (ASPD) and borderline personality disorder (BPD), who tend to misinterpret others' motives. Antisocial characteristics stabilize mentalizing by rigidifying relationships within prementalistic ways of functioning. However, loss of flexibility makes the person vulnerable to sudden collapse when the schematic representation is challenged. This exposes feelings of humiliation, which can only be avoided by violence and control of the other person. The common path to violence is via a momentary inhibition of the capacity for mentalization. In this article, the authors outline their current understanding of mentalizing and its relation to antisocial characteristics and violence. This is illustrated by a clinical account of mentalization-based treatment adapted for antisocial personality disorder. Treatment combines group and individual therapy. The focus is on helping patients maintain mentalizing about their own mental states when their personal integrity is challenged. A patient with ASPD does not have mental pain associated with another's state of mind; thus, to generate conflict in ASPD by thinking about the victim will typically be ineffective in inducing behavior change. Keywords: mentalization; mentalization-based treatment; antisocial personality disorder; borderline personality disorder; self; violence

Attachment theory provides a framework for understanding and predicting critical aspects of aggression in the personality disorders. An association between borderline personality disorder (BPD) and insecure forms of adult attachment marked by high relationship anxiety has been repeatedly observed in the empirical literature. Aggression also has been linked to insecure attachment. The present study extends previous work by exploring the degree to which the underlying attachment dimensions of relationship anxiety and avoidance are associated in BPD with the following forms of hostility: (a) direct aggression (verbal or physical) initiated towards others, (b) expectation/perception of aggression from others (including 'reactive' counteraggression when/if provoked), (c) aggression directed towards the self in the form of suicidality or parasuicidality, and (d) affective experience of irritability or anger. The issue was studied in a sample of 92 patients diagnosed with BPD. Results show significant association between more fearful forms of attachment (simultaneous presence of relationship anxiety and avoidance) and the more reactive form of aggression involving expectation of hostility from others. Self-harm was significantly associated only with relational avoidance while anger and irritability were associated only with relational anxiety. Implications for understanding relational aspects of BPD aggression in research and clinical work are discussed. Keywords: borderline personality disorder; attachment; aggression

Alterations in hypothalamic-pituitary-adrenal axis feedback regulation have been repeatedly reported in patients with borderline personality disorder (BPD). Due to the cross-sectional design of these studies, little is known about the longitudinal course of HPA axis functioning. In a sample of 13 patients with BPD, the dexamethasone suppression test (DST) has been used in a one-year follow-up study. There were no changes of cortisol concentrations before or after dexamethasone intake between baseline and follow-up examination. Patients with comorbid posttraumatic stress disorder (PTSD) showed more pronounced cortisol suppression compared to those without PTSD. The DST seems to be a stable marker of alterations in HPA axis feedback regulation in BPD, which is also reflected by substantial correlations between percentage of cortisol suppression at baseline and follow-up examination. [c] 2007 Wiley Periodicals, Inc. J Clin Psychol 63: 843-850, 2007. Keywords: dexamethasone suppression test: borderline personality disorder; cortisol; stability; posttraumatic stress disorder

Relations among symptoms of the Diagnostic and Statistical Manual of Mental Disorders, Text Revision (DSM-IV-TR, American Psychiatric Association, 2000) borderline personality disorder (BPD) assessed using semi-structured clinical interviews were examined using exploratory principal components analysis in a sample of 82 college men and women who were symptomatic for BPD (30.4% of whom met criteria for a BPD diagnosis at threshold or subthreshold certainty level). A three-component solution was found and, as expected, the first component was characterized by interpersonal instability and included unstable relationships, identity disturbance, and chronic emptiness. The second component reflected affective instability and low impulsivity. The third component reflected stressrelated paranoia and low anger. Results highlight similarities in the structure of BPD criteria in clinical and nonclinical samples, and could inform future research on dimensional models of BPD. [c] 2007 Wiley Periodicals, Inc. J Clin Psychol 63: 805-816, 2007. Keywords: borderline personality disorder; factor analysis; nonclinical sample

This article describes the rationale for applying interpersonal psychotherapy (IPT) to the treatment of patients who have borderline personality disorder and explains the adaptation of standard IPT to that end. The authors describe the preliminary stages of adapting IPT for a pilot study to test its feasibility and potential efficacy and speculate on potentially therapeutic mechanisms for IPT in treating patients who have borderline personality disorder. Keywords: interpersonal psychotherapy; borderline personality disorder

