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PubMed1989

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.

Borderline Personality Disorder↗
PubMed1990

Cognitive features of borderline personality disorder.

Of 50 patients with borderline personality disorder, 100% reported disturbed but nonpsychotic thought, 40% (N = 20) reported quasi-psychotic thought, and none reported true psychotic thought during the past 2 years; only 14% (N = 7) reported ever experiencing true psychotic thought. Disturbed and quasi-psychotic thought was significantly more common among these patients than among patients with other axis II disorders or schizophrenia and normal control subjects; however, true psychotic thought was significantly more common among schizophrenic patients. While disturbed thought was also common among axis II disorder and schizophrenic patients, quasi-psychotic thought was reported by only one of these subjects, suggesting that quasi-psychotic thought may be a marker for borderline personality disorder.

Adult↗
PubMed1991

A current view of the interface between borderline personality disorder and depression.

The recent and dramatic expansion in studies about borderline and depressive disorders is reviewed with respect to the implications about their interface. Revisiting this subject 6 years after an earlier review reveals that intervening research has altered the conclusions that should be drawn. Growing evidence from family history, comorbidity, phenomenology, psychopharmacology, biological markers, and a new domain, pathogenesis, indicates that a surprisingly weak and nonspecific relationship exists between these disorders. Implications are drawn with respect to classification, therapeutics, and defining the borderline construct.

Biomarkers↗
PubMed2002

Functional impairment in patients with schizotypal, borderline, avoidant, or obsessive-compulsive personality disorder.

OBJECTIVE: The purpose of this study was to compare psychosocial functioning in patients with schizotypal, borderline, avoidant, or obsessive-compulsive personality disorder and patients with major depressive disorder and no personality disorder. METHOD: Patients (N=668) were recruited by the four clinical sites of the Collaborative Longitudinal Personality Disorders Study. The carefully diagnosed study groups were compared on an array of domains of psychosocial functioning, as measured by the Longitudinal Interval Follow-Up Evaluation--Baseline Version and the Social Adjustment Scale. RESULTS: Patients with schizotypal personality disorder and borderline personality disorder were found to have significantly more impairment at work, in social relationships, and at leisure than patients with obsessive-compulsive personality disorder or major depressive disorder; patients with avoidant personality disorder were intermediate. These differences were found across assessment modalities and remained significant after covarying for demographic differences and comorbid axis I psychopathology. CONCLUSIONS: Personality disorders are a significant source of psychiatric morbidity, accounting for more impairment in functioning than major depressive disorder alone.

Activities of Daily Living↗
PubMed2001

An intensive outpatient program for patients with borderline personality disorder.

Intensive outpatient programs are designed to promote patients' functioning in the community by offering a more intensive level of structure and support than was previously available for outpatients. This paper describes the intensive outpatient program at McLean Hospital in Belmont, Massachusetts, which is tailored for patients with borderline personality disorder. These patients are susceptible to control struggles and regressive behaviors in more restrictive treatment settings. Through frequent contact with clinicians and other patients in this group-oriented program, patients with borderline personality disorders appear to feel sufficiently "held" and understood to develop their functional capacities as outpatients.

Ambulatory Care↗
PubMed1982

Psychological testing of the borderline patient: a guide for therapeutic action.

The diagnostic ambiguity and difficulties of treating borderline patients call for refined idiographic understanding. Psychological testing can make a significant contribution to treatment of borderline individuals at all phases of the clinical process. First, during the initial consultation, an accurate taxonomical identification can be made which also elucidates the chaotic functioning of these patients. Second, choice of treatment modality and strategy can be made on a more informed basis as a result of test report inferences concerning ego functions and object relations. Third, the management of the ongoing treatment process can be guided by test-report elaborations of ego weaknesses, vulnerability toward particular transference distortions, and predilection toward inducements into specific countertransference traps.

Adult↗
PubMed1984

Emotional and cognitive factors in the borderline profile.

Profiles of ego functions of borderline patients are studied. Three ego functions were found to be significantly more disturbed: reality testing, object relations, and defense mechanisms. Further analysis of these and their subfunctions reveals a significant difference between emotional and cognitive factors. Emotional-internal functions are the more disturbed. This consistent difference illuminates the style of functioning of borderline patients.

Borderline Personality Disorder↗
PubMed1988

Beginning psychotherapy with the borderline patient.

Written as a guide for those about to begin psychotherapy with a borderline patient, this paper succinctly addresses the early stages of therapy. Because it is most helpful to think in accordance with a conceptual framework, the first section of this paper reviews four types of individual psychotherapy, relating these to the borderline patient. The second section deals with larger issues regarding psychotherapy, and the third section focuses on specific interventions.

