Patient-therapist attachment in the treatment of borderline personality disorder

The authors report preliminary findings from a longitudinal study on the impact of attachment state of mind and reflective function on therapeutic process and outcome with borderline patients in Transference-Focused Psychotherapy (TFP). TFP is a manualized, psychoanalytically oriented treatment based on an object relations model of understanding patients with severe personality disorders. The attachment theory constructs of internal working models of attachment and mentalization or reflective function provide an important means of both conceptualizing borderline disorders and assessing therapeutic process and change. In the Personality Disorders Institute at New York Presbyterian Hospital-Weill Medical College of Cornell University, the authors have been using the Adult Attachment Interview (AAI) to assess changes in state of mind with respect to attachment and reflective function over the course of 1 year in borderline patients in TFP treatment. As part of the authors' investigations of the impact of patients' attachment status on the therapeutic process, they have adapted the AAI to evaluate states of mind with respect to attachment within the therapeutic relationship through an interview called the Patient-Therapist Adult Attachment Interview (PT-AAI). The AAI is given at 4 months and 1 year, and the PT-AAI is given to patients after 1 year of TFP, and both interviews are scored for attachment classification and reflective function. The authors present preliminary findings on change in both attachment classification and reflective function ratings at 4 months and 1 year for a subsample of 10 patients and therapists. They also present two cases that illustrate how the quality of mentalization or reflective function in the therapeutic dyad may be seen as a bidirectional process in that therapists' and patients' levels of reflective function are mutually and reciprocally influential. In one case, the patient's and therapist's reflective function mirrored each other directly and remained at a low or rudimentary level for the treatment year. Such a pattern of direct imitation does not necessarily promote intrapsychic change. In the second case, the patient moved from a rejecting or bizarre stance toward mentalization on the AAI to some rudimentary consideration of mental states after 1 year of treatment with a therapist who showed a full and nuanced awareness of mental states, but who adjusted his level of mentalization to that of the patient. These findings suggest that optimally the therapist ought to be one step ahead of the patient in the capacity for mentalization.     

Conduct disorder and antisocial personality disorder in persons with severe psychiatric and substance use disorders

Conduct disorder (CD) and antisocial personality disorder (ASPD) are established risk factors for substance use disorders in both the general population and among persons with schizophrenia and other severe mental illnesses. Among clients with substance use disorders in the general population, CD and ASPD are associated with more severe problems and criminal justice involvement, but little research has examined their correlates in clients with dual disorders. To address this question, we compared the demographic, substance abuse, clinical, homelessness, sexual risk, and criminal justice characteristics of 178 dual disorder clients living in 2 urban areas between 4 groups: No CD/ASPD, CD Only, Adult ASPD Only, and Full ASPD. Clients in the Adult ASPD Only group tended to have the most severe drug abuse severity, the most extensive homelessness, and the most lifetime sexual partners, followed by the Full ASPD group, compared with the other 2 groups. However, clients with Full ASPD had the most criminal justice involvement, especially with respect to violent charges and convictions. The results suggest that a late-onset ASPD subtype may develop in clients with severe mental illness secondary to substance abuse, but that much criminal behavior in clients with dual disorders may be due to the early onset of the full ASPD syndrome in this population and not the effects of substance use disorders.     

Sexually transmitted disease rates and high-risk sexual behaviors in borderline personality disorder versus borderline personality disorder with substance use disorder

We examined the rates of sexually transmitted diseases (STDs) in women with borderline personality disorder (BPD) (using PDE and SCID-II) and substance abuse or dependence (SCID-I) (BPD-SUD) (N=82) compared with those with BPD-only (N=102), exploring mediators of this relationship. Participants were interviewed about STD history (gonorrhea, genital herpes, syphilis, trichomonas, human papillomavirus, and HIV), condom use, number of sexual partners, poverty, and prostitution. BPD-SUD appeared to be particularly at high risk for STDs, reporting significantly more STDs than BPD (F[1,172]=11.74, p=0.001, d=.27), particularly for gonorrhea, trichomonas, and human papillomavirus. The relationship between BPD-SUD and STDs is mediated by poverty, prostitution in the last year, recent unprotected sex with two or more partners, and >20 lifetime partners (z=-2.16 which is p=0.03), with prostitution alone making a significant contribution to this relationship (z=-2.49, p=0.01).     

