Establishing Levels of Personality Functioning Using the Structured Interview of Personality Organization (STIPO-R): a Latent Profile Analysis.

Both the new ICD-11 and the latest Alternative DSM-5 Model for Personality Disorders focus on self and interpersonal functioning as the central feature of personality pathology, also acknowledging that personality disorders are organized along a dimensional continuum of severity. This revised understanding is in line with long-standing psychodynamic conceptualisations of personality pathology, in particular Kernberg's object relations model of personality organization. Despite existing evidence for the clinical utility of the derived Structured Interview of Personality Organization (STIPO-R), empirical support for the identification of clear cut-points between the different levels of personality functioning is missing. For this purpose, a total of 764 adult participants were recruited across two clinical (outpatient and inpatient) settings (n = 250) and two non-clinical (university students and general community) samples (n = 514). Results from the mixture modeling suggested the existence of five groups across the clinical and non-clinical samples that covered: healthy personality functioning, maladaptive personality rigidity, and mild, moderate, and severe levels of personality pathology. All five indicators of personality organization were found to be reliable predictors of personality pathology. Of the five STIPO-R indicators, Aggression and Moral Values had the most discriminative power for differentiating between the Mild, Moderate, and Severe personality disorder groups. Implications of these findings are discussed.

Commentary: Special Issue on Interpersonal Trust.

This commentary reviews the Journal of Personality Disorders special issue "Interpersonal Trust and Borderline Personality Disorder: Insights From Clinical Practice and Research," published in Volume 37, Number 5, October 2023.

Transference-Focused Psychotherapy and Trust Processing in BPD: Exploring Possible Mechanisms of Change.

Individuals with borderline personality disorder (BPD) struggle to identify whom they can safely trust, and this struggle contributes to profound emotional turmoil in their close relationships. Transference-focused psychotherapy (TFP) is an application of object relations theory (ORT) that posits that polarized mental representations of self and other define the personality organization of BPD. TFP aims to utilize a clear treatment frame coupled with an analysis of the therapeutic relationship (i.e., the transference) to help individuals with BPD integrate their polarized mental representations. Improvement in the capacity to trust others is inherent in the mechanisms of change in TFP. In this article, a social cognitive model of trust processing provides a new lens through which we formulate how TFP may enhance trust processing in BPD. Recent evidence from randomized clinical trials supports the argument that TFP may intervene with BPD in a way that is concordant with uniquely improved trust processing.

Evaluating Change in Transference, Interpersonal Functioning, and Trust Processes in the Treatment of Borderline Personality Disorder: A Single-Case Study Using Ecological Momentary Assessment.

Transference-focused psychotherapy (TFP) is an empirically supported treatment for borderline personality disorder (BPD) that improves functioning via targeting representations of self affectively relating to others, particularly as evoked in the therapeutic relationship. If change in TFP operates as theorized, then shifts in patterns of "self affectively relating to others" should be observed in the transference prior to shifts in daily relationships. Using ecological momentary assessment (EMA), a patient with BPD rated daily interpersonal events for 2-week periods during 18 months of TFP; at 9 and 18 months these ratings included interactions with the therapist. Results suggest that positive perceptions of her therapist that ran counter to her negatively biased perception in other relationships preceded changes in her perceptions of others. EMA shifts corresponded to improvements in self-reported symptoms, interview-based personality functioning, and therapist assessments. Implications for assimilation of a trusting experience with the therapist as a mechanism of change in TFP are discussed.

Measurement Invariance of the Pathological Narcissism Inventory and Multimethod Examination of Narcissistic Presentations in Community and Clinical Samples.

The Pathological Narcissism Inventory (PNI) is extensively used in recent empirical literature on pathological narcissism. However, most studies using the PNI are community-based, and no studies have used the PNI to investigate narcissistic presentations in personality disordered patients. This study investigates measurement invariance of the PNI in community participants and patients with personality disorders, and examines differences of narcissistic presentations in these samples through a multimethod approach. Results show that the PNI can be used reliably to measure and compare traits of pathological narcissism in community participants and patients with personality disorders. Personality disordered patients show higher traits reflecting vulnerable narcissism and overt manifestations of grandiose narcissism, compared with controls. Finally, network analysis indicates that traits of grandiose fantasies and entitlement rage have a central role in defining manifestations of PNI pathological narcissism, regardless of the presence of an underlying personality disorder. Research and clinical implications are discussed.

Empirical Developments in Transference-Focused Psychotherapy.

OBJECTIVE: Transference-focused psychotherapy (TFP) is an empirically supported individualized psychotherapy for patients with borderline personality disorder. This review highlights its development and current status. METHODS: A review of the theoretical background underpinning TFP and empirical advances in the development of TFP provide perspective. RESULTS: Otto Kernberg's object relations model of personality and its implications for assessment and diagnosis of personality disorders are described. The authors review the programmatic research that has been developed and has demonstrated the efficacy of TFP. In view of the empirical studies that have demonstrated the successful outcomes and processes of TFP for patients with borderline personality disorder, compared with other approaches, TFP has been applied to a broader range of difficulties related to patients' self-functioning and interpersonal functioning across the range of severities in personality pathology, consistent with the Alternative DSM-5 Model for Personality Disorders. The authors discuss borderline personality organization in the context of interpersonal, neurocognitive, and self-regulatory dysfunction, including preliminary findings. CONCLUSIONS: The theoretical and empirical advances in TFP lead to future directions for research evaluating personality disorder and its treatment.

