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•Randomized clinical trials demonstrate minimal differences between psychotherapies for borderline patients.•Transference-focused psychotherapy (TFP) is effective in randomized trials but the mechanisms of change are not clear.•Pre-treatment patient characteristics relate to improvement in TFP.•Patients in TFP manifest brain changes following treatment consistent with enhanced emotional control.

Background and Goals: Despite general agreement that personality disorders (PDs) have their roots in childhood and adolescence, diagnosing PDs in adolescence remains a topic of debate. Reluctance to diagnose PDs in youth has been supported by the paucity of adapted measures of adolescent personality and by findings suggesting that a PD diagnosis may be less stable and reliable in adolescence. However, despite the reported instability of categorically defined diagnoses, there is increasing evidence that early maladaptive personality traits are predictive of future personality functioning. A more dimensional approach for the assessment of personality pathology in adolescence as well as new assessment measures are thus needed. The aim of this study was to examine the psychometric properties of the adolescent version of the Inventory of Personality Organization (IPO-A), a measure that allows both a categorical and dimensional approach to personality assessment. Moreover, potential differences between adolescents and young adults regarding specific dimensions of personality organization were investigated. Method: Participants included 430 adolescents (M = 16 years old) and 448 young adults (M = 24 years old) from the community. Exploratory structural equation modeling analyses were conducted on both samples. Results: Results suggest that the IPO-A is a valid and reliable instrument for assessing personality functioning in adolescents. Adolescents also reported significantly higher scores on four of the five dimensions, indicating more severe identity disturbance; more impaired reality testing; more aggression; and poorer moral functioning than adults. Significant differences were also observed among adolescents of different age groups as well as between boys and girls in terms of the five identified factors of the IPO-A. Adolescent girls experienced significantly more difficulties with regard to an unstable sense of self and others, and had poorer moral functioning than adolescent boys. Conclusion: From a developmental point of view, a narcissistic reaction may be solicited in the context of the developmental challenges of adolescence and emerging adulthood, which may not necessarily be a part of an enduring stance and pathological narcissism.

AbstractResearch has consistently found high rates of comorbidity between narcissistic personality disorder (NPD) and borderline personality disorder (BPD). Patients with this complex clinical presentation often present formidable challenges for clinicians, such as intense devaluation, entitlement, and exploitation. However, there is a significant gap in the literature in identifying the clinical characteristics of these NPD/BPD patients. In this article, we present recent research describing patients with comorbid NPD/BPD, as compared with patients with BPD without NPD (BPD), from two randomized clinical trials for the treatment of borderline personality disorder, with a particular emphasis on attachment status and mentalization. We anchor our discussion of these patients in object relations and attachment theory, and we describe our treatment approach, transference focused psychotherapy (TFP). We conclude by using case material to illustrate our research findings, highlighting the significant differences between patients with NPD/BPD and BPD/non-NPD in terms of their attachment classification.

In diesem Artikel wird eine deutschsprachige Kurzskala des Inventars der Persönlichkeitsorganisation (IPO-16) vorgestellt und in drei klinischen Stichproben mit insgesamt 1300 Personen validiert. Das IPO ist ein international verbreitetes Selbsteinschätzungsinstrument, das in mehreren Versionen vorliegt und zur Erfassung von struktureller Beeinträchtigung in den Bereichen Identität, Abwehr und Realitätsprüfung eingesetzt wird. Die Kurzskala basiert auf 16 versionsübergreifenden IPO-Items und misst den Schweregrad der strukturellen Beeinträchtigung. In den Studien konnte gezeigt werden, dass das IPO-16 (1) intern konsistent ist, (2) eine modellkonforme Faktorenstruktur hat, (3) eine sehr hohe Überlappung zur IPO-Vollversion aufweist, (4) in der Selbsteinschätzung über konvergente und diskriminante Validität verfügt, (5) den Schweregrad der Persönlichkeitsstörung aus Expertensicht unabhängig vom aktuellen Leidensdruck vorhersagt und (6) eine diagnostische Effizienz erreicht, die mit anderen Screening-Instrumenten im Bereich der Persönlichkeitsstörungsdiagnostik vergleichbar ist. Mit dem IPO-16 liegt für den deutschsprachigen Raum erstmals ein ökonomisches und gut validiertes Selbsteinschätzungsinstrument zur Erfassung von struktureller Beeinträchtigung vor.

