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This study examined the effects of trial therapy interviews using intensive short-term dynamic psychotherapy with 500 mixed sample, tertiary center patients. Furthermore, we investigated whether the effect of trial therapy was larger for patients who had a major unlocking of the unconscious during the interview compared with those who did not. Outcome measures were the Brief Symptom Inventory (BSI) and the Inventory of Interpersonal Problems (IIP), measured at baseline and at 1-month follow-up. Significant outcome effects were observed for both the BSI and the IIP with small to moderate preeffect/posteffect sizes, Cohen's d = 0.52 and 0.23, respectively. Treatment effects were greater in patients who had a major unlocking of the unconscious compared with those who did not. The trial therapy interview appears to be beneficial, and its effects may relate to certain therapeutic processes. Further controlled research is warranted. [ABSTRACT FROM AUTHOR]

The current study examined how techniques in a psychodynamic model of therapy (Blagys and Hilsenroth, Clin Psychol Sci Pract. 7, 167-188, 2000) were related to changes in anxiety symptoms across early treatment process among a transdiagnostic sample of patients with primary anxiety disorder, subclinical anxiety disorder, and no anxiety disorder. Secondary analyses examined the use of specific psychodynamic techniques in relation to symptom change. Results revealed that therapists' use of psychodynamic-interpersonal (PI) techniques were significantly and directly related to changes in anxiety symptoms, in line with previous findings (Pitman, Slavin-Mulford, and Hilsenroth, J Nerv Ment Dis. 202, 391-396, 2014). In addition, patients with co-occurring axis I and II disorders demonstrated positive changes in anxiety symptoms regardless of level of PI technique used, whereas patients without co-occurring disorders experienced greater improvement with more PI. Implications for transdiagnostic treatment protocols for anxiety, notably Leichsenring and Salzer's (Psychotherapy 51, 224, 2104) Unified Psychodynamic Protocol for Anxiety Disorders, are discussed in relation to the current findings. [ABSTRACT FROM AUTHOR]

Background This study assessed the incremental validity of the Personality Inventory for DSM-5 (PID-5) beyond the impact of demographic, burden of illness, five-factor model of personality, and DSM-5 personality disorder criteria with respect to associations with admission psychiatric symptoms and functional disability. Methods Psychiatric inpatients ( N = 927) were administered the Big Five Inventory, PID-5, and personality disorder criteria counts. Prior treatment utilization, as well as baseline depression, anxiety, emotion regulation, and functional disability were administered within two days of the personality measures. Hierarchical regression models were used to explore the association of personality functioning with symptom functioning, emotion regulation and disability. Results Neuroticism was associated with all symptom measures, providing further support for its relevance in clinical populations. Personality trait domains (negative affect, detachment, and psychoticism) from the PID-5 demonstrated incremental validity in predicting baseline symptom and disability functioning over and above demographic, burden of illness, and psychiatric comorbidity and five-factor model (FFM) personality traits. Conclusions Dimensional measures of personality functioning were consistently associated with baseline symptom functioning, supporting the relevance of personality functioning as it relates to psychiatric symptoms. The PID-5 uniquely contributed to the prediction of baseline symptom functioning, thus providing incremental validity over gold-standard personality trait measures. [ABSTRACT FROM AUTHOR]

Objective: Entrenched interpersonal difficulties are a defining feature of those with personality dysfunction. Evening treatment—a comprehensive and intensive group-oriented outpatient therapy program—offers a unique approach to delivering mental health services to patients with chronic personality dysfunction. This study assessed change in interpersonal problems as a key outcome, the relevance of such change to future social functioning, and the influence of early group processes on this change.Method: Consecutively admitted patients (N = 75) to a group-oriented evening treatment program were recruited; the majority were diagnosed with personality disorder. Therapy outcome was represented by scores on the Inventory of Interpersonal Problems. Follow-up outcome was represented by the global score of the Social Adjustment Scale. Group climate, group cohesion, and the therapeutic alliance were examined as process variables.Results: Patients experienced substantial reduction in distress associated with interpersonal problems; early process factors that reflected a cohesive and engaged group climate and stronger therapeutic alliance were predictive of this outcome. Improvement in interpersonal distress was predictive of global social functioning six months later. The therapeutic alliance most strongly accounted for change in interpersonal problems at posttreatment and social functioning at follow-up.Conclusions: A comprehensive and integrated outpatient group therapy program, offered in the evening to accommodate patients’ real-life demands, can facilitate considerable improvement in interpersonal problems, which in turn influences later social functioning. The intensity and intimacy of peer interactions in the therapy groups, and a strong alliance with the program therapists, are likely interacting factors that are particularly important to facilitate such change. [ABSTRACT FROM PUBLISHER]

Background: Cluster B personality disorders (PDs) are prevalent mental health conditions in the general population (1%-6% depending on the subtype and study). Affected patients are known to be heavier users of both mental and medical health care systems than patients with other clinical conditions such as depression.Methods: Several rates were estimated using data from the integrated monitoring system for chronic diseases in the province of Quebec, Canada. It provides a profile of annual and period prevalence rates, mortality rates, and years of lost life as well as health care utilisation rates for Quebec residents. All Quebec residents are covered by a universal publicly managed care health plan. It is estimated that the monitoring system includes 99% of Quebec's 8 million inhabitants.Results: Quebec residents aged 14 years and older were included in the study. The lifetime prevalence of cluster B PDs was 2.6%. The mean years of lost life expectancy were 13 for men and 9 for women compared to the provincial population. The 3 most important causes of death are suicide (20.4%), cardiovascular diseases (19.1%), and cancers (18.6%). In 2011 to 2012, 78% had consulted a general practitioner and 62% a psychiatrist, 44% were admitted to an emergency department, and 22% were hospitalised.Conclusions: Considering mortality, cluster B personality disorder is a severe condition, is highly prevalent in the population, and is associated with heavy health care services utilisation, especially in emergency settings. [ABSTRACT FROM AUTHOR]

