Estudio comparativo de psicoterapia de grupo para el tratamiento de pacientes con trastorno límite de la personalidad / Comparative study of group psychotherapy for the treatment of patients with borderline personality disorder

Nowadays, psychotherapy is regarded as the treatment of choice for patients with Borderline Personality Disorder(BPD). A consensus has yet to be reached, however, despite various controlled studies undertaken to determine the most suitable form of treatment. At both public and private mental health institutions, there is a growing number of BPD patients seeking treatment. These patients pose a challenge for institutional programs because their demands usually exceed the <> of conventional forms of psychiatric treatment. Due to this heavy demand, various strategies have been examined in order to treat this type of patients properly. These include short group therapy. This article presents the results of a controlled clinical study comparing the effectiveness of treatment according to the composition of the groups: a homogeneous group, consisting solely of borderline patients and another in which only half had been diagnosed with BPD while the others only had Axis 1 disorders, with no serious personality pathology. The study considered the variables of psychiatric symptomatology, quality of life, self-esteem, <>, perceived social support, social adjustment and inter-personal problems. Both groups contained female subjects only. The quantitative results of the mixed group show significant changes in the psychiatric symptoms as well as the evolution of interpersonal problems and current quality of life. At the same time, the homogeneous group showed changes in the ideal quality of life and the self-esteem scale. A comparison of the base and final scores showed that the BPD group showed no reduction in psychiatric symptomatology, nor was there a positive evolution in inter-personal relations. At the same time, when other groups were compared, it was obvious that patients in the mixed group showed greater changes in interpersonal problems and depression, anxiety, paranoid and hostility symptoms. As for qualitative results, the BPD group constituted a failed experience from the psychotherapeutic point of view. An analysis of the development of the process in the BPD group reveals three different stages. The first was characterized by the early emergence of numerous transfers based on the idealization/devaluation of colleagues and therapists. The splitting mechanism was clearly observed. This stage saw the emergence of high expectations of a <> In Bion's terms, the group was experiencing a moment of dependency. At that point, the issue of sexuality emerged, triggering an apparent process of identification linked to experiences of early sexual abuse among patients. The bases of incipient group cohesion seemed to be emerging. Nevertheless, <> began to take place, together with the need to exclude the <> group member. Group members subsequently began to complain to the therapists about their <> and the fact that they failed to provide <> Negative transference became obvious, with hatred and suspicion prevailing. This stage may correspond to the process described by Bion as the attack and flight phase, characterized by intensely paranoid attitudes. The prevailing links were based on hatred, with nearly all expressions of love being stifled. The group eventually succumbed due to the spread of hostility triggered by the attacks of patients that participated in destructive alliances. This prevented the group from achieving cohesion and the stage of camaraderie, characterized by Bion as the emergence of loving feelings that usually neutralize hostile components. Two patients in this group, however, showed favorable changes in their attitudes that implied a process of elaborating conflicts primarily derived from feelings of dependence, passivity and anger in relation to parental figures. From the start, patients in the mixed group with and without BPD showed different degrees of participation. Patients with severe personality pathology participated less in the initial sessions, acting as spectators. They gradually joined the group and participated more actively. Patients without BPD, however, took the initiative regarding the issues to be dealt with during the sessions. In our view, this helped establish a <> for borderline patients. Later on, these patients' conflicts became more obvious, being characterized by powerful ambivalence and the activation of primitive defense mechanisms, such as splitting, projective identification and denial. These expressions, however, found a cohesive group that provided them with acceptance and contention. This group evolved like other psycho-therapeutic groups of <> but with differences due to the problems commonly expressed by patients with BPD: suicidal