Concerns have been raised that individuals who are having difficulty coming out as gay or bisexual may be misdiagnosed with borderline personality disorder. In this analogue study, 141 psychologists evaluated a hypothetical client with problems that resembled borderline symptoms but were also consistent with a sexual identity crisis. Client descriptions varied by sexual orientation and gender. Results revealed an effect of sexual orientation for male clients, but not female clients. Male clients whom therapists perceived likely to be gay or bisexual, and male clients with partners of unspecified gender, were more likely to be diagnosed with borderline personality disorder. Therapists were more confident and willing to work with female clients and gave them a better prognosis. Therapists' responses are discussed in light of gender role bias and social desirability. Keywords: borderline personality disorder; psychotherapy; psychotherapist attitudes; diagnostic bias: clinical judgment: human sex differences; sexual orientation; gay; lesbian; bisexual

Preliminary evidence suggests that cognitive therapy (CT) is effective in treating borderline personality disorder (BPD). According to cognitive theory, BPD patients are characterized by dysfunctional beliefs that are relatively enduring and inflexible and that lead to cognitive distortions such as dichotomous thinking. When these beliefs are activated, they lead to extreme emotional and behavioral reactions, which provide additional confirmation for the beliefs. It is hypothesized that a change in dysfunctional beliefs is the primary mechanism of change associated with CT. However, additional mechanisms of change are likely also at work in CT, including enhancement of skills, reduction in hopelessness, and improvement in attitude toward treatment. Each of these mechanisms is discussed in light of cognitive theory, data from an open clinical CT trial, relevant literature, and therapeutic interventions. Findings from the CT trial support the role of cognitive change during therapy and its continuation after termination. Keywords: borderline personality disorder; cognitive therapy; cognitive theory; dysfunctional beliefs

This article presents the Schema Therapy (Young, Klosko, & Weishaar, 2003) approach to the treatment of borderline personality disorder. Schema therapy draws on the cognitive-behavioral, attachment, psychodynamic, and emotion-focused traditions and conceptualizes patients who have borderline personality disorder as being under the sway of five modes or aspects of the self. The goal of the therapy is to reorganize this inner structure. To this end, there are four core mechanisms of change that are used in this therapy: (1) limited reparenting, (2) experiential imagery and dialogue work, (3) cognitive restructuring and education, and (4) behavioral pattern breaking. These interventions are used during the three phases of treatment: (1) bonding and emotional regulation, (2) schema mode change, and (3) development of autonomy. Keywords: schema therapy; borderline personality disorder; schema-focused therapy; schema; personality disorders

We address how Transference Focused Psychotherapy (TFP) conceptualizes mechanisms in the cause and maintenance of borderline personality disorder (BPD) as well as change mechanisms both within the patient and in terms of specific therapists' interventions that engender patient change. Mechanisms of change at the level of the patient involve the integration of polarized representations of self and others; mechanisms of change at the level of the therapist's interventions include the structured treatment approach and the use of clarification, confrontation, and 'transference' interpretations in the here and now of the therapeutic relationship. In addition, we briefly review evidence from our group regarding the following hypothesized mechanisms of change: contract setting, integration of representations, and changes in reflective functioning (RF) and affect regulation. Keywords: mechanisms of change; Transference Focused Therapy; borderline personality disorder

A major development in the field of psychotherapy research is the growing recognition of the need for evidence on the mechanisms of change in psychotherapy. The empirical evidence that psychotherapy has a positive and significant effect must be amplified with data on the mechanisms of action in the various psychotherapies. This special issue is devoted to the articulation of putative mechanisms of change in the psychotherapy of patients with borderline personality disorder by leading researchers in this field. Keywords: borderline personality disorder; mechanisms of change

Although clinical theories suggest that people with Borderline Personality Disorder (BPD) experience a confused sense of self, little empirical research has directly examined the self in BPD (Heard & Linehan, 1993; Westen & Cohen, 1993). In this study, 43 female participants, 15 with BPD and 28 without BPD, completed the closed-ended version of Markus and Wurf's (1987) Possible Selves Questionnaire (PSQ). Participants with BPD were less likely than controls to endorse positive possible selves as current, but more likely to endorse negative possible selves as current, probable, desired, and important. Participants with BPD linked negative and positive selves to their desired selves, which is consistent with the unstable sense of self characteristic of BPD. Keywords: borderline; self; possible selves; personality disorders

