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Both the new ICD-11 and the latest Alternative DSM-5 Model for Personality Disorders focus on self and interpersonal functioning as the central feature of personality pathology, also acknowledging that personality disorders are organized along a dimensional continuum of severity. This revised understanding is in line with long-standing psychodynamic conceptualisations of personality pathology, in particular Kernberg's object relations model of personality organization. Despite existing evidence for the clinical utility of the derived Structured Interview of Personality Organization (STIPO-R), empirical support for the identification of clear cut-points between the different levels of personality functioning is missing. For this purpose, a total of 764 adult participants were recruited across two clinical (outpatient and inpatient) settings ( n =  250) and two non-clinical (university students and general community) samples ( n =  514). Results from the mixture modeling suggested the existence of five groups across the clinical and non-clinical samples that covered: healthy personality functioning, maladaptive personality rigidity, and mild, moderate, and severe levels of personality pathology. All five indicators of personality organization were found to be reliable predictors of personality pathology. Of the five STIPO-R indicators, Aggression and Moral Values had the most discriminative power for differentiating between the Mild, Moderate, and Severe personality disorder groups. Implications of these findings are discussed.

With the publication of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, a set of dimensional criteria was added as an emerging alternative model to the diagnosis of personality disorder (PD; American Psychiatric Association, 2013). Parallel to this, within the object relations conceptualization of personality pathology, a structured interview, the Structured Interview of Personality Organization (STIPO), was developed to assess pathological personality and then revised (STIPO-R). In this study, the reliability and validity of the Chinese version of the STIPO-R were tested on a sample of 236 Chinese participants, including both psychiatric patients and healthy individuals. Overall, the STIPO-R showed good internal consistency, interrater and test-retest reliability, and generally satisfactory results in structure and convergent validity. The STIPO-R also demonstrated discriminant validity (healthy individuals vs. psychiatric patients with PD vs. psychiatric patients without PD). Results are also discussed in light of cultural differences between Chinese and Western cultures. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

This commentary reviews the Journal of Personality Disorders special issue "Interpersonal Trust and Borderline Personality Disorder: Insights From Clinical Practice and Research," published in Volume 37, Number 5, October 2023.

Individuals with borderline personality disorder (BPD) struggle to identify whom they can safely trust, and this struggle contributes to profound emotional turmoil in their close relationships. Transference-focused psychotherapy (TFP) is an application of object relations theory (ORT) that posits that polarized mental representations of self and other define the personality organization of BPD. TFP aims to utilize a clear treatment frame coupled with an analysis of the therapeutic relationship (i.e., the transference) to help individuals with BPD integrate their polarized mental representations. Improvement in the capacity to trust others is inherent in the mechanisms of change in TFP. In this article, a social cognitive model of trust processing provides a new lens through which we formulate how TFP may enhance trust processing in BPD. Recent evidence from randomized clinical trials supports the argument that TFP may intervene with BPD in a way that is concordant with uniquely improved trust processing.

Transference-focused psychotherapy (TFP) is an empirically supported treatment for borderline personality disorder (BPD) that improves functioning via targeting representations of self affectively relating to others, particularly as evoked in the therapeutic relationship. If change in TFP operates as theorized, then shifts in patterns of "self affectively relating to others" should be observed in the transference prior to shifts in daily relationships. Using ecological momentary assessment (EMA), a patient with BPD rated daily interpersonal events for 2-week periods during 18 months of TFP; at 9 and 18 months these ratings included interactions with the therapist. Results suggest that positive perceptions of her therapist that ran counter to her negatively biased perception in other relationships preceded changes in her perceptions of others. EMA shifts corresponded to improvements in self-reported symptoms, interview-based personality functioning, and therapist assessments. Implications for assimilation of a trusting experience with the therapist as a mechanism of change in TFP are discussed.

The Pathological Narcissism Inventory (PNI) is extensively used in recent empirical literature on pathological narcissism. However, most studies using the PNI are community-based, and no studies have used the PNI to investigate narcissistic presentations in personality disordered patients. This study investigates measurement invariance of the PNI in community participants and patients with personality disorders, and examines differences of narcissistic presentations in these samples through a multimethod approach. Results show that the PNI can be used reliably to measure and compare traits of pathological narcissism in community participants and patients with personality disorders. Personality disordered patients show higher traits reflecting vulnerable narcissism and overt manifestations of grandiose narcissism, compared with controls. Finally, network analysis indicates that traits of grandiose fantasies and entitlement rage have a central role in defining manifestations of PNI pathological narcissism, regardless of the presence of an underlying personality disorder. Research and clinical implications are discussed.