Object Relations Theory Model of Personality Disorders.

Contemporary models of the diagnosis and classification of personality disorders have diverged from the categorical diagnostic framework of the DSM system. One response to this movement can be found in the Alternative DSM-5 Model for Personality Disorders (AMPD), which uses dimensions of personality functioning, coupled with identification of dominant pathological traits, to define and classify personality disorders. By applying psychodynamic object relations theory to the AMPD, therapists can enrich the understanding and assessment of personality functioning and pathology as described in the AMPD.

Reflective functioning and its potential to moderate the efficacy of manualized psychodynamic therapies versus other treatments for borderline personality disorder.

BACKGROUND: Impaired reflective functioning (RF) is common among patients with borderline personality disorder (BPD). Transference-focused psychotherapy (TFP) has been demonstrated to improve RF compared to other common BPD treatments. If RF reflects a treatment mechanism for TFP, differences in pretreatment RF may also serve as a prescriptive factor for TFP's effects. METHOD: A total of 194 patients with BPD were randomized across two clinical trials to receive TFP (n = 83), dialectical behavior therapy (DBT; n = 31), supportive psychodynamic therapy (SPT; n = 28), or an enhanced treatment as usual (eTAU; n = 52). A mixed-effects model was used to examine whether baseline RF interacted with treatment condition to predict slopes of change in the Brief Symptom Inventory, the shared symptom outcome between trials. Moderation of changes in RF was also examined. RESULTS: Treatment interacted with baseline RF to predict BSI slopes (p = .011). In TFP/SPT, RF did not predict outcomes, ß = -0.00, p = .973, while higher RF was associated with relatively better outcomes in DBT/eTAU, ß = -0.54, p < .001. Patients with poor RF (scores of 0/1) benefitted more from TFP/SPT, while patients with relatively ordinary RF (score of 4) had better outcomes in DBT/eTAU. Treatment effects on RF change were also moderated by baseline RF (p = .014), such that TFP improved RF most strongly among poor RF patients, SPT only among very poor RF patients, and DBT/eTAU not at all. DISCUSSION: Low RF may reflect a deficit that may be targeted by TFP and other manualized psychodynamic treatments for BPD, which may be especially helpful among patients presenting with low RF. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Assessment of Personality Functioning in Adolescence: Development of the Adolescent Personality Structure Questionnaire.

Adolescence is a crucial period for the development of personality and its dysfunctions. In this regard, it is essential to evaluate the nature and degree of maladaptive personality functioning. However, measures currently available present some limitations, mainly being adaptations from adult's tailored instruments and length. Moreover, no instrument considers the crucial dimensions related to body development and sexuality. This contribution presents data on the Adolescent Personality Structure Questionnaire (APS-Q) development, a self-report measure to capture core aspects of personality functioning in adolescence while being agile and reliable. On two large samples of adolescents (total N = 1,664), we investigated the psychometric properties of the APS-Q. We explored its factor structure and construct and incremental validity in the first sample, testing specific associations with existing measures of severity of personality pathology, maladaptive personality traits, and psychological distress. In the second sample, we confirmed its factor structure, assessing gender and age invariance. Overall, our findings support the APS-Q's validity as a reliable and useful measure to assess personality functioning. Moreover, the APS-Q highlighted developmentally vital dimensions such as self-functioning (encompassing mental and bodily changes and considering the dimension of sexuality), interpersonal functioning (discriminating the dimensions of family and peers), and emotion regulation.

In-session reflective functioning in psychotherapies for borderline personality disorder: The emotion regulatory role of reflective functioning.

OBJECTIVE: The capacity for understanding mental states (reflective functioning; RF) is considered essential for self-growth, social learning, and emotion regulation. Impaired RF is thought to play a central role in borderline personality disorder (BPD). We examined whether asking patients to consider mental states in-session has a down-regulatory effect on emotional arousal in treatments for BPD. METHOD: Early-, middle- and late-phase videotaped sessions from a randomized-controlled trial of transference-focused psychotherapy (TFP; n = 30), dialectical behavior therapy (DBT; n = 29), and supportive psychodynamic therapy (SPT; n = 29) were segmented to therapist and patient talk-turns. Therapist talk-turns were rated as asking patients to consider mental state (bids for RF) or not. Patient talk-turns were rated for RF and acoustically encoded for arousal. RESULTS: Bids were twice as common in TFP compared to DBT and SPT. Across treatments, therapist bids for RF predicted better RF, which, in turn, predicted lower emotional arousal. CONCLUSIONS: Asking patients to consider mental states has a down-regulatory effect on patients' arousal in psychotherapies for BPD. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

TFP Extended: Development and Recent Advances.