Acting Out↗
PubMed1993

Treatment of patients in the borderline spectrum: an overview.

My purpose here has been to provide no more than a brief overview of an approach to the therapy of borderline patients in the framework of a spectrum view of this complex pathology. While the perspective, generated within a tripartite framework of alliance, transference, and countertransference, allows the therapist a sense of orientation and direction in pursuing the therapeutic work with these patients, it can provide little more than guidelines, a theoretical context for thinking about the therapeutic vicissitudes that challenge and frustrate all of us. Within this perspective, I would emphasize the importance of flexibility. The complexity of therapeutic interactions and the wide scope of variation, seen not only in the borderline spectrum itself but in individual patients, calls for an unusual degree of flexibility and therapeutic adaptability to the immediate demands of the ongoing therapeutic interaction. If therapists, as they are being buffeted about by the storms and unsuspected undercurrents of the therapeutic ocean, can at least keep their bearings and know when they are being pulled out of their therapeutic role and function, their ability to deal with and help their patients will be immeasurably enhanced. I would hope that these few guidelines would provide a workable compass for the task.

Borderline Personality Disorder↗
PubMed1993

The outpatient psychotherapy of the borderline patient.

This paper discussed common problems in the outpatient psychotherapy of borderline patients, especially their rage, seductiveness, and abrupt negative shifts. The definition of "borderline" is not settled. Even DSM-III-R mixes it up with other personality disorders. There are no pathognomonic symptoms, no specific personality constellations, and no compelling evidence for a definitive stage in infant development when this disorder is fixed; all stages are involved, from faulty foundational to oedipal periods. It is a descriptive diagnosis and typical presentations of such patients are reviewed. In the psychotherapeutic approach, limits must be set first, but these must be flexible and reasonable. Medications are used rarely and with care. We attempt to form an alliance by (a) getting the patient to join us in a study of himself or herself, especially a study of when rage and maladaptive behavior emerges, and (b) providing a consistent and reasonable ambience. The ultimate aim is uncovering and interpreting when the patient is ready for it, more and more approximating psychoanalytic treatment as the patient's pathology permits. The special phenomena of the self-object (Kohut), transitional object (Modell), and disruptive extreme erotic or raging (Kernberg) transferences were reviewed, as well as the pitfalls of therapist anxiety and impatience in dealing with them. While archaic transferences predominate, we serve as an auxiliary microscopic ego and appeal to the rational adult part of the patient's ego in a phenomenological investigation. We interpret early only if we cannot get the patient to examine what has led to the explosions and when distortions or projection without insight continues to predominate. The dangers of early transference interpretations are discussed. Therapy is long, tedious, and requires the willingness to patiently catalyze the patient's resumed development and endure the periodic disruptions. Countertransference problems and what to do about them are reviewed.

Ambulatory Care↗
PubMed1994

Developmental formulation and psychotherapy of borderline adolescents.

Treatment of the borderline adolescent requires a highly sophisticated, multimodal treatment formulation that is based on a developmental, psychodynamic formulation of the patient and family system. The therapeutic model chosen must fit the case as well as possible, but, of necessity, may change as the patient grows and develops. It is of utmost importance to understand the patient's process of growth and development and the utilization of each particular model of psychotherapy chosen. Therapeutic techniques should derive from the model(s) of treatment and should constantly be analyzed during the course of psychotherapy with these very difficult patients. The case example illustrates the treatment of a borderline personality patient who, in Goldstein and Jones's model, initially was in Group IV, the withdrawn and socially isolated group, but as therapy developed, fell into Group II in her defiance, disrespectful stance toward her mother, belligerance, and antagonism both in the family and in therapy. She progressively was able to relinquish her defensive stance of denial, projection, and splitting, and became more aware of her affect. As she progressed in therapy, her mood shifted from states of anger to states of depression and self-consciousness and her treatment was facilitated by use of pharmacotherapeutic agents and a very close-knit outpatient team. It is important to emphasize the value of a close-knit working outpatient team in the psychotherapy.

Adolescent↗
PubMed1997

Dynamically oriented psychotherapy with borderline patients.

This article outlines a basic framework and strategy for a dynamically oriented psychotherapy with borderline patients. Focus includes arrangements and guidelines for psychotherapy, neutrality, the stability of the therapeutic environment, the therapeutic alliance, transference, the countertransference, activity of the therapist, types of interventions, style of interventions, interventions regarding core difficulties, the conceptual framework of anxiety and defense, trends in the psychotherapy, and termination. A differentiation between analytically oriented psychotherapy and dynamically oriented psychotherapy is provided. For one group of borderline patients, a modified analytically oriented approach is utilized throughout the entire treatment. For a second group, there is a switch from analytically oriented psychotherapy to a dynamically oriented psychotherapy, after the therapeutic alliance has become reasonably stable. Two clinical vignettes are provided.