ideation, sexual abuse, severe conflicts in their relationships with their partners, etc. Nevertheless, due to the atmosphere of camaraderie established, these patients were fully integrated, and in fact, their colleagues were unable to determine which ones belonged to which category. By the end of the treatment, group cohesion and positive dominant transference were obvious. The experience yielded by this study showed that in a psycho-therapeutic group solely comprising BPD patients, situations arise that are extremely difficult to handle. The most important factor was negative transference, which created a hostile atmosphere that neutralized the psychotherapeutic interventions. This generalization should be viewed with caution, however, due to the small number of patients included in this study. The severity of the psycho pathology of the patients included in each group was probably not the same. A propos of this last mechanism, it has been suggested that certain socio-demographic characteristics are associated with better social functioning. The homogeneous group contained more unemployed and single patients and/or patients with highly conflictive interpersonal relations. From the outset, patients in the mixed group displayed higher levels of social performance. Despite the fact that they all met the diagnostic characteristics for BPD according to the SCID-II, a more detailed personality study that would reveal significant differences in the patients' psychic structure was not carried out. A retrospective analysis showed that histrionic, narcissistic and anti-social traits predominated in the homogeneous group; these traits may be included in the category of the malignant narcissistic syndrome described by Kernberg, in which the combination of these three traits produces a poor therapeutic prognosis. It has been established that these subjects tend to develop paranoid transferences and are unable to relate to others due to their inability to invest them with libidinal energy. At the same time, in the mixed group, borderline patients have phobic, dependent features, characteristics associated with a better prognosis, since better functioning is associated with a less primitive psychic structure and the capacity to establish less chaotic relationships. In any case, it seems quite clear that group therapy that combines a restricted number of borderline patients and subjects with Axis I disorders without serious personality disorders could prove a viable option in the search for institutional strategies for the psychotherapeutic treatment of patients with BPD.

En la actualidad se acepta que el tratamiento de elección para los pacientes con Trastorno Límite de la Personalidad (TLP) es la psicoterapia. Sin embargo, a pesar de los diversos estudios controlados que se han realizado con el propósito de determinar cuál es la modalidad de tratamiento más adecuada, no se ha logrado alcanzar consenso. En las instituciones de atención a la salud mental, tanto públicas como privadas, es creciente el volumen de pacientes con TLP que buscan tratamiento. Debido a estas fuertes demandas que operan sobre las instituciones, se han buscado diferentes estrategias para tratar adecuadamente a este tipo de pacientes. Entre ellas se destaca la terapia de grupo breve. La mayoría de los estudios que han respaldado los tratamientos psicoterapéuticos para el TLP derivan de observaciones provenientes de ensayos clínicos individuales. Sin embargo, también existen trabajos entre los que se reseñan algunos que consideramos relevantes y que muestran los beneficios de los tratamientos grupales. En este artículo se presentan los resultados de un estudio clínico controlado comparando dos tipos de conformación de grupos terapéuticos: un grupo homogéneo, constituido únicamente por pacientes limítrofes, y otro heterogéneo en el que se incluyeron además de pacientes con TLP, otros sin patología grave de la personalidad. El objetivo del estudio fue comparar la efectividad del tratamiento en función de la composición de los grupos. El tipo de estudio fue comparativo pre-test post-test. En él se consideraron las variables de sintomatología psiquiátrica, la calidad de vida, la autoestima, la <>, el apoyo social percibido, el ajuste social y los problemas interpersonales. Para el análisis estadístico se utilizaron pruebas no paramétricas. El diagnóstico de TLP se realizó de acuerdo a los criterios del DSM IV. Se excluyeron sujetos con diagnóstico de trastorno agudo en Eje I o trastorno neurológico que afectara de manera significativa su capacidad cognitiva, y sujetos con una probada historia de deserción de sus tratamientos. En ambos grupos sólo se reunieron sujetos del sexo femenino. Los resultados cuantitativos mostraron que las pacientes incluidas en el grupo heterogéneo tuvieron mayores cambios benéficos en las distintas escalas