Objective: Transference-focused psychotherapy (TFP) is an empirically supported individualized psychotherapy for patients with borderline personality disorder. This review highlights its development and current status., Methods: A review of the theoretical background underpinning TFP and empirical advances in the development of TFP provide perspective., Results: Otto Kernberg's object relations model of personality and its implications for assessment and diagnosis of personality disorders are described. The authors review the programmatic research that has been developed and has demonstrated the efficacy of TFP. In view of the empirical studies that have demonstrated the successful outcomes and processes of TFP for patients with borderline personality disorder, compared with other approaches, TFP has been applied to a broader range of difficulties related to patients' self-functioning and interpersonal functioning across the range of severities in personality pathology, consistent with the Alternative DSM-5 Model for Personality Disorders. The authors discuss borderline personality organization in the context of interpersonal, neurocognitive, and self-regulatory dysfunction, including preliminary findings., Conclusions: The theoretical and empirical advances in TFP lead to future directions for research evaluating personality disorder and its treatment.

Contemporary models of the diagnosis and classification of personality disorders have diverged from the categorical diagnostic framework of the DSM system. One response to this movement can be found in the Alternative DSM-5 Model for Personality Disorders (AMPD), which uses dimensions of personality functioning, coupled with identification of dominant pathological traits, to define and classify personality disorders. By applying psychodynamic object relations theory to the AMPD, therapists can enrich the understanding and assessment of personality functioning and pathology as described in the AMPD.

Background: Impaired reflective functioning (RF) is common among patients with borderline personality disorder (BPD). Transference-focused psychotherapy (TFP) has been demonstrated to improve RF compared to other common BPD treatments. If RF reflects a treatment mechanism for TFP, differences in pretreatment RF may also serve as a prescriptive factor for TFP's effects., Method: A total of 194 patients with BPD were randomized across two clinical trials to receive TFP ( n = 83), dialectical behavior therapy (DBT; n = 31), supportive psychodynamic therapy (SPT; n = 28), or an enhanced treatment as usual (eTAU; n = 52). A mixed-effects model was used to examine whether baseline RF interacted with treatment condition to predict slopes of change in the Brief Symptom Inventory, the shared symptom outcome between trials. Moderation of changes in RF was also examined., Results: Treatment interacted with baseline RF to predict BSI slopes ( p = .011). In TFP/SPT, RF did not predict outcomes, β = -0.00, p = .973, while higher RF was associated with relatively better outcomes in DBT/eTAU, β = -0.54, p < .001. Patients with poor RF (scores of 0/1) benefitted more from TFP/SPT, while patients with relatively ordinary RF (score of 4) had better outcomes in DBT/eTAU. Treatment effects on RF change were also moderated by baseline RF ( p = .014), such that TFP improved RF most strongly among poor RF patients, SPT only among very poor RF patients, and DBT/eTAU not at all., Discussion: Low RF may reflect a deficit that may be targeted by TFP and other manualized psychodynamic treatments for BPD, which may be especially helpful among patients presenting with low RF. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Adolescence is a crucial period for the development of personality and its dysfunctions. In this regard, it is essential to evaluate the nature and degree of maladaptive personality functioning. However, measures currently available present some limitations, mainly being adaptations from adult's tailored instruments and length. Moreover, no instrument considers the crucial dimensions related to body development and sexuality. This contribution presents data on the Adolescent Personality Structure Questionnaire (APS-Q) development, a self-report measure to capture core aspects of personality functioning in adolescence while being agile and reliable. On two large samples of adolescents (total N = 1,664), we investigated the psychometric properties of the APS-Q. We explored its factor structure and construct and incremental validity in the first sample, testing specific associations with existing measures of severity of personality pathology, maladaptive personality traits, and psychological distress. In the second sample, we confirmed its factor structure, assessing gender and age invariance. Overall, our findings support the APS-Q's validity as a reliable and useful measure to assess personality functioning. Moreover, the APS-Q highlighted developmentally vital dimensions such as self-functioning (encompassing mental and bodily changes and considering the dimension of sexuality), interpersonal functioning (discriminating the dimensions of family and peers), and emotion regulation.

Adolescence and young adulthood are peak periods for risky sexual behaviors (RSB) and borderline personality disorder (BPD) features. RSB is a major public health concern and adolescents with BPD may be particularly vulnerable to RSB, but this is understudied. The aim of this study was to identify distinct RSB profiles in youth and determine whether a specific profile was associated with BPD features. Participants were 220 adolescents and young adults (age 14-21) recruited from the community. To identify groups of adolescents and young adults who engage in similar RSB, a latent profile analysis (LPA) was conducted on sexually active youth (57%). Next ANOVA was used to identify how profiles differed in terms RSB dimensions and BPD features. We identified three distinct RSB profiles: (1) a Low RSB profile that was manifested by the majority (77.7%) of youth; (2) an Unprotected Sex in Relationships profile (13.3%) and; (3) an Impulsive Sex Outside Relationships profile (12%) which was manifested by youth with significantly higher BPD features. The findings shed light on the difficulties youth with BPD manifest around integrating sexuality, intimacy, fidelity, and love. This contrasts with the majority of youth who are sexually active in the context of relationships and engage in little or no RSB. The findings have important clinical implications. Adolescent sexuality is frequently in the blind spot of clinicians. To address the elevated risk of RSB in adolescents with BPD, interventions are needed to help adolescents navigate this period and improve their understanding of the reasons for RSB while addressing difficulties in establishing sexual and attachment relationships., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Bégin, Ensink, Bellavance, Clarkin and Normandin.)