Objective: The study examined inpatient treatment for major depressive disorder (MDD) when it is complicated by comorbid personality disorder.Methods: In this descriptive analysis of a large data sample from 2013 (German VIPP data set) of 58,913 cases from 75 hospitals, three groups were compared: patients with MDD, patients with MDD and a comorbid personality disorder, and patients with a main diagnosis of personality disorder.Results: Compared with MDD patients, those with comorbid personality disorder had higher rates of recurrent depression and nearly twice as many readmissions within one year, despite longer mean length of stay. Records of patients with comorbidities more often indicated accounting codes for "complex diagnostic procedures," "crisis intervention," and "constant observation." Patients with comorbid disorders differed from patients with a main diagnosis of personality disorder in treatment indicator characteristics and distribution of personality disorder diagnoses.Conclusions: Personality disorder comorbidity made MDD treatment more complex, and recurrence of MDD episodes and hospital readmission occurred more often than if patients had a sole MDD diagnosis. [ABSTRACT FROM AUTHOR]

Working with women in secure services is an infrequent subject of research and discussion in the forensic mental health literature. There are several reasons for this, which will be considered in the introduction to this paper. However, a consequence of this situation is that there remains a lack of clarity in key areas of practice in relation to working with women in secure services, and working with women with personality disorder specifically: how women with personality disorder may present in secure services compared to men, therefore, the particular skills required of the practitioners who work with women and the main design features of the services within which they are managed. The body of this paper attempts to summarise important issues in each of these areas in order to inform future debate and developments in the field. [ABSTRACT FROM PUBLISHER]

Offenders with personality disorders (PDs) and the crimes that they have committed are regularly associated with emotional deficits. A renewed focus in forensic treatment is the use of experiential techniques: techniques that have a strong focus on eliciting emotions. However, there is little empirical evidence on the effectiveness of experiential techniques in forensic clients with PDs. In our pilot study, we examined whether three experiential drama therapy interventions are effective in evoking emotional vulnerability and anger in nine offenders with cluster B PDs, that is, clients with DSM-IV Antisocial, Borderline, or Narcissistic PDs. We used a 5 session drama therapy protocol that consisted of an introduction session, a general experiential session, a session to evoke emotional vulnerability, a session to evoke anger, and a wrap-up session. Emotions were assessed using the Mode Observation Scale. Participants showed significantly more emotional vulnerability within all three experiential invention sessions, comparing peak mood after the experiential intervention was initiated to baseline mood. In contrast, clients did not show more anger after the session to evoke anger, or in the other two experiential sessions. Our findings, though preliminary, suggest that experiential drama therapy methods may be effective in evoking vulnerable emotional states in forensic clients with cluster B personality disorders. We discuss the clinical implications of these findings. [ABSTRACT FROM AUTHOR]

Purpose The purpose of this paper is to examine the levels of clinician burnout in a community forensic personality disorder (PD) service, and explores how burnout may arise and be minimised within a service of this nature.Design/methodology/approach A mixed methods approach was utilised, assessing levels of burnout and making comparisons with a comparable previous study. Focus group data regarding burnout and suggestions for reducing the risk of burnout were analysed using thematic analysis.Findings Levels of burnout were generally found to be higher in the current sample when compared with the generic PD services. Qualitative data suggest that working in a forensic PD setting may pose a range of additional and complex challenges; these are explored in detail. Minimising burnout might be achieved by developing resilience, utilising humour, team coherence and ensuring that breaks are taken, and developing one’s own strategies for “releasing pressure”.Practical implications The risk for burnout in clinicians working with offenders with PD may be higher than other groups of mental health clinicians. Despite this, attempts to minimise burnout can be made through a range of practical strategies at the individual, team and organisational level.Originality/value This is the first project to assess levels of burnout specifically in a team of clinicians working with offenders with PD, and offers an exploration of how burnout may manifest and how it can be managed in this unique area of mental health. [ABSTRACT FROM AUTHOR]

Objective: This study used administrative data to identify characteristics of frequent users of Singapore's largest specialized psychiatric emergency department (ED). Qualitative interviews were conducted to understand staff opinions of frequent visitors.Methods: Data were from administrative records of all adult visits to the ED (N=16,123 visits of 10,108 individual users) in 2014. Random-effects logistic regressions were used to identify demographic and diagnostic characteristics of frequent visitors. To facilitate interpretation of administrative data in a convergent mixed-methods study design, interviews were conducted with 26 service providers who worked in the ED.Results: Frequent use was defined as five or more visits in 2014. This cutoff distinguished the top 3% of users (N=331), and this group accounted for 16% of service use. Frequent users were more likely to have a diagnosis of a psychotic disorder, personality disorder, or alcohol use disorder. Service provider groups (for example, physicians, nurses, and assistants) described similar groups of frequent users and noted that frequent use was related to lack of social supports outside the hospital and feelings of belonging within it. The most frequently cited challenges were managing intoxicated service seekers, managing expectations for admission, and dealing with threats of self-harm.Conclusions: The profiles of frequent ED users in Singapore resembled those reported in other large urban centers. The opinions of service providers and their reactions to difficult situations were similar to those of providers in nonpsychiatric settings. The service providers' perspectives highlight how societal pressures influence the way in which individuals with mental illnesses use services. [ABSTRACT FROM AUTHOR]

Schema therapy (ST) is an evidence-based treatment for personality disorders (PDs). The first research into ST with older adults in a short group format demonstrated its applicability for this population, although with lower efficacy than in younger age groups. This raises the question whether ST can be optimized for older adults. Therefore we conducted a mixed quantitative/qualitative case study of individual ST of a 65-year-old man with a cluster C PD to explore possible adaptations of ST for older adults. We assessed symptomatic distress, early maladaptive schemas, PD diagnosis, and the quality of the working alliance. The patient improved on these parameters and no longer met PD criteria. Five domains of adaptations emerged for possibly enhancing the outcome of ST for older adults: the ST language, the case conceptualization diagram, imagery rescripting, chairwork, and contextualizing to a life span perspective by incorporating wisdom enhancement and reinforcing positive schemas. [ABSTRACT FROM AUTHOR]