psicológicas y psicopatológicas aplicadas, mientras que las pacientes del grupo homogéneo tuvieron pocos o ningún cambio. En cuanto a los resultados cualitativos, se observó que las pacientes del grupo heterogéneo desarrollaron transferencias positivas que influyeron en un mejor desarrollo del grupo y en la obtención de cambios positivos, mientras que en el grupo homogéneo se vieron transferencias negativas que dificultaron el desarrollo adecuado de la terapia grupal, creando un ambiente caótico y con poca cohesión grupal. El desarrollo del proceso terapéutico fue notoriamente distinto en ambos grupos. El grupo homogéneo se caracterizó por una elevada competitividad y rivalidad entre las participantes quienes se disputaban el papel protagónico, además de hostilizar a los terapeutas. En contraste, el grupo heterogéneo alcanzó un nivel de funcionamiento más armónico que posibilitó cambios favorables en las pacientes con TLP. Debido al tamaño tan reducido de la muestra, no se puede afirmar categóricamente que las diferencias en los resultados obedecieron exclusivamente a la composición de los grupos. Es posible que el nivel <> de psicopatología fuera más grave en las pacientes incluidas en el grupo homogéneo, lo cual se puede inferir de su nivel de funcionamiento social en el momento de la inclusión en la terapia y otras observaciones clínicas colaterales. Los resultados sugieren que la composición de los grupos sí resultó ser una variable significativa, que se deberá tomar en cuenta para futuras investigaciones. Al mismo tiempo, estos resultados nos permiten sugerir que los pacientes con diagnóstico de TLP pueden ser tratados exitosamente mediante psicoterapia de grupo, siempre y cuando la composición del grupo incluya otros pacientes sin trastorno severo de la personalidad.

Apego al tratamiento psicoterapéutico grupal en pacientes con Trastorno Límite de la Personalidad. Estudio piloto en pacientes de 18 a 24 años

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Abstract: The treatment of election for patients with Borderline Personality Disorder (BPD), consists on the combination of psychotherapy and pharmacotherapy. Concerning a psychoanalitic and individual focuse, there has been found, that in spite of the differences in orientations and the therapists experience, the manifestations of the disorder tend to decrease. First of all, a decrease in the impulsivity and an increase in the affective stability is seen, whether the identity alterations modify poorly with treatments of a duration of up to two years. Traditionally, patients with BPD have not been considered apt for group therapy, because their disruptive behavior interferes with the development of the groupal cohesion; however, this characteristics are the ones that can be rapidly treated in the group, when putting a slight pressure on the patient so he can modify this maladaptive behavior. The objectives of group therapy, are consistent with the ones in individual therapy. They include stability for patients, management of impulsivity and other symptoms, and management of the reactions in the transference and countertransference. The presence of other patients helps to establish limits between the participants and it also generates an altruistic interaction, in which they can consolídate their changes in the process of helping others. Group therapists suggest that individual therapy can be accelerated if the patient participates in the group in which the primitive fantasies are stimulated and where the group structure provides a support that helps personal growth. One of the most difficult tasks in any therapy is the desertion of the patients. Specially, the group is vulnerable to desertion, in its initial stage, since it has been recorded that there is a 13 to 63% of desertions. The purpose of the present study was to determine the psychological and psychopathological variables in patients with BPD, that influence the compliance in a group therapy. All the candidates in this investigation were patients with a probable diagnose of BPD, that had been sent to the Psychotherapy Department of National Institute of Psychiatry, aged between 18 to 24 years. This diagnose was corroborated with the SCID II. A descriptive study was made with the characteristics of the patients in some different areas: character and temperament, self esteem, quality of life, psychosocial functioning, interpersonal problems, ego strength, and psychiatric symptoms. A total of 24 weekly sessions with a duration of an hour and a half, were conducted under the direction of two psychotherapists and a non active observer. A Spearman correlation was used to correlate the psychological variables with the number of assisted sessions. We included 16 female patients, with an age mean of 20.43 years; the mean of assistance to the group was of 4.5 sessions. None of the subjects