Do personality disorders exist? On the validity of the concept and its cognitive-behavioral formulation and treatment

Reward and Punishment Sensitivity in Borderline and Avoidant Personality Disorders

The authors compared self-reported and behavioral responses to reward and punishment in individuals diagnosed with borderline personality disorder (BPD) or avoidant personality disorder (APD) relative to a healthy comparison (HC) group. As predicted, self-reported sensitivity to reward was significantly higher in the BPD group than in the APD and HC groups. Also as predicted, self-reported sensitivity to punishment was significantly elevated in both disordered groups but significantly higher in APD than in BPD. These hypothesized patterns were also evident in responses to behavioral tasks: Participants with BPD made more errors of commission and fewer errors of omission than HC participants on a passive avoidance learning task, and participants with APD showed greater reactivity to losses than other participants on a probabilistic reversal learning task. Results help characterize differences between these two disorders.

Relationships Among Avoidant Personality Disorder, Social Anxiety Disorder, and Normative Personality Traits: A Twin Study

Avoidant personality disorder (AvPD) and social anxiety disorder (SAD) share risk factors to a substantial degree, and both are characterized by the experience of anxiety in social situations. The authors investigated whether these disorders are differentially related to the Big Five personality traits. They also examined the underlying genetic and environmental influences on these associations. A population-based sample of 1,761 female twins was interviewed at baseline, and 1,471 of these were re-interviewed 10 years later. Associations between AvPD, SAD, and personality traits were investigated with multivariate biometric analyses. The authors found that AvPD and SAD are differentially related to several personality traits at the phenotypic, genetic, and environmental level. The genetic and environmental liability to AvPD could be fully accounted for by the genetic and environmental factors influencing SAD and personality. The findings may increase current etiological understanding of these disorders and inform future classification and treatment efforts.

Group schema therapy versus group cognitive behavioral therapy for social anxiety disorder with comorbid avoidant personality disorder: study protocol for a randomized controlled trial

BACKGROUND

Social anxiety disorder (SAD) with comorbid avoidant personality disorder (APD) has a high prevalence and is associated with serious psychosocial problems and high societal costs. When patients suffer from both SAD and APD, the Dutch multidisciplinary guidelines for personality disorders advise offering prolonged cognitive behavioral therapy (CBT). Recently there is increasing evidence for the effectiveness of schema therapy (ST) for personality disorders such as borderline personality disorder and cluster C personality disorders. Since ST addresses underlying personality characteristics and maladaptive coping strategies developed in childhood, this treatment might be particularly effective for patients with SAD and comorbid APD. To our knowledge, there are no studies comparing CBT with ST in this particular group of patients. This superiority trial aims at comparing the effectiveness of these treatments. As an additional goal, predictors and underlying mechanisms of change will be explored.

METHODS/DESIGN

The design of the study is a multicentre two-group randomized controlled trial (RCT) in which the treatment effect of group cognitive behavioral therapy (GCBT) will be compared to that of group schema therapy (GST) in a semi-open group format. A total of 128 patients aged 18-65 years old will be enrolled. Patients will receive 30 sessions of GCBT or GST during a period of approximately 9 months. Primary outcome measures are the Liebowitz Social Anxiety Scale Self-Report (LSAS-SR) for social anxiety disorder and the newly developed Avoidant Personality Disorder Severity Index (AVPDSI) for avoidant personality disorder. Secondary outcome measures are the MINI section SAD, the SCID-II section APD, the Schema Mode Inventory (SMI-2), the Inventory of Depressive Symptomatology Self-Report (IDS-SR), the World Health Organization Quality of Life-BREF (WHOQOL-BREF), the Difficulties in Emotion Regulation Scale (DERS), the Rosenberg Self-Esteem Scale (RSES) and the Acceptance and Action Questionnaire (AAQ-II). Data will be collected at the start, halfway and at the end of the treatment, followed by measurements at 3, 6 and 12 months post-treatment.

DISCUSSION

The trial will increase our knowledge on the effectiveness and applicability of both treatment modalities for patients suffering from both diagnoses.

TRIAL REGISTRATION

Dutch Trial Register: NTR3921 . Registered on 25 March 2013.