Background: The current case-control study compared rates of clinically significant and reliable change in psychopathology and global functioning, prevalence of clinical deterioration, and rates of symptom remission among adult patients with obsessive compulsive personality disorder OCPD (n=52) and well-matched inpatients with any other personality disorder (n=56) and no personality disorder (n=53).Methods: Propensity score matching (PSM) was utilized to select patients matched on specific criteria present in the OCPD group. Multivariate analysis of variance models measured differences in admission functioning and RCI change across depression and anxiety severity, emotion dysregulation and suicidal ideation.Results: Patients diagnosed with OCPD admit to treatment with higher rates of depression, anxiety, difficulty with emotion regulation and non-acceptance of emotional experience than inpatient controls. Furthermore, OCPD patients respond to treatment at a similar rate to inpatient controls, but experience lower rates of anxiety remission upon discharge. Post-hoc analyses indicate individuals meeting stubbornness and rigidity (OCPD Criteria 8) were nine times more likely to report moderate to severe anxiety at point of discharge.Limitations: Limitations include a predominantly Caucasian, inpatient sample, use of self-report measures and a non-manualized treatment approach.Conclusions: Overall, OCPD inpatients benefit from an intensive multimodal psychiatric treatment, but experience more anxiety than non-PD patients upon discharge. [ABSTRACT FROM AUTHOR]

This study evaluated how change in posttraumatic stress disorder (PTSD) symptoms was associated with residualized change in comorbid personality disorder (PD) features and vice versa over the course of 5-10 years. The sample was comprised of 79 female rape survivors who met criteria for PTSD and who were a part of a larger study examining the effects of trauma-focused therapy. PTSD was assessed with the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) version of the Clinician-Administered PTSD Scale [CAPS-IV (1)] and PD features were assessed with the DSM-IV dimensional PD scales on the Schedule for Non-adaptive and Adaptive Personality [SNAP (2)]. PTSD symptom severity and PD features were assessed at baseline and between 5 and 10 years after completing treatment. Multiple regression analyses revealed that PTSD symptom change was related to residualized change in PD severity for paranoid, schizotypal, antisocial, borderline, avoidant, and dependent PD (ßs ranged from -0.23 to -0.33; all ps < 0.05). In addition, for borderline and antisocial PDs, longitudinal stability of the PD was attenuated among those with greater PTSD symptom improvement (i.e., the relationship between these PDs over time was altered as a function of PTSD symptom change; ßs ranged from -0.27 to -0.29; all ps < 0.05). Similarly, change in severity of paranoid, schizotypal, antisocial, avoidant, and obsessive-compulsive (OC) PD was associated with residualized change in PTSD symptoms (βs ranged from -0.32 to -0.41; all ps < 0.05), and the longitudinal stability of PTSD was attenuated as a product of change in OC PD (β = -0.27; p < 0.02). These findings suggest that these two sets of disorders may impact one another substantially, altering the course of even chronic, characterological conditions. This carries important clinical implications for the treatment of both PTSD and PDs. [ABSTRACT FROM AUTHOR]

Objectives: Outpatient group psychotherapy is frequent within specialist services, recruits a mixed population, but effects are poorly documented. This study investigates long‐term outcomes for patients with personality disorder (PD) treated in outpatient, psychodynamic groups within secondary mental health service. Methods: A naturalistic study (N = 103) with repeated assessments of process and clinical outcomes. Longitudinal statistics are linear mixed models. Results: The main PDs were avoidant, borderline and NOS PD, mean number of PDs 1.4(SD0.7), 60% females and mean initial age 38(SD10) years. Mean treatment duration was 1.5(SD 0.9) years. Therapist alliance and experienced group climate was satisfactory and stable. Improvements were significant (symptom distress, interpersonal problems, occupational functioning and additional mental health services), irrespective of general PD‐severity, but not of PD‐type, age or gender. The study demonstrates PD NOS benefits across all outcomes, occupational improvements for avoidant PD, despite prevailing symptoms, but generally poorer outcomes for males and age >38 years. For borderline PD, experienced conflict was stronger, treatment duration shorter and outcomes poor for early drop‐outs (28%). Conclusion: Psychodynamic group psychotherapy is a recommendable treatment for moderate PDs, which may address avoidant strategies, but may not meet clinical challenges of borderline PD. The outcome differences related to gender and age are noteworthy. Copyright © 2016 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background: Several studies have evaluated the (cost) effectiveness of schema therapy for personality disorders, but little research has been done on the perspectives of patients and therapists. Aim: The present study aims to explore patients’ and therapists’ perspectives on schema therapy. Method: Qualitative data were collected through in-depth semi-structured interviews with 15 patients and a focus group of 8 therapists. A thematic analysis was performed. Results: Most patients and therapists agreed that helpful aspects in schema therapy were the highly committed therapeutic relationship, the transparent and clear theoretical model, and the specific schema therapy techniques. About unhelpful aspects, several patients and some therapists shared the opinion that 50 sessions was not enough. Furthermore, patients lacked clear advance information about the possibility that they might temporarily experience stronger emotions during therapy and the possibility of having telephone contact outside session hours. They missed practical goals in the later stage of therapy. With regard to imagery, patients experienced time pressure and they missed a proper link between the past and the present. For therapists, it was hard to manage the therapeutic relation, to get used to a new kind of therapy and to keep the treatment focused on personality problems. Conclusions: Patients and therapists found some aspects of the schema therapy protocol helpful. Their views about which aspects are unhelpful and their recommendations need to be taken into consideration when adjusting the protocol and implementing schema therapy. [ABSTRACT FROM AUTHOR]

Purpose Dialectical behaviour therapy (DBT) has been widely used in a number of different settings with published outcomes and literature supporting its validity and efficacy. What is less understood is DBT’s application to forensic populations. The purpose of this paper is to qualitatively explore the experiences of high risk and adult male forensic clients (diagnosed with borderline personality disorder (BPD) and antisocial personality disorder (ASPD)) in a forensic adapted version of DBT.Design/methodology/approach Six clients who had completed four modules of DBT and individual therapy engaged in semi-structured interviews which were transcribed and analysed using thematic analysis.Findings The findings identified emerging themes relating to group processes and treatment outcomes. Specifically, the importance of motivation, shared learning, professionalism, reinforcement and reflection in creating a positive experience of DBT were identified. In addition clients identified feeling supported, a sense of belonging, personal achievement, increased knowledge and skills application as being part of their experience of DBT.Research limitations/implications Whilst efforts were made to manage limitations, potential confounders include the impact of the researcher’s direct involvement in the facilitation of DBT and the small sample size.Practical implications This study provides support for the use of DBT with forensic males diagnosed with ASPD and BPD and the importance of the group component to the treatment modality. It emphasises the importance of group cohesion and the development of interpersonal factors including feeling supported, sense of belonging and a sense of achievement.Originality/value This paper provides a unique contribution to the understanding of the application of DBT with forensic male clients with personality disorder. It is the first known study to use qualitative methods to explore forensic male clients’ experiences of group and individual DBT. This paper provides insight into the key themes of clients’ experiences of DBT. These identified themes lend support to the importance of motivation of clients and the experience of shared learning, reinforcement and reflection. Furthermore, feeling supported, having a sense of belonging and a sense of personal achievement were identified as key to the positive experience of clients. [ABSTRACT FROM AUTHOR]

