Conceptualization and treatment of personality disorders

Changes in Attachment Representation and Personality Organization in Transference-Focused Psychotherapy

OBJECTIVE

The aim of this article was to construct an empirical bridge between object relations theory and attachment theory by investigating how researchers in both traditions have contributed to understanding and assessing identity diffusion (a keystone of personality pathology) and object relations in patients with borderline personality disorder during 1 year of transference-focused psychotherapy (TFP).

METHODS

The Adult Attachment Interview (AAI) and the Structured Interview of Personality Organization (STIPO) were administered to patients (N=104, all women) before and after 1 year of treatment. This study was part of a randomized controlled trial in which 104 patients with borderline personality disorder were randomly assigned to receive either TFP (a manualized, structured psychodynamic treatment approach) or treatment by experienced community psychotherapists. Changes on the AAI in attachment representations, narrative coherence, and reflective function were examined for their associations with changes on the STIPO in identity, object relations, and aggression.

RESULTS

Patients who shifted from disorganized (unresolved) to organized attachment on the AAI after 1 year of TFP (but not treatment by experienced community psychotherapists) showed hypothesized improvements in domains of personality organization on the STIPO, including identity, object relations, and aggression. Those who did not change from disorganized (unresolved) to organized attachment improved only in the domain of aggression.

CONCLUSIONS

These findings highlight the centrality of identity diffusion to borderline personality disorder pathology and the importance of targeting it in treatment. Furthermore, the results suggest that identity may be indexed by measures of attachment security, narrative coherence, and personality organization.

Diagnosis on the way out - personality on the way in? Priorities in treatment in child and adolescent psychiatry

The scientific basis for practice in child psychiatry has developed apace. And has thrown up several quandries for an accepted paradigm for good practice anchored to the diagnostic schema developed in adult psychiatry. This paper hopes to stimulate discussion about where alternative paradigms might lead us on a path to precision medicine as applied to child psychiatry.

Child psychiatry: a model for specific goals for in-patient treatment linked to resources and limitations in out-patient treatment

SUMMARY

I present a rationale for two different types of in-patient child psychiatric unit: 24/7 intensive units and 24/5 child and family units. Intensive units address safety requirements. The developing personality of young people is at the centre of in-patient approaches on the child and family units. This requires attachment-informed practice. Families must always be involved and placement of units must facilitate their participation. The primary skill characterising these units is use of the milieu for therapy and combining this with family therapy. In other words, nurses and allied professionals need to be the dominant force in unit development, under the reflective guidance of consultants and clinical psychologists.

Personality, personality disorders, and the process of change

OBJECTIVE

The present paper elaborates a process perspective of change in psychotherapy for personality disorders (PDs). Firstly, the paper reviews the literature of mechanisms of change in treatments of PD, with the main focus on emotional processing and socio-cognitive processing. Secondly, it proposes an illustrative case-series analysis of eight cases, drawn from a mediation analysis conducted within the context of a randomized controlled trial for borderline personality disorder (BPD).

METHOD

As such, cases with good and poor outcomes are compared, as are cases with poor and good intake features and cases with poor and good process markers across treatment.

RESULTS

The results illustrate possible pathways to healthy change over the course of four months of treatment, and possible pathways of the absence of change.

CONCLUSIONS

These results are discussed with regard to three main research perspectives: the combination of qualitative and quantitative methodology in psychotherapy research may be applied to case study research, a neurobehavioral perspective on change may incorporate the individualized experience in the laboratory and therapist responsiveness to patient characteristics may be a core feature of fostering change. Clinical or methodological significance of this article: The present paper illustrates individual pathways to change in personality disorders. It illustrates how coping capacities influence the process of psychotherapy and outcome in personality disorders. It demonstrates the relevance of individualizing treatments for personality disorders. It demonstrates several integrative features of psychotherapy research, in particular the use of neurobehavioral paradigms and the integration of single-case research within randomized controlled trials.