Objective: The capacity for understanding mental states (reflective functioning; RF) is considered essential for self-growth, social learning, and emotion regulation. Impaired RF is thought to play a central role in borderline personality disorder (BPD). We examined whether asking patients to consider mental states in-session has a down-regulatory effect on emotional arousal in treatments for BPD., Method: Early-, middle- and late-phase videotaped sessions from a randomized-controlled trial of transference-focused psychotherapy (TFP; n = 30), dialectical behavior therapy (DBT; n = 29), and supportive psychodynamic therapy (SPT; n = 29) were segmented to therapist and patient talk-turns. Therapist talk-turns were rated as asking patients to consider mental state (bids for RF) or not. Patient talk-turns were rated for RF and acoustically encoded for arousal., Results: Bids were twice as common in TFP compared to DBT and SPT. Across treatments, therapist bids for RF predicted better RF, which, in turn, predicted lower emotional arousal., Conclusions: Asking patients to consider mental states has a down-regulatory effect on patients' arousal in psychotherapies for BPD. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Introduction: Effortful control (EC) is the self-regulatory aspect of temperament that is thought to reflect the efficiency of executive attention (EA). Findings on relationship between EC and performance on EA tasks among adults are still contradictory. This study used a computational approach to clarify whether greater self-reported EC reflects better EA., Methods: Four hundred twenty-seven healthy subjects completed the Adult Temperament Questionnaires and the Attention Network Task-revised, a conflict resolution task that gauges EA as the flanker effect (FE), that is, the difference in performances between incongruent and congruent trials. Here we also employed a drift-diffusion model in which parameters reflecting the actual decisional process (drift rate) and the extra-decisional time are extracted for congruent and incongruent trials., Results: EC was not correlated with the FE computed with the classic approach, but correlated positively with drift rate for the incongruent trials, even when controlling for the drift rate in the congruent condition and the extra-decisional time in the incongruent condition., Conclusion: This study demonstrates an association between self-reported EC and EA among adults. Specifically, EC is not associated with overall response facilitation but specifically with a greater ability to make goal-oriented decisions when facing conflicting information., (© 2021 Wiley Periodicals LLC.)

Recent advances in the understanding of personality pathology have contributed to an emphasis on the core of personality pathology as deficits in self-functioning and interpersonal functioning at different levels of severity that must be assessed for clinical intervention. In concert with these conceptual and empirical advances, transference-focused psychotherapy (TFP), an empirically supported psychodynamic treatment for borderline personality disorder, has been in constant development with extensive clinical use. This article describes an object relations model for conceptualizing and assessing levels of personality organization, a transdiagnostic approach to personality pathology, and related treatment modifications, thus expanding the utilization of TFP beyond borderline personality disorder to the full range of personality dysfunction. The core of this treatment approach is a sequential interpretive process between patient and therapist. This process takes place within the context of a structured treatment frame tailored to the unique individual with problems in self-functioning and interpersonal functioning in his/her particular environment.

The assessment of personality and personality pathology in adolescence represents a critical topic to understand adolescent's difficulties, predict long-term outcome in adulthood, and indicate adequate treatment. Personality Organization, and its underlying dimensions, plays an essential role in shaping how adolescents face their developmental tasks as they are connected with psychosocial functioning and psychopathological severity. However, few measures are available to assess personality organization during adolescence. The aim of the present research is to investigate the psychometric properties of the Interview of Personality Organization Processes in Adolescence (IPOP-A), a semi-structured interview designed for the assessment of the main personality organization dimensions in adolescence. Three studies were performed to explore the psychometric properties of the IPOP-A, in terms of factor structure, reliability, convergent, and discriminant validity. Exploratory and confirmatory factor analysis supported the IPOP-A construct validity. Furthermore, IPOP-A showed good reliability and evidenced a convergent and discriminant validity with DSM-oriented personality patterns, emotion dysregulation, identity disturbance, and psychopathology. Our results provide evidence of IPOP-A validity to assess emerging personality organization in adolescence. Furthermore, the IPOP-A is a promising tool to use in the clinical consultation and treatment planning for the adolescent.

The aim of this study was to explore the viability of a bifactor model for the Inventory of Personality Organization (IPO), which is a self-report measure of personality functioning based on Kernberg's model of personality organization. A heterogeneous, predominantly clinical sample ( N  = 616) completed the German 83-item version of the IPO. Confirmatory and Exploratory Factor Analyses were applied to explore the factor structure of the IPO. We were able to establish a bifactor model with a general factor of personality functioning and three specific factors (Aggression, Reality Testing, Moral Values), which represent additional dimensions of personality organization. Virtually all items showed substantial positive loadings on the general factor, explaining roughly 66% of the common variance. Furthermore, we found support for convergent and discriminant validity of general and specific factors with regard to interview-based assessments of personality disorders and personality organization. The results lend support to a bifactor approach to Kernberg's model of personality organization. We also present a 30-item brief form of the IPO that efficiently implements the bifactor approach and may be further validated in future studies.