Despite a marked increase in research supporting the assessment, diagnosis and treatment of personality disorder (PD) in adolescence, clinicians continue to be reluctant to apply treatment guidelines and psychiatric nomenclature in routine clinical care. This gap arises from several beliefs: (1) psychiatric nomenclature does not allow the diagnosis of PD in adolescence; (2) certain features of PD are normative and not particularly symptomatic of personality disturbance; (3) the symptoms of PD are better explained by other psychiatric syndromes; (4) adolescents' personalities are still developing and therefore too unstable to warrant a PD diagnosis; and (5) because PD is long-lasting, treatment-resistant and unpopular to treat, it would be stigmatising to label an adolescent with borderline personality disorder (BPD). In this paper, the empirical evidence challenging each of these beliefs is evaluated in the hope of providing a balanced review of the validity of adolescent PD with a specific focus on BPD. The paper concludes with recommendations on how routine clinical care can integrate a PD focus. [ABSTRACT FROM AUTHOR]

Background and Objectives: Cultivating compassion seems a promising strategy for ameliorating emotion dysregulation in patients with personality disorders (PDs). Thus far, empirical evidence is lacking. This study aimed to examine whether a brief compassion exercise compared to a neutral exercise would positively impact on (implicit) positive affect (PA) and (implicit) negative affect (NA) and foster the use of more adaptive emotion regulation strategies in an adult clinical sample with PDs.Methods: A total of 24 patients admitted to a Dutch day-hospital treatment center for PDs participated in a two-group cross-over study. Participants were randomly allocated over two groups that were both given the compassion and neutral exercise, yet in a different order. Assessments took place prior to and following each exercise. Participants completed questionnaires assessing (implicit) PA and NA and emotion regulation strategies.Results: Multilevel analyses did not yield significant differences between the neutral and compassion exercise in terms of adaptive and maladaptive emotion regulation and implicit PA. The compassion exercise was able to significantly decrease implicit NA among participants, relative to the neutral exercise. A significant interaction effect was observed between exercise and sequence of exercises on PA and NA.Limitations: Limitations include the brief duration of the exercises, the control exercise and the low reliability for the emotion regulation measure.Conclusions: The compassion exercise decreased implicit NA but seemed not able to impact on PA, NA and emotion regulation in patients with PDs. [ABSTRACT FROM AUTHOR]

Life balance is associated to health, well-being and quality of life and is a target of psychiatric rehabilitation interventions. However, little is known about this life dimension in women living with personality disorders. The purpose of this descriptive-correlational study was to compare and explore relationships between subjective life balance, objective time use, quality of life and perceived stress in women without a mental health disorder (n = 43) and women with a personality disorder (clusters B and C) (n = 30), aged between 18 and 50 years old. The variables were measured with the Life Balance Inventory (subjective life balance), the Occupational Questionnaire (objective time use), the Depression Anxiety Stress Scale (perceived stress) and the Quality of Life Index (satisfaction and importance with life domains). The analyses showed that women with a personality disorder spend significantly less time in work but more time in daily tasks and leisure. Subjective life balance, quality of life and perceived stress were significantly lower in women with a personality disorder (p < 0.05). In women with a personality disorder, subjective life balance was explained by quality of life (R = 27.5 %). In women without a mental illness, subjective life balance was explained by quality of life and motherhood (R = 36.1 %). To support the recovery of women with personality disorders and their quality of life, it is important to address objective and subjective time use to enable accomplishment of a variety of meaningful activities. [ABSTRACT FROM AUTHOR]

The primary aims of this study were to examine the prevalence of personality disorders in problem gamblers, to explore the relationship between personality disorders and problem gambling severity, and to explore the degree to which the psychological symptoms highlighted in the biosocial developmental model of borderline personality disorder (impulsivity, distress tolerance, substance use, PTSD symptoms, psychological distress and work/social adjustment) are associated with problem gambling. A secondary aim was to explore the strength of the relationships between these symptoms and problem gambling severity in problem gamblers with and without personality disorder pathology. Participants were 168 consecutively admitted problem gamblers seeking treatment from a specialist outpatient gambling service in Australia. The prevalence of personality disorders using the self-report version of the Iowa Personality Disorders Screen was 43.3 %. Cluster B personality disorders, but not Cluster A or C personality disorders, were associated with problem gambling severity. All psychological symptoms, except alcohol and drug use, were significantly higher among participants with personality disorder pathology compared to those without. Finally, psychological distress, and work and social adjustment were significantly associated with problem gambling severity for problem gamblers with personality disorder pathology, while impulsivity, psychological distress, and work and social adjustment were significantly associated with problem gambling severity for those without personality disorder pathology. High rates of comorbid personality disorders, particularly Cluster B disorders, necessitate routine screening in gambling treatment services. More complex psychological profiles may complicate treatment for problem gamblers with comorbid personality disorders. Future research should examine the applicability of the biosocial developmental model to problem gambling in community studies. [ABSTRACT FROM AUTHOR]

In this issue of Psychodynamic Psychiatry, Michael Stone discusses therapeutic factors in the treatment of patients with Borderline Personality Disorder (BPD). He emphasizes the great diversity of borderline patients and points out that a number of manual-based therapies, each described by an acronym, generally achieve positive therapeutic results in the short term. Many borderline patients require years of psychotherapy, pharmacotherapy and additional treatments, however. Stone observes that patients with this disorder invariably have other personality characteristics and disorders. Suicidality is common among borderline patients, particularly those who also suffer from major depressive episodes. Stone emphasizes the usefulness of a contextual therapeutic model and a flexible clinical stance. [ABSTRACT FROM AUTHOR]