This paper describes a specific psychoanalytic psychotherapy for patients with severe personality disorders, its technical approach and specific research projects establishing empirical evidence supporting its efficacy. This treatment derives from the findings of the Menninger Foundation Psychotherapy Research project, and applies a model of contemporary psychoanalytic object relations theory as its theoretical foundation. The paper differentiates this treatment from alternative psychoanalytic approaches, including other types of psychoanalytic psychotherapy as well as standard psychoanalysis, and from three alternative non‐analytical treatments prevalent in the treatment of borderline patients, namely, dialectic behavior therapy, supportive psychotherapy based on psychoanalytic theory, and schema focused therapy. It concludes with indications and contraindications to this particular therapeutic approach derived from the clinical experience that evolved in the course of the sequence of research projects leading to the empirical establishment of its efficacy.

This paper describes a specific psychoanalytic psychotherapy for patients with severe personality disorders, its technical approach and specific research projects establishing empirical evidence supporting its efficacy. This treatment derives from the findings of the Menninger Foundation Psychotherapy Research project, and applies a model of contemporary psychoanalytic object relations theory as its theoretical foundation. The paper differentiates this treatment from alternative psychoanalytic approaches, including other types of psychoanalytic psychotherapy as well as standard psychoanalysis, and from three alternative non‐analytical treatments prevalent in the treatment of borderline patients, namely, dialectic behavior therapy, supportive psychotherapy based on psychoanalytic theory, and schema focused therapy. It concludes with indications and contraindications to this particular therapeutic approach derived from the clinical experience that evolved in the course of the sequence of research projects leading to the empirical establishment of its efficacy.

AbstractThis study investigates predictors of health service utilization in individuals with cluster B personality disorders. We hypothesized an association of severity of psychopathology (that is, global psychosocial functioning and psychiatric comorbidity) and attachment style with the length of medical hospitalizations in this population. Forty-one female subjects were interviewed regarding their diagnoses, level of functioning and service utilization. Attachment style was assessed with a self-report questionnaire. Our findings indicate that degree of psychiatric comorbidity and level of psychosocial functioning do not predict length of hospital stays, whereas preoccupied attachment predicted 23.9% of the variance in the length of hospitalizations. We conclude that the quality of interpersonal relatedness appears to be a better predictor of health service use than severity of pathology in patients with cluster B personality disorders.

AbstractImpulsivity has been repeatedly identified as a key construct in BPD; however, its precise definition seems to vary especially regarding the overlap with aggression. The term impulsive-aggression, also generally seen as central to an understanding of BPD, seems to address itself to the interface between the two, but has itself been used inconsistently in the literature, sometimes having reference to a unitary phenotypic dimension, and at other times suggesting some combination of distinct traits. This study examined the relationship between multiple measures of impulsivity, aggression, and impulsive-aggression in a BPD sample (N= 92) in order to clarify the relationship between these measured constructs in this clinical population. Results show little relationship between measures of aggression and impulsivity in BPD, with measures of impulsive-aggression correlating strongly with measures of aggression only. Implications of the present results for future research and clinical work with BPD are discussed.

AbstractIt is argued that borderline personality disorder (BPD) represents the interaction of underlying neurobehavioral systems that are reflected principally in the phenotypic constructs of positive emotion, negative emotion, and nonaffective constraint (Depue & Lenzenweger, 2001). This preliminary and exploratory study sought to examine predictions made from the Depue–Lenzenweger model with respect to controlled (effortful) information processing in BPD. It was hypothesized that (a) BPD subjects may display deficits on tasks that require controlled information processing (sustained attention, spatial working memory, and executive functioning), (b) they may reveal elevated negative emotion as well as decreased positive emotion and nonaffective constraint, and (c) nonaffective constraint should be substantially inversely associated with accurate performance on controlled information processing tasks. The results of this study, which examined 24 BPD diagnosed individuals and 68 normal adults, found support for each of these predictions in relation to performance on the Wisconsin Card Sorting Test. The implications of these results for further experimental psychopathology investigations of BPD as well as further refinement of theoretical models of the disorder are discussed.