Application of CBT in an Inpatient Setting

The following case illustration demonstrates the utility and scope of the cognitive-behavioral modality in treating coexisting Axis I and Axis II symptoms in an inpatient setting. The client, who is referred to as “Jim,” presented for treatment in an acute state at an inpatient hospital. He complained of severe anxiety and depression and reported suicidal ideation with intent. After being stabilized, he was transferred as an inpatient to an intensive psychosocial rehabilitation program within the hospital where he began individual psychotherapy. Over the course of therapy, it became apparent that Jim was also exhibiting symptoms of dependent personality disorder, as well as features of other Axis II disorders. Based on Beck’s cognitive model, treatment was modified to account for the presence of the Axis II symptomatology. Therapy centered around helping Jim attain a sense of autonomy, reconstruct his maladaptive cognitive patterns, establish interpersonal relationships, and build a stronger support network

Prediction of treatment discontinuation and recovery from Borderline Personality Disorder: Results from an RCT comparing Schema Therapy and Transference Focused Psychotherapy

Knowing what predicts discontinuation or success of psychotherapies for Borderline Personality Disorder (BPD) is important to improve treatments. Many variables have been reported in the literature, but replication is needed and investigating what therapy process underlies the findings is necessary to understand why variables predict outcome. Using data of an RCT comparing Schema Therapy and Transference Focused Psychotherapy as treatments for BPD, variables derived from the literature were tested as predictors of discontinuation and treatment success. Participants were 86 adult outpatients (80 women, mean age 30.5 years) with a primary diagnosis of BPD who had on average received 3 previous treatment modalities. First, single predictors were tested with logistic regression, controlling for treatment type (and medication use in case of treatment success). Next, with multivariate backward logistic regression essential predictors were detected. Baseline hostility and childhood physical abuse predicted treatment discontinuation. Baseline subjective burden of dissociation predicted a smaller chance of recovery. A second study demonstrated that in-session dissociation, assessed from session audiotapes, mediated the observed effects of baseline dissociation on recovery, indicating that dissociation during sessions interferes with treatment effectiveness. The results suggest that specifically addressing high hostility, childhood abuse, and in-session dissociation might reduce dropout and lack of effectiveness of treatment.

An experimental Investigation of the Impact of Personality Disorder Diagnosis on Clinicians: Can We See Past the Borderline?

Background: There is concern that diagnostic labels for psychiatric disorders may invoke damaging stigma, stereotypes and misunderstanding. Aims: This study investigated clinicians’ reactions to diagnostic labelling by examining their positive and negative reactions to the label borderline personality disorder (BPD). Method: Mental health professionals (n = 265) viewed a videotape of a patient suffering from panic disorder and agoraphobia undergoing assessment. Prior to viewing the videotape, participants were randomly allocated to one of three conditions and were given the following information about the patient: (a) general background information; (b) additional descriptive information about behaviour corresponding to BPD; and (c) additional descriptive information about behaviour corresponding to BPD, but explicitly adding BPD as a possible comorbid diagnostic label. All participants were then asked to note things they had seen in the videotape that made them feel optimistic or pessimistic about treatment outcome. Results: Participants in the group that were explicitly informed that the patient had a BPD diagnostic label reported significantly fewer reasons to be optimistic than the other two groups. Conclusions: Diagnostic labels may negatively impact on clinicians’ judgments and perceptions of individuals and therefore clinicians should think carefully about whether, and how, they use diagnoses and efforts should be made to destigmatize diagnostic terms.

Factor structure, reliability, and known groups validity of the German version of the Childhood Trauma Questionnaire (Short-form) in Swiss patients and nonpatients

The Childhood Trauma Questionnaire-Short Form is the most widely used instrument to assess childhood trauma and has been translated into 10 languages. However, research into validity and reliability of these translated versions is scarce. The present study aimed to investigate the factor structure, internal consistency, reliability, and known-groups validity of the German Childhood Trauma Questionnaire-Short Form (Bernstein & Fink, 1998). Six-hundred and sixty-one clinical and nonclinical participants completed the German Childhood Trauma Questionnaire-Short Form. A confirmatory factor analysis was conducted to assess the 5-factor structure of the original Childhood Trauma Questionnaire-Short Form. To investigate known-groups validity, the confirmatory factor analysis latent factor levels between clinical and nonclinical participants were compared. The original 5-factor structure was confirmed, with only the Physical Neglect scale showing rather poor fit. As a conclusion, the results support the validity and reliability of the German Childhood Trauma Questionnaire-Short Form. It is recommended to use the German Childhood Trauma Questionnaire-Short Form to assess experiences of childhood trauma.