An increasing challenge of working within Approved Premises is the complex nature of offenders presenting with personality disordered traits. This article outlines how our team of probation and mental health staff utilised training from the Knowledge and Understanding Framework (KUF) to adapt current practice in understanding and managing such complex cases. Some case examples are provided to add context and recommendations have been made for future practice, based on reflection. [ABSTRACT FROM AUTHOR]

The article stresses the urgency for reforms in child and mental health services and policies and for early intervention for borderline personality disorder in young people. Emphasis is given on the incremental utility of personality disorder diagnosis in young people over diagnoses of mental disorders including post-traumatic stress disorder and depression. The author views that delayed diagnosis or substitute diagnosis on the basis of stigma reflects a culture of bigotry and discrimination.

The characteristic features of personality disorder that are found in older people are also present in young people. These features are currently not diagnosed as personality problems by most UK practitioners, through a mixture of fear and prejudice, which is used to justify this avoidant diagnostic behaviour. A simple solution is offered. State that personality function is 'disordered' in those who cross the threshold for diagnosis but emphasise that it is often ephemeral and can be managed. [ABSTRACT FROM AUTHOR]

Background: Barber and Muenz (1996) reported that cognitive behavior therapy (CBT) was more effective than interpersonal therapy (IPT) for depressed patients with elevated levels of avoidant personality disorder, while IPT was more effective than CBT in patients with elevated levels of obsessive-compulsive personality disorder. These findings may have important clinical implications, but have not yet been replicated.Methods: We conducted a study using data from a randomized clinical trial comparing the efficacy of CBT and short-term psychodynamic supportive psychotherapy in the outpatient treatment of depression.Results: We found no evidence indicating that avoidant patients may benefit more from CBT compared to short-term psychodynamic supportive therapy (SPSP).Conclusions: Our results indicate that treatment effect does not depend on the level of avoidance, or obsessive-compulsiveness personality disorders further examine the influence of personality disorders on the effectiveness of CBT or psychodynamic therapy in the treatment of depression. [ABSTRACT FROM AUTHOR]

The focus of this paper is to provide an update on the use of psychotherapy as a treatment in sport psychiatry, and the use of this approach to address common psychiatric issues encountered with this population. Specifically, family therapy, individual therapy, and group psychotherapy prescribed alone, or in combination with medication, will be examined as methods to manage issues/disorders often associated with athletes. These include obsessive-compulsive rituals and perfectionism, and aggressive and risky behaviours, such as gambling, infidelity, substance use, and suicidal ideation, narcissism, and aggression in the context of individual and team competitive sports. [ABSTRACT FROM AUTHOR]

Background: Patient transference patterns play a central role in the psychotherapy of personality disorders. Objective: The aims of this study were to: (1) explore the relationship between patients' personality disorders and specific relational patterns and (2) construct empirically derived prototypes of relational patterns for each personality disorder. Sampling and Methods: A random national sample of 314 clinicians completed the Psychotherapy Relationship Questionnaire, which evaluates patients' relational patterns, and the Shedler-Westen Assessment Procedure-200, which assesses personality disorders in a randomly selected patient currently in the clinician's care and with whom the clinician has worked for a minimum of 8 sessions and a maximum of 6 months (1 session per week). Results: The avoidant/counterdependent transference pattern was associated with all cluster A personality disorders; the angry/entitled transference pattern was strongly positively associated with all cluster B personality disorders, and the anxious/preoccupied transference pattern was positively associated in a significant way with all cluster C personality disorders. Moreover, our empirically derived prototypes showed how the transference phenomena characteristic of each personality disorder are strongly coherent with the personality traits and mental and relational functioning of each specific disorder. Conclusions: The results strongly support a fundamental hypothesis that the patterns emerging in the therapeutic relationship are not arbitrary, and they clearly reflect patterns seen elsewhere in patients' lives that can be crucial to address. Regarding limitations, the same clinician provided data on both the personality pathology and the transference phenomena for each patient. [ABSTRACT FROM AUTHOR]

This study examined male prisoners' experiences of participating in the Chromis programme, which aims to address violent behaviour in offenders with high levels of psychopathic traits. Four men who had completed Chromis and moved to new locations were purposefully sampled. This provided the opportunity for men to discuss their experiences after participating in the full programme and away from any influences of the treatment environment. Interview schedules were designed using interpretative phenomenological analysis (IPA). Interview transcripts were analysed independently by two researchers using IPA who then compared and contrasted findings to develop superordinate themes across the group. Four superordinate themes resulted. These were "It's me and what I want that matters," Reaping the rewards, "It's treatment itself that makes things hard," and Make or break external influences. Across the board, participants benefited at some level from Chromis. Participants' experiences highlighted useful information that can inform practice with individuals with high levels of psychopathy. The clinical implications are discussed. [ABSTRACT FROM AUTHOR]

Many patients with personality disorders (PD) display emotional inhibition or over-regulation (EOR); others display emotional dysregulation (ED)-heightened sensitivity to emotional stimuli with difficulty toning down arousal. To date, most treatments focus on patients with ED, particularly those with borderline disorders, though some focus on EOR. Patients with complex PD often swing from periods of EOR to ED. In this paper, we describe an adaptation of metacognitive interpersonal therapy (MIT), which has been manualized for treating PD with prominent EOR and is aimed at dealing with patients fluctuating from EOR to ED. We first describe the MIT model of personality pathology and offer a summary of the procedures used in MIT to treat patients with prominent EOR. Then, through the analysis of the case of a patient swinging between EOR and ED, we describe how to adapt these procedures to complex cases. [ABSTRACT FROM AUTHOR]