Personality disorders in DSM classifications

In the article an overview of history of personality disorders’ diagnostic criteria has been presented since the publication of The Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1952 up to the fifth edition published in 2013. Describing the beginnings of the classification in psychology, theses of a German philosopher and psychologist William Stern (1871-1938), the founder of psychology of individual differences have been examined, as he defined ‘type’ as a dominating psychological or psychophysiological predisposition. Changes in typologies in subsequent editions of DSM were aimed at increased accuracy of description of differentiated personality disorders’ types. The goal of such descriptions was to increase the accuracy of clinical diagnosis of individuals displaying in various domains of life repeated perceptional and behavioral patterns. Since the first edition of DSM the categorical perspective has been emphasized, which in the present edition has been replaced by the dimensional – categorical model, defined as a hybrid one. This change has already led to various controversies and discussions, and therefore requires further research.

Toward a multidimensional model of personality disorder diagnosis: implications for DSM-5

This article outlines a model of personality disorder (PD) diagnosis that combines clinically useful constructs from the Diagnostic and Statistical Manual of Mental Disorders (DSM) with assessment procedures that maximize reliability and clinical utility while minimizing problems associated with threshold-based PD classification. I begin by addressing limitations in the current DSM conceptualization of PDs: excessive comorbidity, use of arbitrary cutoffs to distinguish normal from pathological functioning, failure to capture variations in the adaptive value of PD symptoms, and inattention to situational influences that shape PD-related behaviors. The revisions proposed by the DSM-5 Personality and Personality Disorders Work Group help resolve some of these issues, but create new problems in other areas. A better solution would be to employ a multidimensional model of PD diagnosis in which clinicians (a) assign a single dimensional rating of overall level of personality dysfunction, (b) provide separate intensity and impairment ratings for each PD dimension, and (c) list those personality traits-including PD-related traits-that enhance adaptation and functioning. Preliminary evidence bearing on the multidimensional model is reviewed, and broader clinical and empirical implications of the model are discussed.

Another day older and deeper in therapy: Can the Dynamic-Maturational Model offer a way out?

Patients referred to adolescent psychiatric units have often been in contact with services for many years. When assessing for admission we consider why the previous approaches might have failed and how milieu therapy might be more effective as the priority treatment. We propose that the information provided by an adolescent's Transition to Adulthood Attachment Interview (TAAI) and the parents' Adult Attachment Interviews (AAI) leads to an especially productive case formulation. The Dynamic-Maturational Model of attachment and adaptation (DMM) uniquely provides a detailed understanding of an extended range of Type A and Type C strategies with modifiers that are useful for planning the milieu therapy, individual and family work. In addition, this case presentation illustrates the usefulness of understanding the phenomenon of "intruded negative affect".

Impaired decentration in personality disorder: a series of single cases analysed with the Metacognition Assessment Scale

BACKGROUND

There is growing support for the idea that an impaired understanding of others' mental states is an underlying feature of personality disorder (PD). Only recently has there begun to be evidence of impairments to subjects' ability to infer and reason about others' intentions and emotions, and detach from their own perspective when doing so.

METHOD

We analysed the transcripts from the first 16 psychotherapy sessions of 14 PD patients. Scales for understanding others' minds from the Metacognition Assessment Scale were used.

RESULTS

Patients were generally able to describe others' mental states, although, at times, they had problems. There was, on the other hand, an inability to decentre while reasoning about others, and this was common to all the patients.

CONCLUSIONS

PDs indeed feature a poor decentration, which is not easily identified with the usual lab tasks. Implications for further research and treatment are discussed.

KEY PRACTITIONER MESSAGE

*Patients with personality disorders have substantial difficulties in adopting others' point of view and standing back from their own, and grasping that they are not the center of other peoples' thoughts.

Psychic structure: exploring an empirically still unknown territory

The Scales of Psychological Capacities (SPC) were developed to gauge structural change, the mode-specific effect of psychoanalysis and psychoanalytic psychotherapies. In this study, as a first step, basic psychometric properties that assess psychic structure were examined. Construct validity was investigated as predictive validity in a known-groups approach. Two predictions were formulated: (1) there are differences in psychic structure between borderline patients, depressive patients, and healthy controls that are verified by the SPC, and (2) borderline patients show inconsistent and divergent self- and object representations most frequently, followed by depressive patients and, finally, by healthy controls, a fact reflected by the SPC. These scales were applied to a sample of 33 borderline patients, 36 depressed women, and 36 healthy controls. Both predictions were confirmed. Thus, empirical evidence is provided of the SPC being a valid measure for assessing psychic structure.