Background: The purpose of the present study was threefold: first, to investigate the facial affective behavior in patients with a borderline personality disorder (BPD); second, to examine whether these patients could be divided into clusters according to facial affective behavior; and third, to test whether these clusters would influence the inpatient treatment outcome., Methods: Thirty inpatients with BPD were assessed with the Structured Clinical Interviews for DSM-IV Axis I and II Disorders (SCID I, SCID II) and had to complete a series of questionnaires before and directly after the 12-week long inpatient treatment. Facial affective behavior was recorded during the structured interview for personality organization (STIPO) and afterward coded with the emotional facial action coding system (EMFACS). Measures on psychopathology [beck depression inventory (BDI), Spielberger state and trait anxiety inventory (STAI), Spielberger state and trait anger inventory (STAXI), and symptom cheklist-90-revised (SCL-90-R)], interpersonal problems [Inventory of Interpersonal Problems (IIP)], and personality organization [inventory of personality organization (IPO)] were administered., Results: Cluster analysis before the treatment yielded two groups that differed in general facial expressivity, and regarding the display of anger, contempt, and disgust. The effect sizes of the repeated measures ANOVAs showed that persons with higher scores on the affective facial expressions benefitted more from the treatment in terms of STAI state anxiety, STAXI state and trait anger, IIP total, and the two scales primitive defenses and identity diffusion of the IPO, whereas persons with lower scores benefitted more on the scale IPO reality testing., Conclusion: Our results indicated some initial trends for the importance of facial affective behavior in patients with BPD and their treatment outcome., (Copyright © 2020 Dammann, Rudaz, Benecke, Riemenschneider, Walter, Pfaltz, Küchenhoff, Clarkin and Gremaud-Heitz.)

The Alternative Model of DSM-5 combines dimensional ratings of self-functioning, interpersonal functioning, and traits with categorical classification. The object relations model has a long tradition pre-dating the Alternative Model and, in part, has been incorporated into the Alternative Model. The object relations model provides a theoretical background (generally missing in the Alternative Model) that enhances the clinical assessment of personality pathology and its relationship to treatment planning., (© 2020 S. Karger AG, Basel.)

Objective: To examine conformity to prototypical therapeutic principles and its relation with change in reflective functioning in 3 treatments for borderline personality disorder (BPD)., Method: Early phase videotaped sessions from a randomized-controlled trial of year-long transference-focused psychotherapy (TFP; n = 27), dialectical behavior therapy (DBT; n = 26), and supportive psychodynamic therapy (SPT; n = 29) were coded using the Psychotherapy Q-sort (Jones, 1985). Ratings were compared to experts' ratings of ideal TFP, DBT, and mentalizing-enhancing principles to quantify conformity to ideal treatments. Reflective functioning was assessed at pre- and posttreatment. Differences among treatments in conformity and its relation with change in reflective functioning were examined., Results: Conformity to TFP and mentalizing-enhancing principles was highest in TFP (ps < .01) while conformity to DBT principles was high in DBT and SPT (DBT vs. SPT: p > .40), but lower in TFP (ps < .01). Larger improvements in reflective functioning were predicted by higher conformity to TFP principles during TFP (p = .04) and higher conformity to mentalizing-enhancing principles during SPT (p = .02)., Conclusions: Treatments for BPD differ in conformity to unique principles of specific modalities. Treatments also differ in the processes that predict increase in reflective functioning. The findings point to specificity and multiple pathways in increasing reflective functioning in the treatment of BPD. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Narcissistic personality disorder (NPD) is associated with both seeming indifference and hypersensitivity to social feedback. This study evaluated whether rejection sensitivity and empathic difficulties in NPD are accounted for by altered facial emotion recognition (FER). Two-hundred non-clinical individuals self-reported NPD features, rejection sensitivity, and empathy and performed an FER task assessing the ability to determine the presence or absence of an emotion when viewing neutral and negative facial stimuli presented at varying emotional intensities (25%, 50%, 75%). Those with higher NPD features were faster at accurately recognizing neutral and low, 25%-intensity emotional stimuli. This response pattern mediated the association between NPD features and increased anger about rejection. Thus, individuals with high NPD traits are hypervigilant toward subtle negative emotions and neutral expressions; this may explain their tendency to experience intense angry feelings when facing the possibility that the others would not meet their need for acceptance.

The intensive treatment of a patient presenting with major depression, chronic suicidal ideation, and a borderline personality disorder with narcissistic features is described as it developed over an 18-month treatment. The treatment approach is a transdiagnostic one with an emphasis on change in the patient's representation of self and others, identity and interpersonal functioning. The intended change is not only in the reduction of depression and suicidal ideation but also an improvement in interactions with others at work and intimate relations. The combination of rich clinical information from the therapist and independent research ratings of patient progress provide a complex picture of the treatment., (© 2019 Wiley Periodicals, Inc.)