Evidence for mentalisation-based therapy (MBT) is increasing in relation to the treatment of personality disorder. Individuals with personality disorder are over-represented in inpatient, forensic and forensic inpatient mental health services. This study explores MBT within a forensic setting as an intervention designed to moderate deficits linked to violence and to improve adaptive coping. Interpretative phenomenological analysis was conducted on interviews with four patients who completed MBT at a high-secure hospital. Findings suggest that MBT-enhanced participants’ mentalising which had a positive impact upon their capacity to manage their behaviour and emotions. MBT further enabled participants to process past experiences of violence and develop some degree of empathy for others, which led to a trend in abstinence from risk behaviours. Findings contribute a secure inpatient perspective on the experience of MBT and to MBT clinical outcomes. [ABSTRACT FROM PUBLISHER]

Background: The most efficacious treatments for social anxiety disorder (SAD) are the SSRIs and cognitive therapy (CT). Combined treatment is advocated for SAD but has not been evaluated in randomized trials using CT and SSRI. Our aim was to evaluate whether one treatment is more effective than the other and whether combined treatment is more effective than the single treatments.Methods: A total of 102 patients were randomly assigned to paroxetine, CT, the combination of CT and paroxetine, or pill placebo. The medication treatment lasted 26 weeks. Of the 102 patients, 54% fulfilled the criteria for an additional diagnosis of avoidant personality disorder. Outcomes were measured at posttreatment and 12-month follow-up assessments.Results: CT was superior to paroxetine alone and to pill placebo at the end of treatment, but it was not superior to the combination treatment. At the 12-month follow-up, the CT group maintained benefits and was significantly better than placebo and paroxetine alone, whereas there were no significant differences among combination treatment, paroxetine alone, and placebo. Recovery rates at 12 months were much higher in the CT group (68%) compared to 40% in the combination group, 24% in the paroxetine group, and 4% in the pill placebo group.Conclusions: CT was the most effective treatment for SAD at both posttreatment and follow-up compared to paroxetine and better than combined treatment at the 12-month follow-up on the Liebowitz Social Anxiety Scale. Combined treatment provided no advantage over single treatments; rather there was less effect of the combined treatment compared to CT alone. [ABSTRACT FROM AUTHOR]

Schema therapy is an integrative approach of psychotherapy developed by Jeffrey E. Young. Its aim is to help clients explore and understand their deep emotional needs and meet them in a healthy manner. It is suitable for complex pathologies, such as comorbidities and personality disorders. In sex therapy, schema therapy can serve as a method for a deep, evidence-based, integrative conceptualization of a client's difficulties and needs. However, its principles have never been demonstrated in sex therapy. In this paper, we briefly review schema therapy and introduce schema domains. We bring a case study of a couple undergoing sex therapy from the cognitive-behavioral perspective. We then return to the same case study, in order to demonstrate the usefulness of a schema therapy conceptualization. [ABSTRACT FROM AUTHOR]

ObjectiveThe study investigated the effectiveness of an 8-week intensive residential treatment programme based on principles from intensive short-term dynamic psychotherapy for patients with known treatment-resistant anxiety- and/or depressive disorders (mainly with comorbid personality disorders).MethodsPatients (N=95) with prior repeated treatment failure were included. Changes in self-reported target complaints, symptom severity, and overall interpersonal problems have been presented for these patients in two previous articles. We now expand upon the existing knowledge by presenting novel data from a number of important observer-based and self-reported outcome domains (diagnostic changes on Axis I and II, changes in overall personality dysfunction, disorder complexity, medication use, health care utilisation, and occupational activity).ResultsThere were pervasive and significant improvements on all measures during treatment, which were maintained or further improved during follow-up. Fourteen months after the end of treatment, 46.26% of patients had recovered in terms of Axis I pathology, 63.79% had recovered in terms of Axis II pathology, 71.18% had returned to work, and there was a 28.62% reduction in regular use of psychotropic medications. Health care utilisation was reduced by 65.55%, and there were large improvements in disorder complexity and levels of personality dysfunction.ConclusionThe treatment programme was highly effective for patients with common and complex treatment-resistant mental disorders. Results are encouraging for the relatively large number of patients who tend not to benefit from standard formats of treatment for debilitating psychological problems. [ABSTRACT FROM AUTHOR]

Emotional dysfunction is by definition central to personality disorders (PDs). In the alternative model in DSM-5, self and relational dysfunctioning constitutes the core of PD, but little is known about the relation between emotional functioning and such core aspects of personality functioning. This study investigated concurrent and prospective associations between emotional and personality functioning as assessed by affect consciousness (AC) and the Severity Indices of Personality Problems (SIPP-118), respectively. The SIPP-118 comprises five domains of personality functioning, including Identity Integration and Relation Capacities, and was applied repeatedly during 3-year follow-up of 63 PD patients who participated in a treatment study. Statistical analyses were based on linear mixed models. Lower AC levels were significantly associated with (a) lower levels of Identity Integration and Relational Capacities at baseline, and (b) poorer long-term improvement of Identity Integration. The study supports the notion that affect consciousness is related to core aspects of personality functioning. [ABSTRACT FROM AUTHOR]

This paper is a case study of a patient with severe personality disorder undergoing treatment at the Cassel Hospital. It looks at a phase of her individual psychoanalytic psychotherapy and how that sits within an institutional model of treatment that can be understood as applied psychoanalysis, in which Tom Main's concept of a 'culture of enquiry' aims to observe and bring together splitting and projective processes operating at all levels of the organisation. The patient, who had been sexually abused and then suffered a prolonged suicidal breakdown, exerted intense pressure on the institution through her experience of herself as both a victim of abuse and a participant in it. A working through is described, in which different parts of the patient that had been projected into different parts of the institution are brought together, and her primitive demand for a two-person world gives way to an acceptance of triangulation. Themes from her individual sessions are enacted in the milieu-based treatment, and conversely struggles in the patient community appear in her sessions. It is from drawing these parts of the patient together as a whole institution that the treatment derives its power and effectiveness. [ABSTRACT FROM AUTHOR]

Purpose This study explores the processes of change during treatment among male forensic inpatients with primary diagnoses of personality disorder. Method Fifty patients in a high secure personality disorder treatment service completed a checklist about how they had changed during treatment and the factors that had caused that change. Results The results support a limited reparenting attachment-based model of therapeutic change. Self-reported levels of change were highly correlated with measures of patient functioning, though significant levels of change did not occur until the later stages of treatment. Conclusions The behaviour of therapists was particularly important throughout treatment, though participants in the final stage of therapy reported that the behaviour of other staff was as important as that of therapists, suggesting that, by this stage of treatment they are able to extend their range of supportive and therapeutic relationships. [ABSTRACT FROM AUTHOR]