assisted to all the 24 sessions and 56% of the patients deserted the group as well as the pharmacological treatment. The findings of the correlations between the number of assisted sessions and the psychological variables, suggested first of all, a positive relation between the persistence scale of the ITC and a negative association with the subscales 1 (preoccupation vs optimism) and 4 (fatigability vs energy). Other findings suggested negative correlations between the psychosis scale of the SCL 90 and the evitative scale. The rest of the scales did not have a significative correlation with the number of assisted sessions. The items mentioned during the sessions by the patients consisted in the extreme dependency to the external criticism, that came from significative figures. The patients also talked about some of the common symptoms of BPD, like frustration, intolerance, suicide, lack of affective stability, self mutilations, rage, ambivalence, poor self concept, feelings of inferiority, and low self esteem. The percentage of desertion in this study was a lot higher than expected, assuming that in a regular group basis, there is 30% to 40% of desertion. It also came to our attention, that groupal phenomena, were not observed. Specially identifications and groupal cohesion, were not developed in this case. The patients collaborated exclusively with the therapists; they did not give any devolutions to other patients. They all waited for their turn, changing the theme, in a way that satisfied their own conflicts. The universality of the experience phenomenon was no seen, since the patients, did not feel that the others had the same problems, conflicts emotions or ideas, feeling supported or relieved by it. In conclusion, the patients with BPD, in our institution have a bad compliance in a group therapy, in which only personality disorders are admitted. These patients did not blend within the environment, because the groupal phenomena that produce the changes were not seen at all. This is probably associated with the intrinsic characteristics of the disorder, and this is why the probable changes in the patients should be evaluated and this technique questioned, as a reliable treatment method for personality disorders. A comparison of this technique with others, such as individual therapy and the combination of both, should be also considered. The Psychobiologic model of Cloninger, used in other investigations to predict the efficacy of pharmacotherapy, can be used to make a prediction of the compliance of BPD with groupal therapy. This data should be considered in the previous evaluation of the patients, with the goal of establishing different strategies, and an adequate treatment, for subjects with these characteristics.

Detección de anticuerpos a proteínas de membrana externa de Salmonella typhi en pacientes con fiebre tifoidea e individuos sanos / Antibody detection to extern membrane proteins of Salmonella typhi in patients with typhoid fever and healthy people

En este estudio hemos usado la electroinmunotransferencia (Western blot) para examinar la respuesta de anticuerpos IgG, IgA e IgM a proteínas de membrana externa (PME) de Salmonella typhi Ty-2 y S. thyphi nativa (9, 12, d, Vi) en sueros de 16 pacientes con fiebre tifoidea (fase aguda y convaleciente), 18 pacientes con cuadros febriles no tifoidea (infecciones a Escherichia coli, proteus vulgaris, Salmonella paratyphi A y virales) y 30 individuos sanos. El patrón electroforético de las proteínas de membrana externa de ambas salmonellas fue similar por geles SDS-poliacrilamida y la contaminación de lipopolisacárodo (LPS) fue del 4,5%. Los sueros de pacientes con fiebre tifoidea mostraron por "immunoblotting" respuesta IgG contra la mayoría de las proteínas de membrana externa de ambas salmonellas, siendo de mayor amplitud e intensidad en fase convaleciente. Los tres grupos de sueros dieron respuesta IgG contra proteínas de 34, 35, 39, 55, y 69 KD. La respuesta IgA e IgM antiproteínas de membrana externa de salmonella fue restringida y con diferencia con respecto a la cepa bacteriana. Sólo los sueros de pacientes con fiebre tifoidea mostraron IgA antiproteínas de membrana externa de S. typhi Ty-2 en bandas de 24 y 60 KD e IgM antiPME de S. typhi Ty-2 en 60 KD. Los tres grupos dieron respuesta IgA e IgM antiPME en la región 34 a 39 KD. Estos datos indican que los sueros de pacientes y de individuos normales poseen anticuerpos IgG, IgA e IgM antiPME que reconocen estructuras que son ubiquitarias. Este estudio concluye que la electroinmunotransferencia puede utilizarse en la identificación de infecciones por Salmonella typhi, ya que la presencia de anticuerpos IgA anti PME de S. typhi Ty-2 detectadas por "immunoblotting" en las badas 24 y 60 KD e IgM antiPME de S. tyyphi Ty-2 en 60 KD permitirá confirmar el diagnóstico de fiebre tifoidea