Poly-substance use and antisocial personality traits at admission predict cumulative retention in a buprenorphine programme with mandatory work and high compliance profile

BACKGROUND

Continuous abstinence and retention in treatment for alcohol and drug use disorders are central challenges for the treatment providers. The literature has failed to show consistent, strong predictors of retention. Predictors and treatment structure may differ across treatment modalities. In this study the structure was reinforced by the addition of supervised urine samples three times a week and mandatory daily work/structured education activities as a prerequisite of inclusion in the program.

METHODS

Of 128 patients consecutively admitted to buprenorphine maintenance treatment five patients dropped out within the first week. Of the remaining 123 demographic data and psychiatric assessment were used to predict involuntary discharge from treatment and corresponding cumulative abstinence probability. All subjects were administered the Structured Clinical Interview for DSM-IV-TR, and the Symptom Checklist 90 (SCL-90), the Alcohol Use Disorder Identification Test (AUDIT), the Swedish universities Scales of Personality (SSP) and the Sense of Coherence Scale (SOC), all self-report measures. Some measures were repeated every third month in addition to interviews.

RESULTS

Of 123 patients admitted, 86 (70%) remained in treatment after six months and 61 (50%) remained in treatment after 12 months. Of those discharged involuntarily, 34/62 individuals were readmitted after a suspension period of three months. Younger age at intake, poly-substance abuse at intake (number of drugs in urine), and number of conduct disorder criteria on the SCID Screen were independently associated with an increased risk of involuntary discharge. There were no significant differences between dropouts and completers on SCL-90, SSP, SOC or AUDIT.

CONCLUSION

Of the patients admitted to the programme 50% stayed for the first 12 months with continuous abstinence and daily work. Poly-substance use before intake into treatment, high levels of conduct disorder on SCID screen and younger age at intake had a negative impact on retention and abstinence.

Early maladaptive schemas and personality disorder symptoms: An examination in a non-clinical sample

OBJECTIVE

This study aimed to examine the overall and specific relationship between early maladaptive schemas (EMSs) and personality disorder (PD) symptoms in a non-clinical sample.

DESIGN

While a notable previous study has examined the relationship between EMSs and PD symptoms after statistically controlling for gender and within-cluster PD symptoms, they did not control for comorbid axis I and inter-cluster PD symptoms. Hence, we redressed this methodological problem by statistically controlling for these conditions in a series of multiple regressions.

METHODS

In a sample of 178 non-clinical participants, we obtained self-reports of PD symptoms, depression, anxiety, eating disorder, and EMSs.

RESULTS

Results of a series of multiple regressions found that EMSs significantly predicted all PD symptoms apart from borderline and antisocial PDs and our hypotheses were largely consistent with hypotheses for cluster A and C PDs. We also found that specific EMSs differentially predicted PD subtypes even after controlling for other PD symptoms, depression, anxiety, and eating disorder symptoms.

CONCLUSION

This study supports the contention that PDs are related to EMSs and there are specific relationships between particular EMSs and particular PDs.

Social anxiety disorder: questions and answers for the DSM-V

BACKGROUND

This review evaluates the DSM-IV criteria of social anxiety disorder (SAD), with a focus on the generalized specifier and alternative specifiers, the considerable overlap between the DSM-IV diagnostic criteria for SAD and avoidant personality disorder, and developmental issues.

METHOD

A literature review was conducted, using the validators provided by the DSM-V Spectrum Study Group. This review presents a number of options and preliminary recommendations to be considered for DSM-V.

RESULTS/CONCLUSIONS

Little supporting evidence was found for the current specifier, generalized SAD. Rather, the symptoms of individuals with SAD appear to fall along a continuum of severity based on the number of fears. Available evidence suggested the utility of a specifier indicating a "predominantly performance" variety of SAD. A specifier based on "fear of showing anxiety symptoms" (e.g., blushing) was considered. However, a tendency to show anxiety symptoms is a core fear in SAD, similar to acting or appearing in a certain way. More research is needed before considering subtyping SAD based on core fears. SAD was found to be a valid diagnosis in children and adolescents. Selective mutism could be considered in part as a young child's avoidance response to social fears. Pervasive test anxiety may belong not only to SAD, but also to generalized anxiety disorder. The data are equivocal regarding whether to consider avoidant personality disorder simply a severe form of SAD. Secondary data analyses, field trials, and validity tests are needed to investigate the recommendations and options.

