Comorbid antisocial and borderline personality disorders: mentalization-based treatment

Mentalization is the process by which we implicitly and explicitly interpret the actions of ourselves and others as meaningful based on intentional mental states (e.g., desires, needs, feelings, beliefs, and reasons). This process is disrupted in individuals with comorbid antisocial (ASPD) and borderline personality disorder (BPD), who tend to misinterpret others' motives. Antisocial characteristics stabilize mentalizing by rigidifying relationships within prementalistic ways of functioning. However, loss of flexibility makes the person vulnerable to sudden collapse when the schematic representation is challenged. This exposes feelings of humiliation, which can only be avoided by violence and control of the other person. The common path to violence is via a momentary inhibition of the capacity for mentalization. In this article, the authors outline their current understanding of mentalizing and its relation to antisocial characteristics and violence. This is illustrated by a clinical account of mentalization-based treatment adapted for antisocial personality disorder. Treatment combines group and individual therapy. The focus is on helping patients maintain mentalizing about their own mental states when their personal integrity is challenged. A patient with ASPD does not have mental pain associated with another's state of mind; thus, to generate conflict in ASPD by thinking about the victim will typically be ineffective in inducing behavior change.     

Differential interventions in psychotherapy of borderline,narcissistic, and schizoid personality disorders: the Masterson approach

Recent years have witnessed an intensified impetus to specify psychotherapy strategies and techniques appropriate to particular psychological disorders. J. F. Masterson has formulated a developmental, self, and object relations theory which proposed diagnosis-specific interventions for the borderline, narcissistic, and schizoid personality disorders: confrontation of maladaptive defences with borderline patients, mirroring interpretation of narcissistic vulnerability with the narcissistic disorder, and interpretation of the ‘schizoid dilemma’ with schizoid patients. This theoretical perspective will be described, and case examples will be used to illustrate the technical differences in the treatment approaches for each. © 1997 John Wiley & Sons, Ltd.     

The big five factors of personality and their relationship to personality disorders

Articles examining the relationship between the Big Five factors of personality and personality disorders (PDs) are reviewed. A survey of these studies indicates that there is some agreement regarding the relationship between the Big Five and PDs. However, the level of agreement varies and may be a function of instrumentation, the method of report, or how data have been analyzed. Future research should consider the role of peer-ratings, examine the relationship between PDs and the first-order factors of the Big Five, consider dimensions over and above the Big Five as predictors of PDs. © 1997 John Wiley & Sons, Inc. J Clin Psychol 53 : 587–593, 1997.     

Hypothesized mechanisms of change in cognitive therapy for borderline personality disorder

Preliminary evidence suggests that cognitive therapy (CT) is effective in treating borderline personality disorder (BPD). According to cognitive theory, BPD patients are characterized by dysfunctional beliefs that are relatively enduring and inflexible and that lead to cognitive distortions such as dichotomous thinking. When these beliefs are activated, they lead to extreme emotional and behavioral reactions, which provide additional confirmation for the beliefs. It is hypothesized that a change in dysfunctional beliefs is the primary mechanism of change associated with CT. However, additional mechanisms of change are likely also at work in CT, including enhancement of skills, reduction in hopelessness, and improvement in attitude toward treatment. Each of these mechanisms is discussed in light of cognitive theory, data from an open clinical CT trial, relevant literature, and therapeutic interventions. Findings from the CT trial support the role of cognitive change during therapy and its continuation after termination.     

Disorganized attachment and borderline personality disorder: a clinical perspective

The aim of this paper is to explore the links between the attachment-theory derived concept of disorganized attachment, and the psychiatric diagnosis of Borderline Personality Disorder (BPD). Disorganized attachment can be understood in terms of an approach-avoidance dilemma for infants for whom stressed or traumatized/traumatizing caregivers are simultaneously a source of threat and a secure base. Interpersonal relationships in BPD including those with care givers is similarly seen in terms of approach-avoidance dilemmas, which manifests themselves in disturbed transference/countertransference interactions between therapists and BPD sufferers. Possible ways of handling these phenomena are suggested, based on notion of 'meta-cognitive monitoring', in the hope of re-instating meaning and more stable self-structures, in these patients' lives.     