The Cognitive-Affective Processing System (CAPS) was used to examine effortful control (EC) as a moderator of daily interpersonal behavior. Participants (N = 240) were nonclinical young adults who completed a 7-day event-contingent experience sampling study of interpersonal perception and affect. Multilevel linear models indicated that EC moderated within-person covariation of interpersonal warmth and affect activation; high EC individuals reported greater momentary warm behaviors when perceiving others as affectively activated. EC also amplified between-person covariation of interpersonal warmth between self and others; high EC individuals generally responded to perceptions of another's warmth with a greater degree of warm behavior. Varying levels of EC predict responses to interpersonal perceptions and affect in daily life, suggesting an important dimension for interpersonal functioning.

The authors describe an object-relations based model drawing on the work of Kernberg and colleagues for the assessment of borderline pathology. The substrate of internal object relations that constitutes borderline pathology internally or structurally is described and a model for assessing such pathology in a clinical interview format focusing on identity, defensive style, and quality of object relations is presented. Two clinical examples illustrate how these data can be compiled for purposes of psychodynamic case formulation and decisions about psychodynamic treatment., (Copyright © 2018 Elsevier Inc. All rights reserved.)

In part 2, the authors argue for a greater focus on a process approach to conceptualizing borderline personality disorder (BPD). The studies reviewed highlight contextual aspects of the pathology, specifically the affective and relational conditions under which BPD features become evident. The authors identify at what level in a complex social cognitive process the pathology may emerge. The implications of these findings for future model conceptualization are discussed, including the centrality of understanding BPD as an emergent phenomenon that cannot be reduced to single explanatory dimensions. The implications of these models for assessment, research, and treatment of BPD are discussed., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Borderline personality disorder (BPD) is a debilitating condition with significant personal and societal costs. Throughout the history of the conceptualization of borderline pathology as a form of psychopathology, there has been debate concerning the essential attributes of this disorder, which has significant implications for its assessment and treatment. The first of this 2-part review evaluates the major approaches to conceptualizing BPD, from the traditional DSM diagnosis through the more recent Alternative Model in DSM-5, Section III, and the research domain criteria initiative of the National Institute of Mental Health that was articulated largely in response to limitations of the DSM., (Copyright © 2018 Elsevier Inc. All rights reserved.)

This study examines psychopathology and clinical characteristics of patients with borderline personality disorder (BPD) and comorbid narcissistic personality disorder (NPD) from two international randomized controlled trials. From a combined sample of 188 patients with BPD, 25 also fulfilled criteria for a comorbid diagnosis of NPD according to DSM-IV. The BPD patients with comorbid NPD, compared to the BPD patients without comorbid NPD, showed significantly more BPD criteria (M = 7.44 vs. M = 6.55, p < .001), fulfilled more criteria of comorbid histrionic (M = 3.84 vs. M = 1.98, p < .001), paranoid (M = 3.12 vs. M = 2.27, p = .014), and schizotypal (M = 1.64 vs. M = 1.02, p = .018) personality disorders, and were more likely to meet criteria for full histrionic PD diagnosis (44.0% vs. 14.2%, p < .001). The BPD-NPD group also reported significantly fewer psychiatric hospitalizations in the previous year (M = 0.40 vs. M = 0.82, p = .019) and fewer axis I disorders (M = 2.68 vs. M = 3.75, p = .033). No differences could be found in general functioning, self-harming behavior, and suicide attempts.

The concept of personality organization (PO) is central to current psychodynamic understanding of normal personality development as well as the development of personality disorders (PDs). However, individual differences in PO have primarily been studied in adult populations, and it remains unclear whether the clinical indicators of normal, neurotic and borderline PO manifest differently during adolescence. This study aimed to address the gaps in current knowledge regarding the potentially different manifestation of pathological PO in adolescence. In addition, we wanted to further establish the validity of the adolescent version of the Inventory of Personality Organization, by identifying cut-off points for each of the main dimensions of Normal, Neurotic, and Borderline PO. Participants included 430 adolescents (M = 16 years old) from the community. Cluster analysis identified three levels of PO corresponding to Normal, Neurotic, and Borderline PO. Cut- off points between the different POs were successfully established using ROC curve analyses., (Copyright © 2018 The Foundation for Professionals in Services for Adolescents. Published by Elsevier Ltd. All rights reserved.)