AbstractThe Personality Disorder Institute/Borderline Personality Disorder Research Foundation randomized control trial (PDI/BPDRF RCT) is a controlled outcome study for borderline personality disorder (BPD), in which 90 participants were randomized to one of three manualized and monitored, active psychosocial treatment conditions. These treatments are: (a) Transference-Focused Psychotherapy (TFP; Clarkin, Yeomans, & Kernberg, 1999), a treatment for BPD based on object-relational and psychoanalytic principles first applied to BPD by Kernberg (1996), notable for its particular emphasis on interpretation of object relations activated in the ongoing therapeutic relationship; (b) Dialectical Behavior Therapy (DBT; Linehan, 1993), a popular treatment for BPD, with evidence of efficacy (Linehan, Armstrong, Suarez, Allmon, & Heard, 1991) that emphasizes a balance between acceptance and change in its combination of cognitive-behavioral and Zen principles; and (c) supportive psychotherapy (Rockland, 1992), another object-relational and psychoanalytically based treatment for BPD which, in contrast to TFP, eschews transference interpretation and places primary emphasis on development of a collaborative engagement with the patient to foster identity development. Patients received medication, if clearly indicated, according to the treatment algorithm developed by Soloff (2000). This article describes the significance and rationale of the study and the overall design, methods, plan of analysis, and demographic characteristics of the recruited sample of patients.

AbstractThis study examines the effectiveness of a modified psychodynamic treatment called Transference Focused Psychotherapy (TFP) designed specifically for patients with borderline personality disorder (BPD). Twenty-three female patients diagnosed with DSM-IV BPD began twice-weekly TFP. Patients were assessed at baseline and at the end of 12 months of treatment with diagnostic instruments, measures of suicidality, self-injurious behavior, and measures of medical and psychiatric service utilization. Compared to the year prior to treatment, the number of patients who made suicide attempts significantly decreased, as did the medical risk and severity of medical condition following self-injurious behavior. Compared to the year prior, study patients during the treatment year had significantly fewer hospitalizations as well as number and days of psychiatric hospitalization. The dropout rate was 19.1%. This uncontrolled study is highly suggestive that this structured and manualized psychodynamic treatment modified for borderline patients shows promise for the ambulatory treatment of these patients and warrants further study.

Psychodynamic psychotherapy, a field that once lagged behind other areas in psychiatry with regard to empirical studies, has gone through a culture change. Methods of research that were once felt to be, at best, an awkward fit with psychodynamic therapy are being applied with positive results. Major efforts have been made in instrument development, the manualization of therapies, and process and outcome studies. There is also increasing dialogue with other fields, such as neurobiology, reflecting sophisticated attempts to link a psychodynamic understanding of pathology and treatment to physiological underpinnings. This review discusses the large variety of current research efforts and highlights some important recent developments.

Studies have suggested that family burden adversely affects clinical outcome in the major mental disorders. Logistic regression analysis was used to evaluate the effect of family burden reported at baseline (acute model), or 7 months (stabilization model), on the risk of having a subsequent affective episode, in a sample of 264 patients with Research Diagnostic Criteria-diagnosed bipolar illness. Higher levels of baseline burden and a depressive index episode significantly increased the risk for a major episode at 7 months. Higher 7-month burden significantly increased the risk for a major episode at 15 months among patients with relatively low 7-month BPRS symptom levels. Caregiver burden reported at times of symptom relapse and during stabilization predicts subsequent adverse clinical outcomes among patients with bipolar disorder and suggests a need for family support.

Structured clinical interviews of 107 female inpatients diagnosed with borderline personality disorder (BPD) were used to determine whether antisocial personality disorder (APD) diagnostic criteria evident prior to age 15 could be used to predict current Axis I and Axis II psychopathology. Diagnostic information was gathered using the Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II) and the Structured Clinical Interview for DSM-III-R——Patient Version (SCID-P). Childhood APD criteria were subjected to principal-components analysis, and three factors——rule-breaking, assault, and sadism——emerged. The severity of the childhood APD criteria was related to psychotic symptoms, as well as to the unstable relationships and labile affect BPD criteria and the current overall severity of BPD criteria. Sadism predicted psychotic symptoms and BPD severity, while rule-breaking predicted unstable relationships and BPD severity. Childhood APD severity also had a larger effect on BPD severity than on psychotic symptoms. Possible explanations for these findings are explored and discussed.

The personality disorders, having become officially recognized disorders separate from the symptom disorders with the arrival of DSM-III, are prevalent and debilitating conditions that require therapeutic intervention. However, research on the treatment of these disorders has been hampered by the multitude of complex and difficult issues of client heterogeneity, early dropout from treatment, length of treatment needed, manualization of therapies, and measurement of change. The existing research findings are reviewed, with an eye to the clinical implications in the treatment of these clients at this point in time. © 1999 John Wiley & Sons, Inc.

Structured clinical interviews of 63 female inpatients diagnosed with borderline personality disorder were used to study the relations of comorbid mood disorders to treatment response. Diagnostic information was gathered using the Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II) and the Structured Clinical Interview for DSM-III-R-Patient Version (SCID-P). Information about psychotic symptoms was also based upon responses to the SCID-P. Treatment response was assessed through weekly ratings on the Symptom Checklist-90-Revised over 25 weeks of hospitalization. Initial depression but not initial or previous bipolar disorder was found to predict treatment course. Initial psychotic symptoms were also found to predict treatment course among patients with initial bipolar disorder and tended to modify the trajectory of symptoms over time among patients with initial depression. Possible explanations for these findings are explored and discussed.