Response to cognitive therapy in depression: the role of maladaptive beliefs and personality disorders

This study examined whether personality disorder status and beliefs that characterize personality disorders affect response to cognitive therapy. In a naturalistic study, 162 depressed outpatients with and without a personality disorder were followed over the course of cognitive therapy. As would be hypothesized by cognitive theory (A. T. Beck & A. Freeman, 1990), it was not personality disorder status but rather maladaptive avoidant and paranoid beliefs that predicted variance in outcome. However, pre- to posttherapy comparisons suggested that although patients with or without comorbidity respond comparably to "real-world" cognitive therapy, they report more severe depressive symptomatology at intake and more residual symptoms at termination.     

A time series evaluation of the treatment of histrionic personality disorder with cognitive analytic therapy

The central aim of this study was to assess the effectiveness of cognitive analytic therapy (CAT) with a patient presenting with Histrionic Personality Disorder (HPD). The methodology employed an A/B single case time‐series experimental design, with additionally 6 months of continuous follow‐up in the experimental measures. Five HPD experimental variables were collected on a daily basis, creating 357 days of continual data for analysis, across various phases of assessment baseline (A), treatment (B) and follow‐up. The therapy contract was 24 sessions of CAT, with 4 additional follow‐up sessions, spread over the 6‐month's post‐therapy period. Three out of the five HPD experimental variables (focus on physical appearance, emptiness and child inside) displayed statistically significant phase of treatment effects. Graphing of such data indicated that a ‘sudden deterioration’ occurred at the point of termination, with eventual recovery and maintenance of the progress made during the intervention. A battery of validated clinical measures were also completed at assessment, termination and final follow‐up sessions; analysis of the general measures illustrated clinically significant change, indexing personality integration and reductions to depression. The study is discussed in terms of methodological and clinical limitations, the central importance of process issues and effective termination in HPD, plus the potential utility of CAT in the treatment of HPD presentations.     

Homework assignments in relational psychoanalytic treatment of personality disorders: A case study of a patient with narcissistic personality disorder

Homework assignments, or specific tasks patients are asked to engage in or complete between sessions, are a controversial topic among psychoanalysts. While many argue these interventions contradict psychoanalytic principles, others believe they can help address problems and promote coping skills. We propose that homework can be a legitimate aspect of relational psychoanalysis when used in a way that is attuned to the patient's experience and that homework may be an important component of treating personality disorders (PD). We present the case of a man diagnosed with narcissistic PD. He often felt superior to and reported that he despised others, though the core self-image was of fragile. He embraced the role of the omnipotent caregiver, which came with boredom and anger and lack of satisfaction in his social life. The patient tried to control therapy, asserting that he could psychoanalyze himself. As a result, therapy was stalled and progress was limited. At this point, the therapist asked him to complete homework assignments that encouraged him to refrain from his compulsive caregiving to better understand what motivated this behavior. Through this process, the patient came to realize he acted out of avoidance, as he did not want to disclose his own vulnerabilities and flaws. At that point he was able to experience relationships while adopting different stances and finding new meanings. We argue that homework can be fully integrated into the relational psychoanalytic repertoire to improve self-reflection and foster change in patients with PD.     

A neurocognitive model of borderline personality disorder: effects of childhood sexual abuse and relationship to adult social attachment disturbance

Borderline personality disorder (BPD) is a paradigmatic disorder of adult attachment, with high rates of antecedent childhood maltreatment. The neurocognitive correlates of both attachment disturbance and maltreatment are both presently unknown in BPD. This study evaluated whether dimensional adult attachment disturbance in BPD is related to specific neurocognitive deficits, and whether childhood maltreatment is related to these dysfunctions. An outpatient BPD group (n=43) performed nearly 1 SD below a control group (n=26) on short-term recall, executive, and intelligence functions. These deficits were not affected by emotionally charged stimuli. In the BPD group, impaired recall was related to attachment-anxiety, whereas executive dysfunction was related to attachment-avoidance. Abuse history was correlated significantly with executive dysfunction and at a trend level with impaired recall. Neurocognitive deficits and abuse history exhibited both independent and interactive effects on adult attachment disturbance. These results suggest that (a) BPD patients' reactivity in attachment relationships is related to temporal-limbic dysfunction, irrespective of the emotional content of stimuli, (b) BPD patients' avoidance within attachment relationships may be a relational strategy to compensate for the emotional consequences of frontal-executive dysregulation, and (c) childhood abuse may contribute to these neurocognitive deficits but may also exert effects on adult attachment disturbance that is both independent and interacting with neurocognitive dysfunction.     