Distress tolerance moderates the relationship between negative affect intensity with borderline personality disorder levels

A number of studies have suggested that negative emotionality and negative affect intensity play key roles in the development and maintenance of borderline personality disorder (BPD). However, more recent research indicates that one's response to affective discomfort may be an even more important variable in the pathogenesis of BPD than either negative emotionality or negative affect intensity per se. As such, the current study aimed to empirically test the moderating role of 2 well-validated laboratory measures of the ability to tolerate psychological distress (distress tolerance) in the relationship of negative emotionality and negative affect intensity with BPD levels. Results provide laboratory-based evidence for a moderating effect of distress tolerance on the relationship of negative emotionality and negative affect intensity with levels of BPD. Specifically, the 2 former variables were related to levels of BPD among those with low distress tolerance. The current results add support to existing developmental frameworks of BPD and suggest the importance of modifying one's response to affective distress along with levels of negative emotionality in treatment settings.     

Discriminant efficiency of antisocial and borderline personality disorder criteria in Hispanic men with substance use disorders

The authors examined the discriminant efficiency of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition ( DSM-IV ) criteria for borderline personality disorder (BPD) and antisocial personality disorder (APD). Subjects were 74 men admitted to an outpatient substance abuse program for monolingual Hispanic adults. All were reliably assessed with the Spanish-language version of the Diagnostic Interview for DSM-IV Personality Disorders. Conditional probabilities were calculated to determine the diagnostic efficiency and discriminant efficiency of BPD and APD symptoms. Twenty-five (34%) subjects met diagnostic criteria for BPD, and 16 (22%) met criteria for APD. The diagnostic co-occurrence of these disorders was statistically significant. Whereas the diagnostic efficiency of the BPD criterion set was comparable to that reported in other clinical studies, these criteria were not significantly more efficient in diagnosing BPD than APD. By contrast, the APD criteria were more efficient in diagnosing APD than BPD; this was true for both the "adult" and the "conduct disorder" APD criterion subsets. In male Hispanic outpatients with substance use disorders, BPD and APD show significant diagnostic overlap. The APD criteria are useful in discriminating these 2 disorders, whereas the BPD criteria are not. These findings have implications for the discriminant validity of the BPD and APD criteria and support the value of the conduct disorder criteria in predicting APD in adulthood.     

Relapse of substance use disorder and its prevention among persons with co-occurring disorders

This article summarizes the scientific literature on the relapse process, describes the basic principles of relapse prevention treatment, highlights the major empirical studies, and offers suggestions for future research and application, especially in terms of ongoing care for persons with co-occurring disorders. Relapse prevention treatments have a well-established efficacy and effectiveness for persons with substance use disorders. Key ingredients include reducing exposure to substances, fostering motivation for abstinence, self-monitoring, recognizing and coping with cravings and negative affect, identifying thought processes with relapse potential, and deploying, if necessary, a crisis plan. Relapse prevention approaches may be best suited for persons in the action of maintenance stages of treatment or recovery. Further research is needed to examine relapse prevention therapies as a key component to continuing care for persons with co-occurring substance use and psychiatric disorders.     

Oscillations of attachment in borderline personality disorder

The authors propose that oscillations of attachment in borderline personality disorder stem from a central problem with regulation of interpersonal distance. This problem derives from borderline patients' conflicts between fears of abandonment and domination. When they move closer to others, they fear that they will be dominated; when they move away, they fear that they will be abandoned. Whichever direction they move, they experience negative feedback. This gives rise to recurrent oscillations between attachment to and detachment from others. Because the oscillations are reinforced by the ambivalent reactions of significant others and the involvement of third parties, family therapy is often indicated.     