Estudos sobre transtornos de personalidade Antissocial e Borderline

OBJETIVO: Este estudo objetivou revisar, na literatura, os critérios diagnósticos e as intervenções nos transtornos de personalidade do tipo Antissocial e Borderline. MÉTODOS: Uma pesquisa manual foi realizada no acervo bibliográfico particular do autor, selecionando-se 12 referências; outra pesquisa sistematizada foi desenvolvida no período de 1990 a 2008, no mês de janeiro de 2009, na Biblioteca Virtual em Saúde, selecionando-se 23 artigos. RESULTADOS: Os achados indicaram duas abordagens - uma que classifica como doença, mas que necessita de revisão dos critérios diagnósticos e avaliação e a segunda, que classifica como problemas morais. CONCLUSÃO: Independente da abordagem é necessário que o enfermeiro aprimore seu conhecimento e compreenda a dificuldade desse sujeito ao relacionar-se adequadamente com outras pessoas; assim, é de fundamental importância que os membros da equipe de saúde analisem seus sentimentos, atitudes e reações em relação ao comportamento do cliente, uma vez que a relação com esta clientela é considerada uma das mais complexas em saúde mental.

History, context, process, and rationale for the development of clinical guidelines

This paper sets out the rationale and process for the development of clinical guidelines, particularly as they apply to psychological therapies and mental health more generally. The methods by which they are produced are briefly reviewed and some commonly identified problems associated with guideline development are also discussed. The evidence for their effective implementation is reviewed and likely future development in clinical guidelines in mental health and psychological therapies are discussed.

Generalized social anxiety disorder and avoidant personality disorder: structural analysis and treatment outcome

There has been considerable controversy about whether generalized social phobia (GSP) and avoidant personality disorder (APD) are redundant diagnostic categories. In light of the ongoing controversy, more data are needed to help determine whether GSP and APD are independent constructs. Data were obtained from 335 people seeking treatment for GSP at a two site clinical trial. Indicators of GSP and APD were obtained along with assessments of demographic factors, level of functioning, and indicators of related psychopathology. Confirmatory factor analyses of indicators of GSP and APD suggested a somewhat better fit for a two-factor solution. Comparisons of GSP patients with and without APD suggested that in addition to having more severe social phobia symptoms, patients with APD were more depressed on a self-report measure and had more functional impairment, thereby suggesting potential utility of the diagnostic category of APD. Furthermore, the presence of APD predicted treatment response, in that patients with APD had more change early in treatment than those without APD. APD and GSP remain highly related constructs, and different aspects of these data support and dispute the utility of the diagnosis of APD in GSP. Possible new directions in conceptualizing APD are discussed.

Generalized social phobia and avoidant personality disorder: meaningful distinction or useless duplication?

Participants with generalized social phobia (GSP) with (n=36) and without (n=19) avoidant personality disorder (AVPD) were compared via contrasts of group means and classification analysis on purported core features of AVPD. GSP-AVPD participants proved to be more severely impaired or distressed on some group contrasts. Cluster analysis identified two groups in the sample, with group membership significantly correlated to AVPD diagnosis. However, almost all significant findings were nullified when severity of social phobia was statistically controlled. Thus, at least where participants with social phobia are concerned, it seems most parsimonious to consider AVPD a severe form of GSP rather than a separate diagnostic category.

Effectiveness of treatment of childhood memories in cognitive therapy for personality disorders: A controlled study contrasting methods focusing on the present and methods focusing on childhood memories

This study tested the hypothesis that treatment of childhood memories is an effective way to change personality disorder related schemas and psychopathology in cognitive therapy for personality disorders. To test this hypothesis, a crossover design was used to compare the effectiveness of methods focusing on the present and methods focusing on childhood memories. After the exploration period, the therapist focused either first on the present during 24 sessions and than for 24 sessions on childhood memories, or followed the reverse order. Twenty-one patients with one or more Axis II disorders were included. Participants were randomly assigned to order of focus. Results indicate that CT methods focusing on childhood memories produce good outcomes, comparable to those of methods focusing on the present. There was no significant effect of order, but both patients and therapists preferred the past-present order. Total effects of the package were large and were maintained till one-year follow-up (d's 0.97-1.90). Experience of the therapist with CT for personality disorders was related to better outcome (d=0.73).