There is a general lack of self-report data from service users with an intellectual disability (ID) about their views of psychological interventions. This research explored the views and experiences of female inpatients, with a diagnosis of a personality disorder and an ID, about dialectical behaviour therapy (DBT). Semi-structured interviews were used with 10 women, recruited from two independent mental health hospitals. The interviews were analysed using interpretative phenomenological analysis. Participants showed varying levels of understanding of DBT. Findings highlight the need for a standardized approach with a suitably adapted structure and curriculum to meet the needs of inpatients with an ID. Factors such as the therapeutic relationship were identified as playing a role in participants' motivation, engagement and participation in DBT. [ABSTRACT FROM AUTHOR]

Offering the opportunity for research participants to draw pictures can be useful in uncovering multiple meanings to develop, support, and supplement other research findings. The processes of research engaged in this study, exploring experiences of eating disorder and sexual abuse, gave women a voice to describe and process their historical and current responses. The first section reports the response of one research participant in a study that used spoken, written and visual data to examine seven women’s experiences of eating disorders, and child sexual abuse. The second section presents a case study to demonstrate how drawings created by clients in Schema Therapy for eating disorders can provide a pathway to access emotional states, which may otherwise be inaccessible through verbal dialogue. Using drawing enables research participants to share insights and experiences in non-verbal ways. Drawing as part of schema therapy can provide the opportunity for the practitioner and the client to feel and experience complex emotional states related to current and past experience. [ABSTRACT FROM AUTHOR]

Background: Health anxiety, hypochondriasis and personality disturbance commonly coexist. The impact of personality status was assessed in a secondary analysis of a randomised controlled trial (RCT).Aims: To test the impact of personality status using ICD-11 criteria on the clinical and cost outcomes of treatment with cognitive-behavioural therapy for health anxiety (CBT-HA) and standard care over 2 years.Method: Personality dysfunction was assessed at baseline in 444 patients before randomisation and independent assessment of costs and outcomes made on four occasions over 2 years.Results: In total, 381 patients (86%) had some personality dysfunction with 184 (41%) satisfying the ICD criteria for personality disorder. Those with no personality dysfunction showed no treatment differences (P = 0.90) and worse social function with CBT-HA compared with standard care (P<0.03) whereas all other personality groups showed greater improvement with CBT-HA maintained over 2 years (P<0.001). Less benefit was shown in those with more severe personality disorder (P<0.05). Costs were less with CBT-HA except for non-significant greater differences in those with moderate or severe personality disorder.Conclusions: The results contradict the hypothesis that personality disorder impairs response to CBT in health anxiety in both the short and medium term. [ABSTRACT FROM AUTHOR]

Background: Therapeutic communities (TCs) could reduce the health care use of people with personality disorder (Davies S, Campling P and Ryan K, Psychiatrist 23:79-83, 1999; Barr W, Kirkcaldy A, Horne A, Hodge S, Hellin K and Göpfert M, J Ment Health 19:412-421, 2010) and in turn reduce the financial and environmental costs of services. Our hypothesis is that 3 years following entry to a TC service, patients have reduced subsequent health care use and associated reductions in financial costs and carbon footprint. Methods: A retrospective 4-year cohort study examined changes in health care use following entry to the Oxfordshire TC service. Comparative analysis was undertaken on a treated (n = 40) and a control group (referred but who declined treatment; n = 45). Financial costs and carbon footprint of health care use were calculated using national tariffs and standard carbon conversion factors. Mean changes in these outcomes were compared over 1, 2 and 3 years and adjusted for costs and carbon footprints in the year prior to joining the TC service. Results: Compared to baseline, the group receiving TC care had greater reductions in financial costs and carbon footprint associated with A&E attendances (p = 0.04) and crisis mental health appointments (p = 0.04) than the control group. There were significantly greater reductions in carbon footprint for all secondary health care use, both physical and mental health care, after 3 years (p = 0.04) in the TC group. Conclusions: TC services may have the potential to reduce the financial cost and carbon footprint of health care. [ABSTRACT FROM AUTHOR]

Empirical research has demonstrated a link between legal coercion and treatment engagement following conviction among those with severe personality disorder. Legal coercive pressures were often applied by the Indeterminate Sentence for Public Protection (IPP), until it was replaced by the Extended Determinate Sentence by the Legal Aid, Sentencing and Punishment of Offenders Act 2012. In this paper, it is proposed that use of the new determinate sentence will lessen motivation for treatment engagement. One effect of treatment refusal may be greater reliance by the Secretary of State for Justice on his jurisdiction to transfer prisoners due for release to secure hospital transfers under the Mental Health Act 1983. Not only will this risk posturing undermine the principal aim of the Offender Personality Disorder Implementation Pathway to improve treatment engagement among the target group, it will also have negative implications for medical practitioners working in secure forensic hospitals. To demonstrate what is at stake, the paper briefly recapitulates empirical findings familiar to readers of the journal, before drawing on original unpublished data. [ABSTRACT FROM AUTHOR]

The article discusses the annual International Royal Australian and New Zealand College of Psychiatrists (RANZCP) Congress of Psychiatry that was held in Hong Kong, China from May 8-12, 2016. Topics discussed include the advocacy in mental health, early detection and treatment of personality disorder, and the National Disability Insurance Scheme in Australia. the event featured several speakers including Naomi Fineberg, Nitin Gogtay, and Robert Howard.