The NEO Personality Inventory was given to 33 married patients with bipolar disorder. Consistent with previous findings, patients with bipolar disorder did not show an abnormal personality profile as a group. Extremely wide variation on all scales indicated that the group profile tells little about individual patients. Trait neuroticism robustly predicted psychiatric symptoms at entry to the study when assessed retrospectively for the two years prior to entry and when averaged over a year of treatment. Neuroticism also negatively predicted the self-confidence of the patients in this sample. The patients identified as outliers on neuroticism form a clinically difficult group for whom the distinction between Axes I and II appears to be less meaningful.

This article reviews the empirical evidence supporting the role of psychotherapy and psychosocial interventions in the treatment of patients with depression. Treatment models and the evidence for their effectiveness in the acute- and maintenance-treatment phases are reviewed. Whereas the sophistication of research designs and data analysis for the study of psychotherapy have substantially improved, the review highlights current gaps in our knowledge. Most important for reform of the health care system is the need for studies of efficacy to lead to large-scale investigations of effectiveness.

• Although family intervention is practiced in most psychiatric hospitals, there are no adequately controlled studies of its efficacy. This study was designed to answer, in part, the following question: What is the relative efficacy of hospitalization with family intervention as compared with hospitalization without family intervention for patients with major psychiatric disorders who are in need of hospital treatment and for whom both treatments are judged clinically feasible? This is our first report, presenting preliminary data on six-month follow-up for the first three quarters of the total sample of 144 patients (80 with schizophrenic disorder and 64 with major affective disorder).

• As part of each evaluation, the clinician must decide whether or not a psychiatric treatment is indicated. It is unfortunate that there is little available research to aid in this decision, and it has not received much attention in the clinical literature. In actual practice, therapists tend to recommend treatment almost automatically and without a careful consideration of its necessity or possible harmful effects. The research methodology and problems in defining those patients who are better off without psychiatric treatment is discussed. This group is categorized into negative responders and nonresponders and spontaneous improvers. A set of preliminary criteria for no treatment and clinical examples are provided.

This paper illustrates the advantages of time series analysis in documenting treatment effects through a case study of a trial of fluoxetine in a borderline woman being treated in a long-term inpatient unit for severe personality disorders. Data consisted of weekly self-reports of symptomatology over 58 weeks of hospitalization. Intervention analysis carried out after the patient was discharged documented the effectiveness of the medication and the differential timing of response in individual symptoms.

Recent revisions of the psychodiagnostic nomenclature have relied on the specification of explicit criteria and decision rules for psychiatric diagnosis. Although both features have contributed to the increased reliability of psychiatric diagnosis, most empirical attention has been devoted to establishing the reliability of the criteria and the diagnoses, and relatively scant attention has been paid to the development of procedures for the optimization of the decision rules. The present report combines data from four independent studies of borderline personality disorder to illustrate a strategy for the optimization of psychodiagnostic decision rules which rely on polythetic criteria. The strategy considers the relationships among the criteria and the joint conditional probability structure of criteria combinations in optimizing the decision rule for the diagnosis. The advantages to the clinician, researcher, and theoretician of this, or any other, attempt to optimize the decision rules are discussed.

This article reviews and integrates the previous articles under central concerns facing the field about the treatment of patients with borderline personality disorder. Since borderline is a heterogenous category, various authors have isolated treatment-relevant subgroups. One approach to structuring treatment with these impulsive and chaotic patients is to begin with an explicit treatment contract. The choice of treatment tactics and techniques is related to the types of outcomes conceptualized by the various orientations. Finally, the therapist training needed to work with this patient population is examined. © 1998 John Wiley & Sons, Inc.

Charts of 76 adolescents, who had been recently discharged from a psychiatric hospital, were reviewed by a research team for evidence of DSM-III axis I and axis II disorders. Research diagnoses were assigned to patients on the basis of documented symptomatology and irrespective of the discharge diagnosis of the clinical staff. Forty-five patients met criteria for an affective disorder. Of these, 15 were diagnosed major depression and 24 dysthymia or atypical depression (i.e., dysthymia of briefer duration than 1 year). Two patients were manic, one was bipolar depressed, one was schizoaffective, and two were atypical depressed with psychotic features. No patient with dysthymia had a past history of major depression as the earliest manifestation of psychiatric disorder. Four patients with major depression, however, had past histories of dysthymia as the earliest manifestation of psychiatric disorder. Forty per cent of patients with major depression had parents with depression. Excepting one schizophrenic, every patient who had ever attempted suicide met criteria for a depressive disorder.