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., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Patients with borderline personality disorder (BPD) show poor psychosocial functioning over the course of their lives. To date, predictors of functionality in BPD patients have remained mostly unexplored. In this study, we aimed to assess the association between personality organization and clinical and functional features in a sample of 50 patients with BPD referred to a specialized outpatient clinic. We used the Structured Interview of Personality Organization (STIPO) to assess personality organization and the Global Assessment of Functioning (GAF) scale to measure functionality. Clinical and demographic associations with personality organization were also explored. STIPO scores were negatively correlated with GAF scores (i.e. higher scores in the STIPO dimensions, which reflected greater personality pathology, were significantly associated with lower psychosocial functioning). After controlling for potential confounders, the STIPO domain "identity" significantly accounted for 26.7% of the variance in the GAF, while the STIPO subscale "sense of self" significantly accounted for 31.2% of the variance in the GAF. These findings suggest that identity and its pathological correlate, identity diffusion, may play a key role in the functional prognosis of BPD patients., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Models of personality pathology have been used to guide treatment development for patients with borderline personality disorder. The existing treatments are effective, but mechanisms of change related to the model have not been adequately explored.

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.

Background: Normal and pathological narcissism have been the focus of considerable theoretical discussion and empirical research in recent years in personality psychology and psychopathology. Kernberg [1-4] has argued that there is a particularly dysfunctional and impairing variant of narcissistic disturbance known as malignant narcissism. This exploratory study sought to develop, using established assessment methods, a dimensional measure of malignant narcissism that incorporates the key features of grandiose narcissism, paranoid propensities, psychopathic features, and proclivity for a sadistic and aggressive interpersonal style. Method and Sampling: This study examined 57 subjects, diagnosed with borderline personality disorder that were treated using 3 different empirically supported treatments in a previous study [5], for possible deviance on the proposed malignant narcissism index. It also evaluated 2 important clinical domains of change in relation to malignant narcissism. To wit, it was predicted, based on Kernberg's [3, 4] clinical model, that elevated levels of malignant narcissism would be significantly associated with slower rates of improvement in both general psychosocial/psychological functioning and anxiety among treated individuals., Results: Higher levels of malignant narcissism were associated, as predicted, with slower rates of improvement in both global functioning and anxiety. The proposed malignant narcissism index was a more powerful predictor of slowed improvement in global functioning than simple narcissistic personality disorder features., Conclusions: The heuristic potential of the malignant narcissism construct is discussed and the utility of a dimensional approach to this construct is explored, especially in reference employing personality traits/processes to better understand pathological configurations and personality disturbance., (© 2018 S. Karger AG, Basel.)

Background: Impairment in personality functioning (PF) represents a salient criterion of the DSM-5 alternative diagnostic model for personality disorders (AMPD). The main goal of this study is to analyze the relationship of the borderline personality disorder (BPD) clinical components derived from the DSM-5 categorical diagnostic model (affective dysregulation, behavioral dysregulation, and disturbed relatedness) with personality organization (PO), i.e., PF, assessed by the Structured Interview of Personality Organization (STIPO)., Methods: STIPO and the Structured Clinical Interviews for DSM-IV (SCID-I and -II) were administered to 206 BPD patients. The relationship between PO and BPD components were studied using Spearman correlations and independent linear regression analyses., Results: Significant positive correlations were observed between STIPO scores and several DSM-5 BPD criteria and comorbid psychiatric disorders. STIPO dimensions mainly correlated with disturbed relatedness and, to a lesser extent, affective dysregulation components. Each BPD clinical component was associated with specific STIPO dimensions., Conclusions: Both diagnostic models, DSM-5 BPD criteria and PO, are not only related but complementary concepts. The results of this study particularly recommend STIPO for the assessment of relational functioning, which is a major domain of the Personality Functioning Scale Levels of the DSM-5 AMPD., (© 2018 S. Karger AG, Basel.)

The impact of borderline personality pathology on facial emotion recognition has been in dispute; with impaired, comparable, and enhanced accuracy found in high borderline personality groups. Discrepancies are likely driven by variations in facial emotion recognition tasks across studies (stimuli type/intensity) and heterogeneity in borderline personality pathology. This study evaluates facial emotion recognition for neutral and negative emotions (fear/sadness/disgust/anger) presented at varying intensities. Effortful control was evaluated as a moderator of facial emotion recognition in borderline personality. Non-clinical multicultural undergraduates (n = 132) completed a morphed facial emotion recognition task of neutral and negative emotional expressions across different intensities (100% Neutral; 25%/50%/75% Emotion) and self-reported borderline personality features and effortful control. Greater borderline personality features related to decreased accuracy in detecting neutral faces, but increased accuracy in detecting negative emotion faces, particularly at low-intensity thresholds. This pattern was moderated by effortful control; for individuals with low but not high effortful control, greater borderline personality features related to misattributions of emotion to neutral expressions, and enhanced detection of low-intensity emotional expressions. Individuals with high borderline personality features may therefore exhibit a bias toward detecting negative emotions that are not or barely present; however, good self-regulatory skills may protect against this potential social-cognitive vulnerability., (Copyright © 2017 Elsevier Ireland Ltd. All rights reserved.)