Intentional self-harm behavior is an important clinical phenomenon that appears highly related to borderline personality disorder (BPD). Self-harm behavior in the context of borderline personality probably exists along a continuum from graphic, self-harm behavior to milder forms of self-sabotaging behavior that might be viewed as self-defeating. Relatively little attention has been paid to developing a self-report measure of intentional self-harm, particularly as a screening device for detecting BPD. In Study 1, an initial list of self-harm behaviors encountered in clinical practice was narrowed to those behaviors related to BPD in a sample comprised of adults from both a mental health and non-mental health setting. All participants (N = 221) underwent a semistructured diagnostic interview for BPD. Using a cut-off score of 5 on the resulting 22-item Self-Harm Inventory (SHI), 83.7% of research participants were correctly classified as having BPD or not. In Study 2, women (N = 285) sampled from an outpatient medical setting completed the SHI and a widely used self-report measure of BPD. The SHI cut-off score resulted in correct classification of 87.9% of the individuals. In Study 3, using a sample of adults involuntarily hospitalized for psychiatric reasons (N = 32), the SHI performed at least as well as another self-report measure of BPD in diagnosing participants (the final diagnosis was based on a semistructured interview). The results are discussed with regard to potential advantages and utility of the SHI and need for further validation.

The purpose of this study was to examine psychotherapists' differential countertransference reactions toward either clients diagnosed with either Major Depression or Borderline Personality Disorder. Specifically, psychotherapists' personal perceptions and emotional reactions to these clients were assessed utilizing the Impact Message Inventory and the Stress Appraisal Scale (N = 155). Direct feelings, action tendencies, cognitive attributions, and perceived anxiety were evaluated. Results indicated that clients with Borderline Personality Disorder are perceived as significantly more dominant and hostile, whereas clients with Major Depression were considered significantly more submissive, friendly, and salient. In addition, it was found that as clinicians' years of experience increased, degree of countertransference decreased. These results suggest that countertransference reactions can be measured empirically, that differential countertransference reactions are evoked toward clients manifesting different symptoms, and that awareness of countertransference may be important for positive therapeutic outcome.

This study tested the hypothesis that borderline personality characterizes extreme violence by assessing features of borderline and schizotypal personality in three groups: Murderers, Violent, and Nonviolent adult offenders. Murderers had higher borderline personality scores than nonviolent offenders (p < .04). A test for linear trend indicated a linear increase in borderline scores with increasing degree of violence across the three groups (p < .02). No group differences were observed for schizotypal personality. Borderline traits associated with extreme violence consisted of unstable, intense relationships and affective instability. Group differences were not an artifact of group differences in age, social class, IQ, or number of previous custodies. It is concluded that borderline personality may predispose toward extreme forms of violence.

A study was conducted to determine the effect of organic factors in borderline personality disorders (BPD). Neurological functions of a sample group of borderline patients were assessed and compared to a control group. The BPD group exhibited a pattern of impairments that indicates a fronto-temporal locus. This result suggests that some deficits in BPD may be organically based.

This study examined the MCMI-I BPD scale's accuracy in assigning borderline personality disorder as a primary diagnosis. Clinicians with particular expertise in Axis II pathology diagnosed borderline patients in two groups in this sample. Results indicate that the MCMI-I BPD scale has very limited utility as a screening instrument for individual diagnoses when a well-defined borderline sample is used as a criterion. This study further suggests that at present only clinicians with particular expertise in the diagnosis of personality disorders can assess the degree and type of Axis II pathology present in a given patient. Because most structured interview and self-report validation studies have not included well-defined criterion groups, diagnostic validity of particular measures generally has not been established beyond the level of concordance.

This study is an attempt to delineate symptom clusters that may be considered most distinctive of patients diagnosed with borderline personality disorder (BPD). Medical records were examined to assess the extent to which each of the eight DSM-III-R BPD criteria was present in 89 psychiatric inpatients diagnosed with BPD. Structural analysis revealed three symptom clusters that can explain symptomatology for a majority of the sample. BPD patients can be identified initially by a core factor and separated subsequently into several BPD subtypes based on the patients' remaining symptomatology. A hierarchical diagnostic scheme for delineating BPD subtypes is proposed, and the implications of these findings for a theoretical separation of several BPD subtypes are discussed.