Experiential techniques and therapeutic relationship in the treatment of narcissistic personality disorder: The case of Laura

Experiential techniques can be used to address maladaptive interpersonal patterns in patients with personality disorders (PDs) as long as they are delivered minding about the therapeutic relationship. We present the case study of Laura, a 38-year-old woman presenting with covert narcissism, generalized anxiety disorder, depression, and complicated grief treated with metacognitive interpersonal therapy. Laura initially refused to engage in any experiential work out of fear of being judged and abandoned by her therapist. To navigate this therapeutic obstacle, the therapist focused on exploring and eventually repairing early alliance ruptures. Thereafter, Laura engaged in experiential work, which helped her address her narcissistic interpersonal patterns. After 2 years, Laura's symptoms and narcissistic problematic behaviors decreased. This case study can help us understand how experiential techniques can be successfully used in PD psychotherapy as long as attention to the therapy relationship is paid.     

The role of attachment characteristics in dialectical behavior therapy for patients with borderline personality disorder

Attachment characteristics play a key role in understanding borderline‐specific problems with respect to childhood maltreatment. The aim of this study was to investigate how attachment representations may influence the trajectory of change in a 1‐year outpatient dialectical behavior therapy (DBT) for patients with borderline personality disorder (BPD). Attachment representations were assessed in 26 BPD patients and 26 healthy controls (HC) using the Adult Attachment Projective Picture System (AAP) before treatment. Borderline and global symptom severity and interpersonal problems were examined before, during, and after completing the intervention. Analysis of variance and stepwise hierarchical regression analyses were used to explore the course of symptomatology. As expected, BPD patients displayed a predominance of unresolved attachment in the AAP compared with HC, by showing a lack of ability to integrate attachment related trauma. Whereas both resolved and unresolved attachment groups revealed significant improvement in symptom severity during treatment, dimensional AAP scores showed differences. Patients with higher scores in “synchrony” demonstrated more indicators of mutual care in their narratives to dyadic pictures and displayed a significantly stronger decrease of interpersonal problems than patients with lower synchrony scores. Assessing attachment representations prior to DBT might provide a helpful insight into individual attachment related resources or lack of these capacities. Responsiveness and synchrony in dyadic interactions with significant others are crucial for healthy interpersonal relations. A stronger therapeutic focus on the patient's capacity to show synchrony in dyadic attachment situations might improve the patient's interpersonal problems towards sensitive and mutual interaction.     

Personal relatedness and attachment in infants of mothers with borderline personality disorder

The principal aim of this study was to assess personal relatedness and attachment patterns in 12-month-old infants of mothers with borderline personality disorder (BPD). We also evaluated maternal intrusive insensitivity toward the infants in semistructured play. We videotaped 10 mother-infant dyads with borderline mothers and 22 dyads where the mothers were free from psychopathology, in three different settings: a modification of Winnicott's Set Situation in which infants faced an initially unresponsive ("still-face") stranger, who subsequently tried to engage the infant in a game of give and take; the Strange Situation of Ainsworth and Wittig; and a situation in which mothers were requested to teach their infants to play with miniature figures and a toy train. In relation to a set of a priori predictions, the results revealed significant group differences as follows: (a) compared with control infants, toward the stranger the infants of mothers with BPD showed lower levels of "availability for positive engagement," lower ratings of "behavior organization and mood state," and a lower proportion of interpersonally directed looks that were positive; (b) in the Strange Situation, a higher proportion (8 out of 10) of infants of borderline mothers were categorized as Disorganized; and (c) in play, mothers with BPD were rated as more "intrusively insensitive" toward their infants. The results are discussed in relation to hypotheses concerning the interpersonal relations of women with BPD, and possible implications for their infants' development.     

Depressive mood states and their cognitive and personality correlates in college students: They improve over time

About 30% of 171 college student respondents reported at least mild dysphoria. Depressed mood states were associated with dysfunctional attitudes and self-esteem problems, but not with gender or self-reported problem-solving ability. Findings about sex role orientation were mixed. The freshmen reported the highest levels of dysphoria, problem-solving difficulties, and dysfunctional attitudes, but there appeared to be consistent, gradual improvements, such that by the senior year students reported significantly less dysphoria. However, a 2-month follow-up found no significant changes in these areas, which suggests that the observed improvements may occur more gradually or may be an artifact of selective attrition from college. Implications of the results and directions for future research were discussed.