Individuals high in rejection sensitivity (RS) are at risk for experiencing high levels of interpersonal distress, yet little is known about the interpersonal profiles associated with RS. This investigation examined the interpersonal problems, sensitivities, and values associated with RS in 2 samples: 763 multicultural undergraduate students (Study 1) and 365 community adults (Study 2). In Study 1, high anxious RS was associated with socially avoidant interpersonal problems, whereas low anxious RS was associated with vindictive interpersonal problems. In Study 2, we assessed both anxious and angry expectations of rejection. Circumplex profile analyses showed that the high anxious RS group reported socially avoidant interpersonal problems, sensitivities to remoteness in others, and valuing connections with others, whereas the high angry RS group reported vindictive interpersonal problems, sensitivities to submissiveness in others, and valuing detached interpersonal behavior. Low anxious RS was related to domineering interpersonal problems, sensitivity to attention-seeking behavior, and valuing detached interpersonal behavior, whereas low angry RS was related to submissive interpersonal problems, sensitivity to attention-seeking behavior, and valuing receiving approval from others. Overall, results suggest that there are distinct interpersonal profiles associated with varying levels and types of RS.

This investigation examined the moderating role of effortful control (EC) in the association between rejection sensitivity (RS) and its subsequent interpersonal distress (IP-distress) on borderline personality disorder (BPD) features. In total, 625 multicultural undergraduates (Study 1) and 562 community international adults (Study 2) completed scales evaluating EC, RS, IP-distress, and BPD features; Study 2 participants also self-reported both anxious and angry expectations of rejection. In both samples, EC moderated the mediating effect of IP-distress in the link between RS and BPD-related psychopathology. The extent to which RS was associated with BPD symptoms through increased IP-distress was greater for individuals with low EC and less so for those with high EC. Thus, low self-regulatory abilities may foster the association between RS and BPD by magnifying interpersonal distress. The implications and limitations of findings are discussed.

Background: Borderline personality disorder (BPD) is a very common illness; interpersonal problems are one of the core features. The purpose of this study was to investigate the changes in interpersonal problems after transference-focused psychotherapy (TFP)-based disorder-specific treatment and to explore whether the severity of interpersonal problems could serve as a predictor for other variables., Sampling and Methods: A sample of 37 inpatients with BPD was assessed with the Structured Clinical Interviews for DSM-IV Axis I and II Disorders (SCID I and II) and had to complete a questionnaire including the Inventory of Interpersonal Problems (IIP-C), Inventory of Personality Organization (IPO), Beck Depression Inventory (BDI), Spielberger State and Trait Inventory (STAI), Spielberger State and Trait Anger Inventory (STAXI), and Symptom Checklist-90 (SCL-90-R). After 12 weeks of TFP-based disorder-specific treatment, the patients repeated the same questionnaire; 7 patients had to be excluded from the study, and thus calculations were conducted with 30 patients., Results: After treatment, the patients showed a significant decrease in the IIP total item score and all 8 subscales except the domineering, intrusive, and cold scales. The IIP total item baseline score was correlated with borderline symptomatic and psychopathology [e.g. anxiety, Global Severity Index (GSI)] after 12 weeks as well as with most IIP postsubscales., Conclusions: Although interpersonal problems are considered one of the more stable features of BPD, our results showed a significant improvement after 12 weeks of TFP-based disorder-specific inpatient treatment, especially in the total score and the subscales on the friendly submissive level. The severity of interpersonal problems at baseline was connected to outcome values of other borderline features as well as general psychiatric complaints. It therefore seems important to consider the treatment of interpersonal problems in therapy to be of greater significance., (© 2016 S. Karger AG, Basel.)

Aims: Borderline personality disorder (BPD) is characterized by self-regulation deficits, including impulsivity and affective lability. Transference-focused psychotherapy (TFP) is an evidence-based treatment proven to reduce symptoms across multiple cognitive-emotional domains in BPD. This pilot study aimed to investigate neural activation associated with, and predictive of, clinical improvement in emotional and behavioral regulation in BPD following TFP., Methods: BPD subjects (n = 10) were scanned pre- and post-TFP treatment using a within-subjects design. A disorder-specific emotional-linguistic go/no-go functional magnetic resonance imaging paradigm was used to probe the interaction between negative emotional processing and inhibitory control., Results: Analyses demonstrated significant treatment-related effects with relative increased dorsal prefrontal (dorsal anterior cingulate, dorsolateral prefrontal, and frontopolar cortices) activation, and relative decreased ventrolateral prefrontal cortex and hippocampal activation following treatment. Clinical improvement in constraint correlated positively with relative increased left dorsal anterior cingulate cortex activation. Clinical improvement in affective lability correlated positively with left posterior-medial orbitofrontal cortex/ventral striatum activation, and negatively with right amygdala/parahippocampal activation. Post-treatment improvements in constraint were predicted by pre-treatment right dorsal anterior cingulate cortex hypoactivation, and pre-treatment left posterior-medial orbitofrontal cortex/ventral striatum hypoactivation predicted improvements in affective lability., Conclusions: These preliminary findings demonstrate potential TFP-associated alterations in frontolimbic circuitry and begin to identify neural mechanisms associated with a psychodynamically oriented psychotherapy., (© 2015 The Authors. Psychiatry and Clinical Neurosciences © 2015 Japanese Society of Psychiatry and Neurology.)