The influence of certain personality characteristics (tendency to depressive experiences, personal boundary preferences) on psychotherapist reaction to patients with borderline personality disorder was assessed by semantic differential ratings in an analogue study. Vignettes presented one of two patients enacting the Rewarding and Withdrawing object relations unit in two separate therapy sessions. Therapists higher on anaclitic depressive and fusion tendencies evaluated themselves less positively than other therapists (p < .01) in the Withdrawing condition. They evaluated the patient less positively regardless of condition (p < .05). High boundary therapists evaluated patients more positively (p < .05) in the Withdrawing condition. They evaluated themselves more positively regardless of condition (p < .05) and showed less tendency to devalue self and patient with the lower functioning borderline patient.

Psychotherapists' reactions to patients with borderline personality disorder were assessed by semantic differential ratings in an analogue study. Vignettes presented one of two patients who enacted the Rewarding and Withdrawing object relations units in two separate therapy sessions. In response to the Rewarding object relations unit therapists evaluated themselves more positively and perceived themselves as more active and more potent than in response to the Withdrawing object relations unit (p < .01). They also evaluated the patients more positively and perceived them as less active (p < .01). These patterns were modified by some order effects and some differences in response to the two vignettes, which represented a lower and higher functioning borderline patient.

The division between Axis I clinical syndromes and Axis II personality disorders is a long-standing distinction based primarily on three guiding principles: phenomenology, cause, and course. Clinical syndromes were generally thought to be characterized by transient symptoms with biological causes and an unstable course; personality disorders were supposed by many to be characterized by long-standing personality traits, whose roots were primarily psychological, and a stable and unremitting course. Borderline personality disorder (BPD), however, is a condition characterized by distinct clinical symptoms, varied causes, and a relatively unstable course. Past theorizing about the distinction between Axis I and Axis II disorders is presented in light of recent empirical evidence refuting the rationalization for the separation of personality disorders and clinical syndromes using BPD as a means for comparison. Keywords: psychodiagnostic typologies; borderline personality; personality disorders; classification; Diagnostic and Statistical Manual

Although results; have been variable, studies suggest that individuals with borderline personality disorder (BPD) exhibit cognitive deficits suggestive of frontal- and temporal-lobe dysfunction. Patients diagnosed with BPD (n = 18) using two structured interviews, and who were carefully screened for neurological and substance-use disorders, were compared to depressed patients (n = 18) and a nonpsychiatric control group (n = 18) on a series of neuropsychological tasks. The role of emotion on cognitive functioning was assessed by including emotional stimuli and interference on several of the tasks. Little support was found for the neurobehavioral hypothesis of BPD. The BPD group performance did not differ from the normal group on most tasks of executive functioning or memory, and the introduction of emotional stimuli did not impair performance. The depressed group performed less effectively than the other groups. Reasons for variable findings and factors, affecting the cognitive functioning of patients with BPD are discussed. There may be considerable heterogeneity in the cognitive functioning of BPD patients, with those exhibiting significant cognitive deficits comprising only a subgroup. [C] 2000 John Wiley & Sons, Inc. J Clin Psychol 56:1587-1600, 2000. Keywords: borderline personality disorder; neuropsychology; cognitive functioning

This study focused on the clinical field validity of the Rorschach comprehensive system revised DEPI and CDI indices. Forty admission protocols from two inpatient adult DSM-III-R diagnosed samples, one with Major Depressive Disorder, uncomplicated, and one with Major Depressive Disorder and concurrent Borderline Personality Disorder, were compared. Hypotheses were (a) both groups would be identified by the revised DEPI and (b) if the Depressed Borderline group was not identified by the DEPI, it would be identified by the CDI. Both hypotheses were negated, raising questions regarding the validity of the indices for use in clinical diagnosis, treatment, and clinical research.

Methodological variations in the scoring and interpretation of the MMPI and their effects on discrimination between borderline and non-borderline personality disordered alcoholics were investigated. Subjects were 49 male and female inpatient alcoholics in an Icelandic psychiatric hospital. Gunderson's Diagnostic Interview for Borderlines and the Michigan Alcoholism Screening Test were used to diagnose borderline personality disorder and alcoholism, respectively. Scoring and interpretation of the MMPI were varied in terms of the use and non-use of high F-scale profiles, and their impact on the frequency of various code types among borderline and non-borderline personality disordered alcoholics was considered. It was found that such methodological variations do not affect the frequency of some profile types, and, consequently, the discrimination between the diagnostic groups. Studies and coding systems should consider methodological variations in the scoring and interpretation of MMPI profiles and their consequent effects on diagnosis.

