Conceptual Models of Borderline Personality Disorder, Part 2: A Process Approach and Its Implications

Commentary: Special Issue on Interpersonal Trust

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.

Evaluating Change in Transference, Interpersonal Functioning, and Trust Processes in the Treatment of Borderline Personality Disorder: A Single-Case Study Using Ecological Momentary Assessment

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.

Empirical Developments in Transference-Focused Psychotherapy

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.

Clinical Applications: What Can Multimethod Designs Tell Us about Personality Functioning?

The goal of this commentary is to highlight clinical applications of personality assessment research via two recent studies that are distinguished by their use of innovative experimental, multimethod designs. These studies evaluate implicit behaviors as predicted by clinically relevant facets of personality functioning. Parallels to implicit behaviors evoked in the context of psychotherapy are discussed, as is the value of assessing and intervening on the subtle manifestations of personality dysfunction observed by clinicians, especially when they do not comport to the patient's self-assessment.

The borderline interpersonal-affective systems (BIAS) model: Extending understanding of the interpersonal context of borderline personality disorder

Prominent explanatory models for borderline personality disorder (BPD) are intrapersonal in nature and hold that it is an emotional disorder. However, the empirical support for emotional models of BPD is mixed. Refinements to BPD explanatory models are needed to increase the precision with which BPD can be understood and treated. Drawing on existing theoretical and empirical research in BPD, this manuscript presents the Borderline Interpersonal-Affective Systems (BIAS) model. The BIAS model purports that harmful early life relationships and subsequent conflictual relationships lead individuals with BPD to develop a sensitivity to interpersonal threat in the form of attentional and appraisal biases. Individuals with BPD are posited to 1) experience heightened emotional reactivity specifically to perceived interpersonal threat and 2) engage in destructive behaviors both to regulate increasing emotion and to meet interpersonal needs. We review the empirical support for each component of the BIAS model, along with the role of the cognitions, emotions, and behaviors of significant others in influencing BIAS model processes in individuals with BPD over time. The BIAS model highlights a novel way of understanding and integrating interpersonal and emotional components of the disorder. Key directives for future research and clinical implications are discussed.

Borderline personality disorder diagnosis in a new key

BACKGROUND

Conceptualizations of personality disorders (PD) are increasingly moving towards dimensional approaches. The definition and assessment of borderline personality disorder (BPD) in regard to changes in nosology are of great importance to theory and practice as well as consumers. We studied empirical connections between the traditional DSM-5 diagnostic criteria for BPD and Criteria A and B of the Alternative Model for Personality Disorders (AMPD).

METHOD

Raters of varied professional backgrounds possessing substantial knowledge of PDs (N = 20) characterized BPD criteria with the four domains of the Level of Personality Functioning Scale (LPFS) and 25 pathological personality trait facets. Mean AMPD values of each BPD criterion were used to support a nosological cross-walk of the individual BPD criteria and study various combinations of BPD criteria in their AMPD translation. The grand mean AMPD profile generated from the experts was compared to published BPD prototypes that used AMPD trait ratings and the DSM-5-III hybrid categorical-dimensional algorithm for BPD. Divergent comparisons with DSM-5-III algorithms for other PDs and other published PD prototypes were also examined.

RESULTS

Inter-rater reliability analyses showed generally robust agreement. The AMPD profile for BPD criteria rated by individual BPD criteria was not isomorphic with whole-person ratings of BPD, although they were highly correlated. Various AMPD profiles for BPD were generated from theoretically relevant but differing configurations of BPD criteria. These AMPD profiles were highly correlated and showed meaningful divergence from non-BPD DSM-5-III algorithms and other PD prototypes.

CONCLUSIONS

Results show that traditional DSM BPD diagnosis reflects a common core of PD severity, largely composed of LPFS and the pathological traits of anxiousness, depressively, emotional lability, and impulsivity. Results confirm the traditional DSM criterion-based BPD diagnosis can be reliably cross-walked with the full AMPD scheme, and both approaches share substantial construct overlap. This relative equivalence suggests the vast clinical and research literatures associated with BPD may be brought forward with DSM-5-III diagnosis of BPD.