The association between depressive personality and treatment outcome for depression following a group cognitive–behavioral intervention

The present study investigated the association of depressive personality traits to treatment outcome for depression. One hundred and nineteen patients with a primary diagnosis of major depression were divided into high- and low-depressive personality groups, and depression symptomatology was assessed pre- and postparticipation in a standardized group cognitive-behavioral intervention. Analyses revealed poorer pre-state and end-state functioning for the high-depressive personality group. However, rate of improvement pre- to posttreatment was comparable between the two groups. Subsequent multiple regression analyses revealed that when controlling for pretreatment depression severity, depressive personality was not a predictor of depression treatment outcome. Within the methodological parameters of the current study, depressive personality traits were not associated with a poorer response to cognitive-behavioral treatment for depression.

Schema modes and childhood abuse in borderline and antisocial personality disorders

Complex personality disorders (PDs) have been hypothesized to be characterized by alternating states of thinking, feeling and behavior, the so-called schema modes (Young, Klosko, & Weishaar (2003). Schema therapy: A practioner's guide. New York: Guilford). The present study tested the applicability of this model to borderline personality disorders (BPD) and antisocial personality disorders (APD), and related it to a presumed common etiological factor, childhood trauma. Sixteen patients with BPD, 16 patients with APD and 16 nonpatient controls (all 50% of both sexes) completed a Schema Mode Questionnaire assessing cognitions, feelings and behaviors characteristic of six schema modes. Participants were interviewed to retrace abusive sexual, physical and emotional events before the age of 18. BPD as well as APD participants were characterized by four maladaptive modes (Detached Protector, Punitive Parent, Abandoned/Abused Child and Angry Child). APD displayed most characteristics of the Bully/Attack mode, though not significantly different from BPD. The Healthy Adult mode was of low presence in BPD and of high presence in APD and the nonpatients. Frequency and severity of the three kinds of abuse were equally high in both PD groups, and significantly higher than in nonpatients.

A search for consensus on the dimensional structure of personality disorders

Previous attempts to elucidate the dimensional structure of personality disorders (PDs) have been based on single samples and measures. Like one-item tests, they are useful but scattered and potentially misleading glimpses at the true structure of PDs. Therefore, reanalyses of 33 previously published data sets were conducted using recommended statistical procedures to arrive at consensus structures. Similar reanalyses of published data were conducted on associations between PDs and the five-factor model of normal personality characteristics. High degrees of congruence were observed between the consensus PD structures and the consensus structures suggested by dimensions of normal personality. The analytic techniques used in the present study helped bypass methodological problems inherent in previous tests and revealed higher levels of support for both theoretically and empirically based representations of the five-factor model approach to PDs.

The factor structure of the DSM-III-R personality disorders: an evaluation of competing models

Confirmatory factor analysis was used to test a series of competing models to determine the best way to characterize the factor structure of the DSM-III-R personality disorder scores. Data were collected from 301 clients with a primary diagnosis of anxiety disorder. The Structured Clinical Interview for DSM-III-R (SCID) was used to determine Axis I and Axis II diagnoses, and adequate to good reliability was obtained for the number of criteria met for a given personality disorder. Several factor models were tested, including a single-factor model, a three-factor model based on the DSM grouping of odd, dramatic, and anxious personality disorders, and a four-factor model based on normal personality theories. Only the DSM three-factor model received strong and unequivocal support.

Difficulties in the assessment of personality traits and disorders in eating-disordered individuals

There are compelling reasons to examine personality variables in the eating disorder (ED) field but many impediments to the collection of useful data. In addition to the conceptual and methodological difficulties associated with personality assessment in the general case, the EDs present a number of special problems. These include patients' young age at onset and evaluation, the "state" effects of semi-starvation and chaotic eating, denial and distortion in self-report, the instability of ED subtypes, and the intrusion of eating and weight concerns into a wide range of apparently unrelated domains. Although there is substantial support for the clinical view that personality variables are linked to anorexia nervosa (AN) and bulimia nervosa (BN), the identification of stable traits and Axis II disorders in individual patients should be deferred until after the initial phase of treatment.