This study assessed the prevalence of borderline personality symptomatology among women with eating disorders. The Diagnostic Interview for Borderlines, Millon Clinical Multiaxial Inventory, and Borderline Syndrome Index were administered to 28 women in a hospital-based eating disorders program. Results revealed that 39% were classified as borderline on at least one measure, 29% on at least two measures, and 18% on all three. Recovered restricters were particularly prone to borderline personality symptomatology. This study improves upon previous work in this area by employing multiple measures of borderline personality, assessing eating disorder subgroup differences, and recruiting subjects from a single eating disorder treatment program.

Rorschach data has been useful in identifying the DSM Borderline Personality Disorder (BPD) and has potential for improving our understanding of this disorder. Recently, the DSM-IV BPD has been shown to be composed of 3 primary or core factors: Factor I - unstable self-other images, Factor II - deficits in affect and thought modulation, and Factor III - impulsive self-damaging actions. In a sample of outpatients with personality disorders, we explored the relationships among 6 psychoanalytically derived Rorschach scales (primitive aggression, oral dependency, self-other differentiation, splitting, devaluation, and projectile identification), and the core BPD features. Significant correlations were found between 5 of the Rorschach variables and BPD total scores. Correlations between these 5 variables and the BPD core features showed that oral dependency needs were negatively associated with all 3 BPD core features, whereas the defenses of devaluation and splitting were positively associated with these core features. The clinical implications of these findings are reviewed.

A growing number of children are experiencing marital transition. The effects of divorce on children have typically been considered deleterious, although factors can buffer the difficulty of postdivorce adjustment. One of these factors is a positive relationship with a parental figure. Unfortunately, divorce often overwhelms parents with a series of changes that compromise their parenting skills. One new approach to improving parenting after divorce is mindful parenting, which aims to enhance interpersonal and emotional connection in the parent-child relationship. This program is intended to facilitate parents' self-awareness, their mindfulness, and their intentionality in responding to their child's needs, The present study reports on the implementation of the Mindful Parenting Program, delivered in two groups to 12 recently divorced parents with preschool-aged children. Program effectiveness was conducted on two levels. First, mindfulness measured by the Toronto Mindfulness Scale revealed significant increases over the intervention and posttest period. Second, in-home behavioral observations conducted pre- and postintervention revealed no changes in parent-child relationships, These findings are discussed within the larger context of facilitating effective parenting postdivorce. Keywords: borderline personality disorder; dexamethasone suppression test

Dialectical behavior therapy (DBT) can be considered a well-established treatment for borderline personality disorder (BPD) as evidenced by seven well-controlled randomized clinical trials across four independent research teams. The primary purpose of this article is to address a variety of potential mechanisms of change that may be associated with those aspects of DBT that are unique to the treatment and its theoretical underpinnings. Based on the biosocial theory of BPD, many of these mechanisms can be distilled down to the following process: the reduction of ineffective action tendencies/inked with dysregulated emotions. Specifically we address the following interventions and associated mechanisms of change: mindfulness, validation, targeting and chain analysis, and dialectics. Patient change in BPD is conceptualized primarily as helping the patient to engage in functional, life-enhancing behavior, even when intense emotions are present. Ultimately, our goal was to provide guidance for theoretically and empirically grounded research on the mechanisms of change in DBT. Keywords: dialectical behavior therapy; mechanisms of change; borderline personality disorder; mindfulness; exposure therapy

Skills training is a crucial mode of treatment in dialectical behavioral therapy (DBT; Linehan, 1993b), yet a psychometrically sound measure of DBT skills use does not exist. We adapted the Revised Ways of Coping Checklist (RWCCL; Vitaliano, Russo, Carr, Maiuro, & Becker, 1985) to create the DBT Ways of Coping Checklist (DBT-WCCL). Using factor analysis procedures, two subscales emerged: one assessing coping via DBT skills, the DBT Skills Subscale (DSS), and one assessing coping via dysfunctional means, the Dysfunctional Coping Subscale (DCS). Principal component, internal consistency, test-retest reliability, and content validity analyses suggested that the scale has good to excellent psychometric properties. In addition, the DSS successfully discriminated patients who received skills training during 4 months of treatment from patients who did not. Moderators of skills use are also discussed. The DBT-WCCL appears to be a promising new measure of DBT skills use. [c] 2010 Wiley Periodicals, Inc. J Clin Psychol: 66:563-582, 2010. Keywords: dialectical behavior therapy; borderline personality disorder; skills training; measurement; psychometrics DOI: 10.1002/jclp.20685