[The empirical development of transference-focused psychotherapy]

The author describes the stages of elaboration of Transference Focused Psychotherapy (TFP) : choice of theoretical model, observation and analyses of several sessions of psychotherapy led by experienced therapists, team discussions on problems encountered that rise both from the pathology itself and from the therapeutic approach applied, a quest of empirical data to explain as much the personality disorder as its neurological and psychological roots, etc. The author reviews the efforts made to arrive at the description in writing of a manual on TFP, a manual that meets the criteria of a treatment method. Finally, the author summarizes studies conducted to measure the psychotherapeutic efficacy of the method and the possibilities of generalizability.

[Predictors of dropout during psychoanalytic treatments of patients with personality disorders]

OBJECTIVES

Are there predictive factors which impair the progress in psychoanalytic treatments of patients with severe personality disorders?

METHODS

In 38 psychoanalytic treatments, severity of symptoms (SCL-90-R), interpersonal problems (IIP), character traits and psychostructural functioning (SWAP-200) were investigated half-yearly. Predictors for drop-out were identified using stepwise binary logistic regression models and repeated ANOVA models. The statistical stability was controlled using a jackknife algorithm.

RESULTS

For the first year denial of needs for closeness, conflicts around engagement and abandonment, as well as fears of an impulsive breakthrough of negative affects predicted dropout of therapy. During the second year externalizing defence, projection/projective identification, somatisation, hypochondria and dismissive interpersonal behaviour predicted break-ups.

CONCLUSIONS

For psychoanalytic technique, it is necessary to perceive and catch paranoid anxieties, negative affects, externalizing mechanisms and projective identification from the very beginning as well as to interpret and work through these elements in transference thoroughly in order to prevent treatment dropout.

The relationship between avoidant personality disorder and social phobia

The main explanatory hypothesis for the distinction between social phobia (SP) and avoidant personality disorder (APD) has been the severity continuum hypothesis, stating that APD only differs from SP in terms of severity of dysfunction and symptomatic distress, that is, social anxiety and depressive symptoms. This study aimed at a comprehensive evaluation of this hypothesis in a large sample (n = 2192) of thoroughly assessed patients, most of whom had a diagnosis of personality disorder. Social phobia was stronger associated with APD than with other personality disorders, and APD was stronger associated with SP than with other symptom disorders. Social phobia-pure patients had a higher level of global functioning and lower levels of general symptom distress and interpersonal problems than APD-pure patients. The 2 groups were similar on domains that pertain to social anxiety and introversion, but APD was associated with a broader array of symptoms and interpersonal problems and was substantially lower on the personality domain of conscientiousness. Avoidant personality disorder was stronger associated with eating disorders, and SP was stronger associated with panic disorder. The APD diagnosis seems to capture a broader constellation of symptoms and personality features pointing toward more severe personality dysfunction. Our findings suggest that the severity continuum hypothesis lacks specificity and exploratory power to account for both similarities and differences between SP and APD.

The mechanisms of change in the treatment of borderline personality disorder with transference focused psychotherapy

We address how Transference Focused Psychotherapy (TFP) conceptualizes mechanisms in the cause and maintenance of borderline personality disorder (BPD) as well as change mechanisms both within the patient and in terms of specific therapists' interventions that engender patient change. Mechanisms of change at the level of the patient involve the integration of polarized representations of self and others; mechanisms of change at the level of the therapist's interventions include the structured treatment approach and the use of clarification, confrontation, and "transference" interpretations in the here and now of the therapeutic relationship. In addition, we briefly review evidence from our group regarding the following hypothesized mechanisms of change: contract setting, integration of representations, and changes in reflective functioning (RF) and affect regulation.