Is avoidant personality disorder more than just social avoidance?

Although social avoidance is a defining feature of avoidant personality disorder (APD), some theorists posit that APD is characterized by a broader pattern of avoidance that extends beyond social situations. This paper describes a series of four studies that examined the different types of nonsocial avoidance hypothesized to characterize APD in three undergraduate student samples and a clinical sample of adults with APD. Overall, the findings revealed low to moderate associations between APD and emotional and novelty avoidance, as well as avoidance of various nonsocial events. The results provide support for contemporary models of APD.

Beliefs in personality disorders: a test with the Personality Disorder Belief Questionnaire

The hypothesis that each personality disorder (PD) is characterized by a specific set of beliefs was tested in a sample of 643 subjects, including non-patient controls, axis-I and axis-II patients, diagnosed with SCID-I and -II interviews. Beliefs of six PDs (avoidant, dependent, obsessive-compulsive, paranoid, histrionic, borderline) were assessed with the Personality Disorder Belief Questionnaire (PDBQ). Factor analyses supported the existence of six hypothesized sets of beliefs. Structural equation modeling (SEM) supported the hypothesis that each PD is characterized by a specific set of beliefs. Path coefficients were however in the medium range, suggesting that PDs are not solely determined by beliefs. Nevertheless, empirically derived cutoff scores of the six belief subscales were reasonably successful in classifying subjects, percentages ranging form 51% to 83%. It appeared that there was a monotonical increase in scores on each belief subscale from non-patient controls, to patients without any PD, to patients with PDs (other than the pertinent PD), to patients with the pertinent PD. This suggests that PD-related beliefs are at least partly associated with (personality) psychopathology in general. Another explanation is that many patients' position on the underlying dimensions is not high enough to lead to a DSM PD diagnosis, but high enough to lead to an elevated belief score.

Personality pathology and cognitive-behavioral treatment of fear of flying

Studies have been inconclusive about the influence of personality pathology on treatment outcome in anxiety disorders. In general, it has been presumed that treatment outcome is negatively influenced by the presence of personality pathology. This is a study of the prevalence of personality pathology among persons who were seeking help for fear of flying. Moreover, the effects of personality pathology on the results of a multimodal, standardized, cognitive-behavioral fear of flying treatment program employed by an agency that specializes in treating people with fear of flying were studied. Personality pathology was determined with a self-report questionnaire, which provides ICD-10 diagnoses of personality disorders and dimensional severity scores for personality pathology. Treatment outcome was assessed with three different fear of flying questionnaires. Based on clinical judgment after individual-case conceptualization, participants (N=922) were assigned to a particular treatment for fear of flying. Self-report data for fear of flying were collected at pretreatment and at 3, 6 and 12-month follow-ups in 659 participants who followed the 2-day treatment program. Moreover, the number of flights made in the year following treatment was determined.The results of this study showed that participants with personality pathology, mainly from cluster C (anxiety), report greater fear of flying before treatment than participants without personality pathology. After treatment fear of flying was significantly reduced. Presence of personality pathology was not predictive of the number of flights after treatment and scores on the VAFAS scale at short or long term. Only on two questionnaires for fear of flying collected at short-term participants with personality pathology obtained significantly higher scores, although the size of the differences was relatively small. It was concluded that participants with personality pathology also benefited from fear of flying treatment and that the presence of personality pathology although cannot be regarded as a contra indication for a standardized, cognitive-behavioral group treatment.

Is treatment-resistant depression a unique subtype of depression?

Treatment-resistant depression (TRD) continues to represent a major challenge for treating clinicians. This report reviews the relevant literature to evaluate whether TRD can be considered a specific subtype of depression based on 1) clinical characteristics and course (behavioral phenotype), 2) neurobiological profile, and 3) context and environment in which TRD develops. Although patients with TRD share a number of clinical, neurobiological, and context and environment characteristics, the lack of available data and the clinical heterogeneity of this condition do not currently permit the classification of TRD as a unique subtype of depression; however, this topic is worthy of further evaluation and research. Performing genetics and neuroimaging studies on patients enrolled in large, prospective and controlled studies may provide enough data for classifying TRD (or at least a part of what is currently described as TRD) as a specific subtype of depression. This in turn may facilitate the identification of more effective treatment strategies.