There are very few less contentious issues than the role of attachment in psychotherapy. Concepts such as the therapeutic alliance speak directly to the importance of activating the attachment system, normally in relation to the therapist in individual therapy and in relation to other family members in family-based intervention, if therapeutic progress is to be made. In group therapy the attachment process may be activated by group membership. The past decade of neuroscientific research has helped us to understand some key processes that attachment entails at brain level. The article outlines this progress and links it to recent findings on the relationship between the neural systems underpinning attachment and other processes such as making of social judgments, theory of mind, and access to long-term memory. These findings allow intriguing speculations, which are currently undergoing empirical tests on the neural basis of individual differences in attachment as well as the nature of psychological disturbances associated with profound disturbances of the attachment system. In this article, we explore the crucial paradoxical brain state created by psychotherapy with powerful clinical implications for the maximization of therapeutic benefit from the talking cure. Keywords: mentalization-based therapy; borderline personality disorder; attachment

Analysis of the data on children with borderline personality disorder according to the Rorschach autisms is considered along with current theoretical hypotheses of adult borderline psychopathology and examination of the association between child and adult borderline disorders. A case study of a sexually abused child is used as an illustration.

Analysis of a taxonomy of Rorschach autisms of perceptual-cognitive disorders scored on 3 categories through the Rorschachs of outpatient schizophrenics, inpatient schizophrenics, borderline personality disorders and Cluster A personality disorders revealed that the Rorschach categories HYPOs and HYPERs gave improved differential diagnoses than RELERs among all the patients indicating the validity of such scores in regular screening for thought disorders.

A study used cross-sectional design to compare ratings for social functioning and object relations for schizophrenic patients and those with borderline personality disorders. Results indicate that the borderline group had higher measures of object relations. However, over the long term, schizophrenic patients adapted better than borderline patients in terms of social functioning.

Borderline personality disorder (BPD) is a disorder characterized by severe disturbances in emotion regulation. In Dialectical Behavior Therapy (DBT), affect dysregulation is seen as a consequence of a transaction between a biological predisposition to emotion vulnerability and invalidating environmental experiences. In the past few years, a growing body of research has accumulated demonstrating the efficacy of DBT in treating severely disordered, chronically suicidal, and substance-dependent individuals with BPD. This article describes a DBT approach to the treatment of emotion regulation in individuals with BPD. [C] 2001 John Wiley & Sons, Inc. J Clin Psychol/In Session 57:183-196, 2001. Keywords: borderline personality disorder: emotion dysregulation; Dialectical Behavior Therapy; affect regulation

Utilizing the Rorschach and the Wechsler, groups of borderline adolescents (n = 26) and adolescents with other personality disorders (n = 26) were compared to determine whether there were differences in magnitude and type of disturbances in ego functioning. The specific aspects of ego functioning that were studied included disturbances in identity integration, reliance on primitive defensive operations, vulnerability to regressive thinking, and lapses in reality appreciation. Results indicated that during adolescence the borderline personality represents a more severe form of character pathology than other personality disorders, as revealed by more disturbances in identity integration, a greater regression to primary-process thinking in unstructured settings, and more frequent lapses in reality testing. This contrast was most striking in the area of identity integration, where identity disturbances tended to be associated with lapses in reality testing in borderline adolescents, while there was essentially no relationship between these two indicators of ego pathology in non-borderline adolescents. This supports the notion that disturbances in identity integration, or the sense of self, form an important part of the borderline diagnosis, even during adolescence.

Emotional abilities were measured with a performance test of emotional intelligence (The Mayer-Salovey-Caruso Emotional Intelligence Test; Mayer, Salovey, & Caruso, 2002) in patients diagnosed with major depressive disorder, substance abuse disorder, or borderline personality disorder (BPD), and a nonclinical control group. Findings showed that all clinical groups differed from controls with respect to their overall emotional intelligence score, which dovetails with previous findings from self-report measures. Specifically, we found that the ability to understand emotional information and the ability to regulate emotions best distinguished the groups. Findings showed that patients with substance abuse disorder and BPD patients were most impaired. Keywords: emotional intelligence; borderline personality disorder; major depressive disorder; substance abuse disorder; emotion regulation

In this article, the author presents and illustrates the treatment of a patient with dependent and borderline personality disorders and other maladaptive traits using an integrated and eclectic approach tailored to the patient's psychopathology and personality. Interventions are selected where possible based on evidence of what works. However, because empirical evidence on treatment efficacy for personality disorder is limited, interventions were often selected based on a rational analysis of the most effective way to treat a given problem. The delivery of an eclectic array of interventions was integrated and coordinated through an emphasis on generic methods and on a phases of change model that targets symptoms and problems in a systematic way based on evidence of the stability of symptoms and personality. Keywords: integrated treatment; eclectic therapy; borderline personality disorder; dependent personality disorder