• Although family intervention is practiced in most psychiatric hospitals, to our knowledge, no adequately controlled studies of its efficacy exist. This study was designed to answer, in part, the question of the relative efficacy of hospitalization with family intervention as compared with hospitalization without family intervention for patients (1) with major psychiatric disorders, (2) in need of hospital treatment, and (3) for whom both treatments are judged clinically feasible. This article compares treatment results at the time of hospital discharge for 169 patients randomly assigned to the Inpatient Family Intervention or comparison conditions. Inpatient Family Intervention had greater efficacy than the comparison treatment, mostly attributable to its effect on female patients, especially those patients (and their families) with affective disorder.

This study examined the course of 40 hospitalized female borderline personality disorder patients over 25 weeks of inpatient treatment. Course was measured through weekly administration of the SCL-90-R. Level of identity and interpersonal problems, hypothesized by Kernberg to be at the center of the borderline patient’s pathology, were found to be powerful predictors of treatment course. Patients with the most severe identity and interpersonal problems reported more symptoms throughout treatment and increasing symptom levels over time. This was very different from patients with the lowest level of identity and interpersonal problems, who reported fewer symptoms overall and decreasing symptoms over time.

Since the DSM-III-R Axis II borderline personality disorder (BPD) is a polythetic categorization, it is both theoretically and clinically important to examine the covariation of the eight BPD criteria. Seventy-five hospitalized female borderline patients were interviewed with an expanded SCID-II and given dimensional ratings on each of the borderline criteria. These dimensional data were used to factor analyze the criteria, and three factors emerged. The first factor reflected identity problems and interpersonal difficulties. A second factor included affect difficulties and self-harm, and a final factor was composed of only the impulsivity criterion. Results are discussed in terms of implications for treatment planning and future work on construct validity.

• This study critiques and extends the DSM-III use of fixed and explicit criteria by applying principles and statistics common within actuarial decision theory (eg, conditional probabilities). The value and limitations of sensitivity and specificity rates are discussed and compared with an interesting but rarely used statistic, positive predictive power. The statistics and analyses provided herein also provide an empirical method for developing diagnostic criteria and determining when and how the DSM-III cutoff points might be adjusted, recognize the importance of base rates and utilities to efficient diagnosis, and provide an explicit, quantitative means by which to make optimal differential diagnoses and to make use of the overlap among psychiatric diagnoses. The issues are illustrated in the differential diagnosis of the Borderline Personality Disorder, but they have a relevance to the development and application of the other DSM-III diagnoses.

No abstract.

The editors have compiled a useful and timely volume. It is useful because it brings together some of the more important theories of personality disorder in a single volume, thereby facilitating comparison and analysis. The editors express the hope that this will fill the conceptual and theoretical void in the study of personality disorder. It is timely because the study of personality disorder is at an interesting juncture; after a period of steady growth, the field seems to lack direction. The editors suggest that the field is progressing to a second stage of its development in which greater emphasis is placed on etiology and development. The problem that the field faces is that the impetus and conceptual support for recent empirical work was largely provided by the DSM-III. The decision to classify personality disorders on a separate axis drew attention to the importance of personality disorder and promoted interest in

THE ARTICLE by Horowitz and colleagues1 is most helpful in defining and illustrating some of the difficulties facing clinical researchers who are investigating psychodynamic constructs and psychotherapy. Horowitz et al rightly point out the gap between symptoms and the in-therapy focus on psychotherapeutic intervention. Even when the final goal of treatment is symptom reduction, eg, reduction in depression, the various schools of psychotherapy approach this final goal with quite different mediating goals of treatment. How to measure these mediating goals is extremely important to the advancement of the field. Horowitz and colleagues attempt to bridge dynamic and cognitive-behavioral constructs and to measure these constructs in a reliable manner.See also pages 625, 633, 637, 639, 642, 646, 649, 651, and 654Horowitz and colleagues' own work highlights some of the difficulties they and others have faced. Is their method reliable? The data suggest that it is reliable, although one

There is a small but growing amount of empirical literature on the occurrence, nature, and impact of personality disorders in elderly individuals.Recent work has concentrated on extending longitudinal studies into late life, and the presence and impact of personality disorders in elderly who are depressed and cognitively compromised.