The relationship between borderline personality disorder and anxiety disorders

Eleven "pure" borderlines, ten borderlines with depression, 16 "pure" depressives, and 31 normal subjects were compared on a number of standardized inventories of anxiety. While patient groups experienced more anxiety of all types than did normals, borderlines did not emerge as more anxious than other patient groups. Qualitative differences in the anxiety experienced by borderlines and nonborderlines are discussed.     

A multimodal assessment of the relationship between emotion dysregulation and borderline personality disorder among inner-city substance users in residential treatment

The concept of emotion dysregulation has been integrated into theory and treatment for borderline personality disorder (BPD), despite limited empirical support. Expanding upon existing research on the relationship between emotion dysregulation and BPD, the present study utilized a multimodal approach to the assessment of emotion dysregulation (including two behavioral measures of the willingness to tolerate emotional distress, and a self-report measure of emotion dysregulation broadly defined) to examine the relationship between emotion dysregulation and BPD among inner-city substance users in residential treatment (n = 76, with 25 meeting criteria for BPD). Results provide laboratory-based evidence for heightened emotion dysregulation in BPD, extending extant research on BPD to underserved clinical populations. Specifically, the presence of a BPD diagnosis among a sample of inner-city inpatient substance users was associated with both higher scores on the self-report measure of emotion dysregulation and less willingness to tolerate emotional distress on the behavioral measures of emotion dysregulation. Moreover, both self-report and behavioral measures of emotion dysregulation accounted for unique variance in BPD status, suggesting the importance of utilizing comprehensive assessments of emotion dysregulation within studies of BPD. Findings suggest the need to further explore the role of emotion dysregulation in the development and maintenance of BPD among inner-city substance users in residential treatment.     

Temperament and character in persons with borderline personality disorder

High comorbidity, suicidal ideation, difficult temperament, and character are key symptoms of persons with borderline personality disorder (BPD). We investigated 478 persons, 40 of whom had a BPD according SCID-II, self-rating. Participants were examined with a semistructured interview and several self-rating questionnaires in their households. Taking the high comorbidity of persons with BPD into account, we compared the BPD group with four control groups with different axis 1 or personality disorders and one nonclinical group. Persons with BPD showed high comorbidity with affective, anxiety, and alcohol use disorders. With respect to suicidality, 75% reported that they wish to be dead at least sometimes, and about one-third said that they had already attempted suicide. Regarding temperament and character dimensions, our analyses revealed higher novelty seeking for persons with BPD compared to participants without BPD, although this difference was primarily attributable to males with BPD. Additionally, participants with BPD reported higher harm avoidance compared to control groups, while this was more distinctive for females. Finally, we found that persons with BPD had very low levels of self-directedness. This effect was independent from gender and was found in all group comparisons. Therapy of BPD should take into account high comorbidity and suicidality of patients. Moreover, our results show that low self-directedness seems to be specific for persons with BPD. Therefore, therapy must address those deficits by focusing on skills training as well as on aspects of maturation.     

Gambling disorders among homeless persons with substance use disorders seeking treatment at a community center

OBJECTIVES: Epidemiological research suggests that homelessness is a risk factor for elevated levels of psychiatric comorbidity and other health risks. This study examined the prevalence of disordered gambling and its association with treatment of psychiatric and substance use disorders among a cohort of homeless people seeking treatment at a community services program. METHODS: Between 1998 and 2000, intake workers evaluated the level of gambling disorder among 171 consecutive homeless persons with substance use disorders who sought treatment at the Moving Ahead Program in Boston. Program staff administered the DSM-IV subscale of the Massachusetts Gambling Screen at intake. RESULTS: The prevalence rates of level 2 and level 3 gambling disorders were 12.8 percent and 5.5 percent, respectively. These rates are higher than that of the general adult population but comparable to those of other patients with substance use disorders and psychiatric diagnoses. Program participants with level 3 gambling disorders had been homeless more often and at a younger age and had had less substance abuse treatment and more psychiatric treatment than participants with level 1 or level 2 gambling disorders. Participants with level 2 gambling disorders had been homeless more often and for a longer duration than participants without gambling disorders. CONCLUSIONS: These findings should encourage clinicians working with homeless people to screen for gambling-related problems and disorders.     