The authors address psychodynamic therapies, particularly transference-focused psychotherapy (TFP), in the treatment of patients who present with non-suicidal self-injury. In doing so. they briefly discuss various psychodynamic approaches with empirical evidence for their effectiveness. They describe TFP, including its treatment rationale, putative change mechanisms, and outcome research. They then present a case illustration of a patient with borderline personality disorder who engages in non-suicidal self-injury to demonstrate how TFP can be applied to such cases. Keywords: psychodynamic treatment; transference-focused psychotherapy: self-injury; borderline personality disorder

The study's aims are to explore ethnic differences in rates of adverse childhood experiences and lifetime traumatic events and in rates of psychiatric disorders for patients exposed to similar traumas. Rates of these events and rates of major depressive disorder, posttraumatic stress, substance use, and borderline personality disorders were compared among 506 non-Hispanic Whites (N-HW), 108 Latina(o)s, and 94 African Americans (AA) participating in the Collaborative Longitudinal Personality Disorder Study. We found that Whites reported higher rates of neglect than African Americans and Latina(o)s, higher rates of verbal/emotional abuse than African Americans, and higher rates of accidents and injuries/feared serious injury than Latina(o)s. African Americans had higher rates of seeing someone injured/killed than Whites. No significant interaction was observed between adverse events and ethnicity for mental disorders. [c] 2010 Wiley Periodicals, Inc. J Clin Psychol: 66:583-598, 2010. Keywords: trauma; child abuse; African Americans; Latinos DOI: 10.1002/jclp.20686

Non-suicidal self-injury (NSSI) is a growing clinical problem, especially among adolescents and young adults. Anecdotal accounts, clinical reports, and popular media sources suggest that observing the blood resulting from NSSI often plays an important role in the behavior's reinforcement. However, research to date has not systematically assessed the role of blood in NSSI. The current study examined this phenomenon in 64 young adults from a college population with histories of non-suicidal skin-cutting. Approximately half the participants reported it was important to see blood during NSSI. These individuals reported spending five minutes or less looking at the blood after each instance of NSSI, and that seeing blood served several functions including 'to relieve tension' and 'makes me feel calm.' In addition, wanting to see blood was associated with greater lifetime frequency of skin-cutting and greater endorsement of intrapersonal functions for NSSI (e.g., affect regulation, self-punishment). Finally, participants who reported wanting to see blood were more likely to endorse symptoms of bulimia nervosa and borderline personality disorder. Theoretical and clinical implications are discussed. Keywords: self-injurious behavior; deliberate self-harm; non-suicidal self-injury; skin-cutting; self-mutilation; self-damaging behaviors; blood DOI: 10.1002/jclp.20661

Plan Analysis provides case conceptualization for psychotherapy patients in general and for personality disorders in particular. Plan Analysis emphasizes the instrumental aspect of behavior and emotions by asking what motives or goals do a patient's functioning serve. The authors briefly describe Plan Analysis and then illustrate it with the psychotherapy of Nicole, a young patient with avoidant personality disorder, personality disorder not otherwise specified, and major depression. The case illustrates a flexible procedure, dealing with different topics in parallel, and using techniques from a variety of treatment approaches in a heuristic way. Keywords: comorbidity; Plan Analysis; case conceptualization; avoidant personality disorder; borderline personality disorder; therapeutic relationship

Dialectical behavior therapy (DBT) was originally designed as a treatment of emotionally dysregulated, impulsive, and dramatic disorders (e.g., borderline personality disorder) and populations (e.g., parasuicidal women). However, a number of complex disorders represent the dialectical opposite of BPD and related disorders; these disorders are characterized by being overcontrolled, emotionally constricted, perfectionistic, and highly risk-averse. In this article, the authors introduce a recent adaptation of DBT that targets cognitivebehavioral rigidity and emotional constriction and illustrates its application through the case of a man suffering from both paranoid personality disorder and obsessive-compulsive personality disorder. Keywords: comorbidity; personality disorders; dialectical behavior therapy; emotional constriction; risk aversion