No evidence for overgeneral memories in borderline personality disorder

The hypothesis that borderline personality disorder (BPD) is related to overgeneral memories was tested in a mixed sample of 39 patients. A memory test with emotional cue words and the instruction to produce specific autobiographical memories was used. Specificity was judged by an independent rater. Regression analyses indicated that age and major depressive disorder were related to the production of less specific memories, whereas educational level and presence of personality disorder were positivily related to number of specific memories. Borderline personality disorder, anxiety disorders and childhood traumas were not related to number of specific memories.

Anorexia nervosa: obsessive-compulsive disorder, obsessive-compulsive personality disorder, or neither?

Anorexia nervosa (AN) is a severe and often chronic disorder with uncertain aetiology and poor prognosis. New approaches to the understanding of the disorder are needed in order to aid the development of more effective treatments. Several authors have suggested that AN has a considerable overlap with obsessive-compulsive disorder (OCD) and that this may reflect common neurobiological, genetic, or psychological elements. However, more recent studies have suggested that AN may have a closer relationship with obsessive-compulsive personality traits such as those found in obsessive-compulsive personality disorder (OCPD). In this paper, evidence for links between the three conditions is reviewed, suggestions for further research are outlined and possible implications for the treatment of AN are presented.

In-patient treatment of borderline personality disorder: convergences and divergences between a psychoanalytical and a cognitive-behavioral approach

For more than 20 years, patients with borderline personality disorder have been treated as in-patients in the UC St-Jozef in Kortenberg, Belgium. The majority of these patients were treated in a psychoanalytical or a behavior therapy ward. During these years, the treatment programs of these wards were gradually adjusted to the challenges provided by these patients. In this paper, we will describe the process of change that both wards have experienced. We will highlight similarities and differences between the approaches that are the result of an evolution over years. In both approaches, there is a strong emphasis on training and support for staff. While the psychoanalytical ward uses a group approach, the behavior therapy ward evolves towards a more individualized treatment.

Avoidant personality disorder: current status and future directions

Avoidant Personality Disorder (APD) is the topic of a growing body of research literature. In this article, we review empirical studies of APD with the goals of identifying the themes that underlie this work and pointing to new directions for future research. In particular, we recommend that future studies evaluate several unique factors postulated by personality theorists to be central to this condition.

Evaluations of others by borderline patients

This study investigated evaluations of other people in specific emotional situations by patients with borderline personality disorder (BPD). BPD patients (N = 16), control patients with cluster C personality disorder (PD; N = 12) and normal controls (N = 15) saw film clips with emotional themes centering on abandonment, rejection and abuse, hypothesized to be specific for borderline pathology. Subjects wrote down their spontaneous reactions to six film personalities, divided over three clips, including what they thought to be characteristic traits of these persons. Spontaneous reactions were coded on two dimensions, based on earlier studies by Westen and colleagues: a) affect-tone of ascribed qualities and b) complexity of evaluations of people. The number of trait dimensions constituted the third scale. The overall pattern of findings suggests that the BPD group, as well as the cluster C group, show poorly differentiated evaluations with a low number of dimensions. Thus, this seems characteristic for personality disorders in general. The BPD group shows a lower affect-tone, reflecting a stronger tendency to view others negatively, compared with both control groups.

Is electroconvulsive therapy effective for the depressed patient with comorbid borderline personality disorder?

Among the more common current indications for electroconvulsive therapy (ECT) is treatment-resistant depression. Treatment resistance is correlated with a number of factors, including the presence of comorbid personality disorders, such as borderline personality disorder (BPD). A detailed review of the literature was undertaken and very few reports or studies have dealt specifically with ECT in borderline patients. Thirteen original reports on ECT outcome in personality disordered patients were identified. Depressed patients with a personality disorder, particularly BPD, may have a poorer outcome on some measures. However, the available data suggests that depression in these patients can be effectively treated with ECT. The depressed, borderline patient appears to have two distinct disorders, one which is responsive to ECT and the other which is not. Unfortunately, the literature is limited by lack of rigorous randomized treatment studies, lack of long-term follow-up, and other methodological weaknesses. Clinical guidelines are suggested.