This work aims to further validate the object-relations-based model of personality pathology assessment, evaluating the psychometric properties of the Italian version of the Inventory of Personality Organization (IPO), a self-report instrument for the assessment of personality organization according to O. Kernberg's model of personality pathology. Six hundred ninety-six nonclinical volunteers and 121 psychiatric patients completed a set of questionnaires including the IPO, the Severity Indices of Personality Problems, the Borderline Personality Disorder Checklist, the Response Evaluation Measure 71, and the Symptom Checklist 90-Revised. Confirmatory factor-analyses on the IPO items supported the 1-, 2-, 3-, and 4-factor solutions. The last (Instability of sense of self/others, Instability of goals, Instability of behaviors, Psychosis) resulted in relatively better fit indexes. Invariance across samples (nonclinical, clinical) and gender was confirmed. The 4 IPO subscales showed good levels of internal coherence and, in the nonclinical sample, good test-retest reliability. Associations with the convergent measures were in line with theoretical expectations and supported the benefit of adopting a 4-factor solution. The 4 factors showed the expected criterion relations: All the dimensions discriminated between clinical and nonclinical subjects, whereas only Instability of self/others and Instability of goals discriminated patients with borderline personality disorder from patients with other diagnoses. Our results suggest that the Italian version of the IPO is a reliable and valid tool for the assessment of personality organization according to Kernberg's model. Results are discussed in the context of the current directions in the evaluation of personality disorders proposed by the Diagnostic and Statistical Manual of Mental Disorders, 5th edition., ((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).)

This study examined whether the relationship between low effortful control (EC), general psychopathology and interpersonal maladjustment previously reported among children extends to adulthood. Two hundred and forty undergraduate students were assessed using the EC scale of the Adult Temperament Questionnaire, the General Severity Index of the Brief Symptom Inventory (BSI-GSI) and the interpersonal distress index of the Inventory of Interpersonal Problems-Short Circumplex (IIP-distress). Both the BSI-GSI and the IIP-distress scores were related to low levels of EC. Furthermore, interpersonal distress mediated the association between low EC and greater psychopathology severity. These results suggest that deficits in regulatory temperament among adults may be associated with experiencing greater psychopathology distress, and that this relationship may be explained by an impairment in interpersonal adjustment. Such preliminary findings may constitute a useful starting point for investigating this hypothesis among clinical populations., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Research has linked individual differences in effortful control (EC) with variations in interpersonal functioning in children and adolescents. Using the Inventory of Interpersonal Problems-Short Circumplex (Hopwood, Pincus, DeMoor, & Koonce, 2008), this study investigated interpersonal problem profiles associated with EC in 763 nonclinical young adults. We found that individuals with low EC reported intrusive interpersonal problems and high levels of interpersonal distress, whereas individuals with high EC reported cold interpersonal problems but low levels of interpersonal distress. Results suggest that EC might play an important role in shaping interpersonal functioning.

Drawing on a sample of 372 French-Canadian couples, this study examined the factorial structure of a 20-item abbreviated version of the Inventory of Personality Organization (IPO) across a sample of couples and tested if identity diffusion, primitive defenses, and reality testing explain additional variance in couple distress when controlling for neuroticism. The IPO is based on Kernberg's conceptualization of personality organization (Kernberg, 1976 ). Gender differences were also studied through an examination of the value of both self-reported and partner-reported personality in the prediction of each partner's couple satisfaction. Results of confirmatory factor analyses indicated that the tripartite model of the short version of the IPO provided an acceptable fit and proved invariant when tested on couples. Actor-Partner Interdependence Model analyses (Kenny, Kashy, & Cook, 2006 ) showed that elevated neuroticism predicted higher endorsement of primitive defenses, which in turn predict couple dissatisfaction. There was also a direct, negative path from neuroticism to dyadic adjustment. Finally, self-reported neuroticism scores predicted high utilization of primitive defenses by the partner, and low partner-reported couple satisfaction. Furthermore, high self-reported utilization of primitive defenses predicted low couple satisfaction.

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.

The present study evaluates the psychometric properties of a therapist measure for evaluating the affective communication created between the patient and therapist during the initial stages of treatment. The Affective Communication Questionnaire (ACQ) was administered to a sample of 81 therapists, each rating a single patient, and principal component analysis indicated the measure has coherent dimensions with strong internal consistency. The construct validity of the ACQ was then established in a sample of 16 therapists rating 73 patients diagnosed with Borderline Personality Disorder (BPD). The measure was found to have a strong relationship to the related constructs of transference, countertransference, and affect experience in predicted directions. The measure also was found to have a modest relationship to independent assessments of patient functioning; most notably more negative affect was significantly related to more odd/eccentric (cluster A) and less anxious/fearful (cluster C) personality disorder symptoms, and greater narrative coherence. Differences in affective communication as a function of treatment type were also evaluated. The clinical and research implications of the findings are discussed.

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.