Recent advances in the conceptualisation of borderline personality disorder (BPD) have highlighted the role of relational trauma as central to the onset of the disorder, whilst observing deficits in the structure of the self-concept as a result of developmental adversity. Understanding borderline states within a psychiatric framework alone has attracted significant criticism due to the lack of the medical model's explanatory properties, which fail to account for the complexity and variation of borderline symptomatology. A reliance on psychodynamic formulation instead, can provide an aetiological framework where BPD can be understood as a disorder of the sense of self, originating in the client's relational matrix. The purpose of the current paper is to discuss a borderline case study with a focus on formulation rather than diagnosis, in an attempt to shed light on the relational and unconscious processes underpinning the disorder and thus inform treatment interventions. [ABSTRACT FROM AUTHOR]

Short-term inpatient psychotherapy based on transactional analysis (STIP-TA) in patients with personality disorders (PD) has shown to be more effective than comparable other specialized psychotherapies (OP). The aim of this study was to assess whether the higher effectiveness of STIP-TA also results in a better cost-effectiveness. Patients treated with STIP-TA were matched with patients treated with OP by the propensity score. Healthcare costs and lost productivity costs were measured over 3 years and from the societal perspective. Cost-effectiveness was represented by costs per quality adjusted life years (QALYs). Uncertainty was assessed using bootstrapping. Mean 3-year costs were €59,834 for STIP-TA and €69,337 for OP, a difference of −€9,503, 95% CI [−32,561, 15,726]. QALYs were 2.29 for STIP-TA and 2.05 for OP, a difference of .24, 95% CI [.05, .44]. STIP-TA is a dominant treatment compared to OP: less costly and more effective. We conclude that STIP-TA is a cost-effective treatment in PD patients. [ABSTRACT FROM AUTHOR]

In the UK, patients with personality disorders presenting complex needs frequently experience an unhelpful pattern of acute treatment followed by community care—with associated high cost implications for services. With UK mental health resources under severe pressure, this leaves commissioners with difficult decisions to make. Yet studies on cost‐effectiveness in respect of personality disorder treatment are scarce, particularly for treatments taking place outside of major teaching hospitals in the USA. This paper studies the benefits of an intensive, holistic approach and finds that the Network achieved substantial reductions in health care usage and expenditure in the short to medium term. Copyright © 2016 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background: This pilot study focused on the feasibility and potential effectiveness of a protocol based on Narrative Exposure Therapy (NET) that was integrated into a standard inpatient program to treat patients with comorbid Borderline Personality Disorder (BPD) and Posttraumatic Stress Disorder (PTSD). Methods: Eleven patients (1 male, 10 female) without previous stabilization periods or the absence of intentional self-injury received NET during a ten-week inpatient program. Patients were assessed again at post-treatment and a 12-month follow-up. Results: Drop-out rates during treatment were low, with 90.9% completing NET. Furthermore, acceptance of NET was high, with only one patient rejecting treatment. The program was safe because it did not lead to aggravations in symptom severity at either the post-treatment or 12-month follow-up. Additionally, the rate of self-harming behaviors throughout the treatment phase was low (18.2%). In fact, treatment was associated with positive effects on PTSD and BPD symptom severity as well as secondary outcome measures, including depression, dissociation and quality of life. Conclusions: The present study found that NET is feasible and safe in an inpatient setting for treating highly burdened patients with BPD and PTSD. There is also evidence for the potential effectiveness of NET in this highly burdened population. [ABSTRACT FROM AUTHOR]

Background: It is often suggested that, in general, co-morbid personality disorders are likely to interfere with CBT based treatment of Axis I disorders, given that personality disorders are regarded as dispositional and are therefore considered less amenable to change than axis I psychiatric disorders. Aims: The present study aimed to investigate the impact of co-occurring obsessive-compulsive disorder (OCD) and obsessive-compulsive personality disorder (OCPD) on cognitive-behavioural treatment for OCD. Method: 92 individuals with a diagnosis of OCD participated in this study. Data were drawn from measures taken at initial assessment and following cognitive-behavioural treatment at a specialist treatment centre for anxiety disorders. Results: At assessment, participants with OCD and OCPD had greater overall OCD symptom severity, as well as doubting, ordering and hoarding symptoms relative to those without OCPD; however, participants with co-morbid OCD and OCPD demonstrated greater treatment gains in terms of OCD severity, checking and ordering than those without OCPD. Individuals with OCD and OCPD had higher levels of checking, ordering and overall OCD severity at initial assessment; however, at post-treatment they had similar scores to those without OCPD. Conclusion: The implications of these findings are discussed in the light of research on axis I and II co-morbidity and the impact of axis II disorders on treatment for axis I disorders. [ABSTRACT FROM AUTHOR]

Background: The Camden and Islington Impact Personality Disorder Project provided psychologically informed consultation and training to probation staff in a Public Protection Unit and staff in two 'approved premises' (probation hostels) working with high-risk prison sentenced offenders on licence in the community; some direct therapeutic work was also conducted jointly with probation officers. Most of the offenders had behaviours associated with personality disorder, although had not necessarily received a diagnosis of personality disorder.Aims: To evaluate this service (the intervention) and test the hypothesis that its work would be associated with a reduction in recalls to prison.Methods: Local and national probation records were used to identify all prison recalls made by 10 consistently available probation officers for 1 year before the intervention and up to 3 years after its introduction; reasons for recall and evidence of new arrests or charges were also extracted.Results: There was a significant decrease in rate of recalls in the first year of the intervention, sustained over the second year and, for the smaller number of officers still available, also over the third year. Non-compliance with supervision as a reason for recall was cut by two-thirds; other reductions were in responses to 'challenging' behaviours. There was no evidence of increase in serious further offending.Conclusions: Our findings provide preliminary evidence that psychologically informed practice by probation officers supervising offenders at highest risk of serious harm re-offending can reduce the rate of recall to prison, a costly alternative to maintaining offenders in the community, without apparently reducing community safety. Further research should clarify the extent to which the intervention helped the officers merely to tolerate challenging behaviours from these offenders and the extent of real change in the behaviours. Copyright © 2015 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Purpose: Short‐term group cognitive‐behavioral therapy (GCBT) with weekly homogeneous group sessions for treating specific anxiety disorders is relatively well developed and recognized. However, 12 weeks of intensive daily therapy for mixed anxiety and personality disorders is not. The current article aims to fill this gap by presenting the method of intensive transdiagnostic GCBT for anxiety disorders with comorbid personality disorders in a day hospital setting. Preliminary studies showed that participants exhibited significant improvement during this type of treatment. Conclusions: This article reviews the advantages of group therapy that is transdiagnostic over the homogeneous group and individual therapy formats. Practice Implications: The detailed description of the current therapeutical program may facilitate the development of similar programs in day clinic settings. [ABSTRACT FROM AUTHOR]