Substance use in borderline personality disorder

The authors investigated the prevalence of substance abuse in 137 inpatients with DSM-III borderline personality disorder. Ninety-two (67%) of these patients were given DSM-III substance use disorder diagnosis. The most frequently used substances were alcohol and sedative-hypnotics. When substance abuse was not used as a diagnostic criterion for borderline personality disorder, 32 (23%) of the 137 patients no longer met borderline criteria. These patients differed significantly from the rest of the patients in severity and course of illness. These data suggest that there might be a subgroup of borderline patients for whom substance use plays a primary role in the development of borderline psychopathology.     

Health service use among persons with comorbid bipolar and substance use disorders

OBJECTIVE: This study tested the hypothesis that patients with comorbid bipolar and substance use disorders use health services to a greater extent than patients with either bipolar or substance use disorder alone. METHODS: A retrospective chart review was conducted among patients who used health services at the Ralph H. Johnson Department of Veterans Affairs medical center in Charleston, South Carolina, and had bipolar disorder alone, substance use disorder alone, and comorbid bipolar and substance use disorders. Patients with a psychiatric admission between 1999 and 2003 were included in the study. Information was collected on the use of health services one year before and including the index admission. RESULTS: The records of 106 eligible patients were examined for this study: 18 had bipolar disorder alone, 39 had substance use disorder alone, and 49 had both bipolar and substance use disorders. Compared with the other two groups, the group with comorbid bipolar and substance use disorders was significantly more likely to be suicidal. Compared with the group with bipolar disorder alone, the group with comorbid disorders had significantly fewer outpatient psychiatric visits and tended to have shorter psychiatric hospitalizations. Among patients with an alcohol use disorder, those who also had bipolar disorder were significantly less likely than those with an alcohol use disorder alone to have had an alcohol-related seizure. Patients with comorbid bipolar and substance use disorders were significantly less likely than those with substance use disorder alone to be referred for intensive substance abuse treatment, even though both groups were equally likely to enter and complete treatment when they were referred. CONCLUSIONS: Despite significant functional impairment among patients with comorbid bipolar and substance use disorders, they had significantly fewer psychiatric outpatient visits than those with bipolar disorder alone and were referred for intensive substance abuse treatment significantly less often than those with substance use disorder alone.     

Sexual practices among patients with borderline personality disorder

The authors found that 12 (57%) of 21 consecutive male patients with borderline personality disorder who presented for psychiatric treatment at two distant geographic sites were homosexual. They then obtained the sexual histories of 80 patients who met standardized criteria for borderline disorder and found that 17 (21%) of these patients were homosexual, four (5%) were bisexual, and nine (11%) had diagnoses of paraphilias. Ten (53%) of the 19 men with borderline disorder were homosexual, compared with seven (11%) of the 61 women. Homosexuality was 10 times more common among the men and six times more common among the women with borderline personality disorder than in the general population or in a depressed control group.     

Chronic suicidality among patients with borderline personality disorder

OBJECTIVE: This paper reviews research on chronic suicidality among patients with borderline personality disorder. METHODS: MEDLINE and PsycINFO databases were searched for all English-language articles published between 1984 and 2000 containing the keywords "borderline personality disorder" and "suicide" or "suicidality." A total of 170 articles located through this search and additional key articles published before 1990 were reviewed. The most relevant articles were selected of review. RESULTS AND CONCLUSIONS: One in ten patients with borderline personality disorder completes suicide, but this outcome is not readily preventable and does not necessarily occur during the course of treatment. In outpatient psychotherapy, chronic suicidal behavior by patients with borderline personality disorder can be best understood as a way of communicating distress. Hospitalization is of unproven value in preventing suicide by these patients and can sometimes have negative effects. Clinicians' fear of potential litigation resulting from a completed suicide should not be the basis for admission. With no evidence that full hospitalization prevents suicide completion by patients with borderline personality, suicidal risk is not a contraindication for day hospital treatment.