Acting Out↗
PubMed1983

The treatment of antisocial and borderline personality disorders.

Because of continuing diagnostic confusion, little empirical evidence exists to guide the clinician in treating patients with antisocial and borderline personalities. However, there is an extensive clinical literature based on the experience of many workers in the field, and it is possible to outline broad areas of agreement and major controversies. The resistance of the patient and the intense countertransference be typically evokes make treatment difficult no matter what the approach. Most authors agree that treatment of the antisocial personality must begin in a residential setting with an active milieu if it is to have any chance of success. Severe borderlines may also require a great deal of structure to supplement psychotherapy; with them, however, the therapist can feel more optimistic about an approach stressing the clarification of maladaptive defenses and the interpretation of negative transference.

Antisocial Personality Disorder↗
PubMed1991

Assessment and diagnosis of borderline personality disorder.

Borderline personality disorder is common in treatment settings and may be so in the general population. In this guide to assessment strategies for diagnosing borderline personality disorder, the authors discuss the reliability and validity of structured interviews and self-report instruments and suggest the use of a self-report questionnaire as a cost-effective screening test. Assessment problems, such as the need for longitudinal observation, are reviewed. Essential features of the recommended diagnostic approach include clarity about the diagnostic concept, consideration of the full range of diagnostic criteria, incorporation of recently developed diagnostic methodologies, care in distinguishing personality disorders from comorbid axis I syndromes, and complete assessment of the full range of axis II disorders.

Borderline Personality Disorder↗
PubMed1991

Biological and pharmacological aspects of borderline personality disorder.

Biological and psychopharmacological research focusing on patients with a DSM-III-R diagnosis of borderline personality disorder suggests that the disorder may encompass three clusters of symptoms--affective instability, transient psychotic phenomena, and impulsive aggressive behavior--that have different underlying biological substrates that respond to different classes of pharmacological agents. Affective instability, which may be related to abnormalities in the brain's adrenergic and cholinergic systems, appears to respond to agents such as lithium and carbamazepine that are effective in treating major affective disorders. Abnormalities in central dopaminergic systems may underlie transient psychotic symptoms. This relationship is consistent with reports of beneficial effects of low-dose neuroleptics in treating some borderline patients. Abnormalities in central nervous system serotonergic functioning appear to underlie impulsive aggressive behaviors. These behaviors may respond to serotonergic agents such as fluoxetine.

Borderline Personality Disorder↗
PubMed1995

Characteristics of effective day treatment programming for persons with borderline personality disorder.

Day treatment, or partial hospitalization, may have unique advantages for the treatment of patients with borderline personality disorder. Such treatment may offer patients the optimal level of intensiveness and containment, resulting in less regressive dependency and acting-out behavior. To be successful in treatment of patients with borderline personality disorder, a day treatment program should facilitate the patient's need to experience and express affect safely, optimize the program's ability to provide less restrictiveness than inpatient treatment but more sustained and intensive support than outpatient treatment, and use verbal and nonverbal approaches to help patients maintain primary responsibility for their well-being. A length of stay of three weeks allows patients to regain baseline functioning and resume long-term outpatient care. Treatment goals should be clear and resolvable in three weeks.

Acting Out↗
PubMed1998

Use of dialectical behavior therapy in a partial hospital program for women with borderline personality disorder.

Dialectical behavior therapy, an outpatient psychosocial treatment for chronically suicidal women with borderline personality disorder, has been adapted for use in a partial hospital program for women. Patients attend the program for a minimum of five days of individual and group therapy, and full census is 12 women. About 65 percent of participants meet at least three criteria for borderline personality disorder, and most have suicidal and self-injurious behavior. Their comorbid diagnoses include trauma-related diagnoses and anxiety disorders, severe eating disorders, substance abuse, and depression. The partial hospital program is linked to an aftercare program offering six months of outpatient skills training based on dialectical behavior therapy. Both programs focus on teaching patients four skills: mindfulness (attention to one's experience), interpersonal effectiveness, emotional regulation, and distress tolerance. Two years of operation of the women's partial hospital program provides promising anecdotal evidence that dialectical behavioral therapy, an outpatient approach, can be effectively modified for partial hospital settings and a more diverse population.

Adult↗