Non-suicidal self-injury is the intentional destruction of body tissue without suicidal intent and for purposes not socially sanctioned. In this practice-friendly review, the authors summarize the empirical research on who self-injures, why people self-injure, and what treatments have demonstrated effectiveness. Self-injury is more common in adolescents and young adults as compared to adults. Common forms include cutting, severe scratching, burning, and banging or hitting; most individuals who self-injure have used more than one method. Although diagnostically heterogeneous, self-injurers typically exhibit two prominent characteristics: negative emotionality and self-derogation. Self-injury is most often performed to temporarily alleviate intense negative emotions, but may also serve to express self-directed anger or disgust, influence or seek help from others, end periods of dissociation or depersonalization, and help resist suicidal thoughts. Psychotherapies that emphasize emotion regulation, functional assessment, and problem solving appear to be most effective in treating self-injury. Keywords: self-injury; self-mutilation; deliberate self-harm; borderline personality disorder

This article reviews the complexity of adaptation and symptomatology in adult survivors of childhood neglect and abuse who meet criteria for the proposed diagnosis of Complex Posttraumatic Stress Disorder (Complex PTSD), also known as Disorders of Extreme Stress, Not Otherwise Specified (DESNOS). A specific EMDR protocol, Resource Development and Installation (RDI), is proposed as an effective intervention in the initial stabilization phase of treatment with Complex PTSD/DESNOS. Descriptive psychometric and behavioral outcome measures from two single case studies are presented which appear to support the use of RDI. Suggestions are offered for future treatment outcome research with this challenging population. Keywords: childhood neglect; childhood abuse; PTSD; borderline personality disorder; suicidal ideation

The present article comments on a classic study by Garfield (1947) then reviews research on the Rorschach and psychiatric diagnoses. Despite a few positive findings, the Rorschach has demonstrated little validity as a diagnostic tool. Deviant verbalizations and bad form on the Rorschach, and indices based on these variables, are related to Schizophrenia and perhaps to Bipolar Disorder and Schizotypal Personality Disorder. Patients with Borderline Personality Disorder also seem to give an above-average number of deviant verbalizations. Otherwise the Rorschach has not shown a well-demonstrated relationship to these disorders or to Major Depressive Disorder, Posttraumatic Stress Disorder (PTSD), anxiety disorders other than PTSD, Dissociative Identity Disorder, Dependent, Narcissistic, or Antisocial Personality Disorders, Conduct Disorder, or psychopathy.

The issue of comorbidity within the Axis II personality disorders was explored using a large sample of university students who were administered the Coolidge Axis II Inventory (CATI). Comorbidity patterns with this normal sample were compared with recent clinical data reported by several other researchers. The results confirm the high degree of comorbidity within Axis II and the similarity in the comorbidity patterns with clinical and nonclinical samples. With the CATI, a 30.4% comorbidity rate was obtained for Histrionic and Narcissistic Personality disorders (Pd). The paranoid, passive-aggressive and borderline personality disorder traits were comorbid with several other Pds. For Cluster A, there was low comorbidity except for Paranoid Pd and Schizotypal Pd. With Cluster B, the co-occurrence was moderate to strong. A moderate amount of interrelationship was obtained for the Cluster C Pds. The DSM-IV clusters were also strongly interrelated. An additional finding was the similarity between self-report and structured interview methodology in obtained personality disorder comorbidity.

Distortions in interpersonal perceptions among patients with borderline personality disorder (BPD) were explored to investigate the validity of object relations theories. Depressed patients with BPD were compared to patients with major depressive disorder (MD) without BPD. Subjects were 77 male and female inpatients (BPD = 55, MD = 22). The mean ages were 30.5 for BPD subjects and 36.3 for MD subjects. Perceptions of patients, relatives, and interviewers were compared on the following measures: Structural Analysis of Social Behavior, Perceived Criticism Scale, and Camberwell Family Interview. Findings are consistent with object relations theory. BPD patients saw themselves as hostile, labile, and unstable. MD patients avoid acknowledging and responding to relatives' criticality.

Forty-eight residents of a therapeutic community took part in a prospective study aimed at assessing overall outcome and which components of the program were most helpful. All subjects had a DSM-III-R axis II diagnosis, usually borderline personality disorder (N = 34). As well, subjects had a mean of 1.3 axis I diagnoses, underlining the severity of their psychiatric disorders. Significant symptom reduction on the Brief Symptom Inventory occurred at discharge after a mean stay of 64 days, with further significant falls at three month follow-up. These changes were paralleled in the Hostility and Direction of Hostility Questionnaire, a measure of personality. Hospital admission rates fell significantly in the year after discharge. Clients rated group therapy as the most helpful component of the program. [C] 1996 John Wiley & Sons, Inc.