Recent advances in the understanding of personality pathology have contributed to an emphasis on the core of personality pathology as deficits in self-functioning and interpersonal functioning at different levels of severity that must be assessed for clinical intervention. In concert with these conceptual and empirical advances, transference-focused psychotherapy (TFP), an empirically supported psychodynamic treatment for borderline personality disorder, has been in constant development with extensive clinical use. This article describes an object relations model for conceptualizing and assessing levels of personality organization, a transdiagnostic approach to personality pathology, and related treatment modifications, thus expanding the utilization of TFP beyond borderline personality disorder to the full range of personality dysfunction. The core of this treatment approach is a sequential interpretive process between patient and therapist. This process takes place within the context of a structured treatment frame tailored to the unique individual with problems in self-functioning and interpersonal functioning in his/her particular environment.

Effortful control is associated with executive attention: A computational study.

INTRODUCTION: Effortful control (EC) is the self-regulatory aspect of temperament that is thought to reflect the efficiency of executive attention (EA). Findings on relationship between EC and performance on EA tasks among adults are still contradictory. This study used a computational approach to clarify whether greater self-reported EC reflects better EA. METHODS: Four hundred twenty-seven healthy subjects completed the Adult Temperament Questionnaires and the Attention Network Task-revised, a conflict resolution task that gauges EA as the flanker effect (FE), that is, the difference in performances between incongruent and congruent trials. Here we also employed a drift-diffusion model in which parameters reflecting the actual decisional process (drift rate) and the extra-decisional time are extracted for congruent and incongruent trials. RESULTS: EC was not correlated with the FE computed with the classic approach, but correlated positively with drift rate for the incongruent trials, even when controlling for the drift rate in the congruent condition and the extra-decisional time in the incongruent condition. CONCLUSION: This study demonstrates an association between self-reported EC and EA among adults. Specifically, EC is not associated with overall response facilitation but specifically with a greater ability to make goal-oriented decisions when facing conflicting information.

Development and Validation of the Interview of Personality Organization Processes in Adolescence (IPOP-A).

The assessment of personality and personality pathology in adolescence represents a critical topic to understand adolescent's difficulties, predict long-term outcome in adulthood, and indicate adequate treatment. Personality Organization, and its underlying dimensions, plays an essential role in shaping how adolescents face their developmental tasks as they are connected with psychosocial functioning and psychopathological severity. However, few measures are available to assess personality organization during adolescence. The aim of the present research is to investigate the psychometric properties of the Interview of Personality Organization Processes in Adolescence (IPOP-A), a semi-structured interview designed for the assessment of the main personality organization dimensions in adolescence. Three studies were performed to explore the psychometric properties of the IPOP-A, in terms of factor structure, reliability, convergent, and discriminant validity. Exploratory and confirmatory factor analysis supported the IPOP-A construct validity. Furthermore, IPOP-A showed good reliability and evidenced a convergent and discriminant validity with DSM-oriented personality patterns, emotion dysregulation, identity disturbance, and psychopathology. Our results provide evidence of IPOP-A validity to assess emerging personality organization in adolescence. Furthermore, the IPOP-A is a promising tool to use in the clinical consultation and treatment planning for the adolescent.

A Bifactor Model of Personality Organization.

The aim of this study was to explore the viability of a bifactor model for the Inventory of Personality Organization (IPO), which is a self-report measure of personality functioning based on Kernberg's model of personality organization. A heterogeneous, predominantly clinical sample (N = 616) completed the German 83-item version of the IPO. Confirmatory and Exploratory Factor Analyses were applied to explore the factor structure of the IPO. We were able to establish a bifactor model with a general factor of personality functioning and three specific factors (Aggression, Reality Testing, Moral Values), which represent additional dimensions of personality organization. Virtually all items showed substantial positive loadings on the general factor, explaining roughly 66% of the common variance. Furthermore, we found support for convergent and discriminant validity of general and specific factors with regard to interview-based assessments of personality disorders and personality organization. The results lend support to a bifactor approach to Kernberg's model of personality organization. We also present a 30-item brief form of the IPO that efficiently implements the bifactor approach and may be further validated in future studies.

Risky Sexual Behavior Profiles in Youth: Associations With Borderline Personality Features.

Adolescence and young adulthood are peak periods for risky sexual behaviors (RSB) and borderline personality disorder (BPD) features. RSB is a major public health concern and adolescents with BPD may be particularly vulnerable to RSB, but this is understudied. The aim of this study was to identify distinct RSB profiles in youth and determine whether a specific profile was associated with BPD features. Participants were 220 adolescents and young adults (age 14-21) recruited from the community. To identify groups of adolescents and young adults who engage in similar RSB, a latent profile analysis (LPA) was conducted on sexually active youth (57%). Next ANOVA was used to identify how profiles differed in terms RSB dimensions and BPD features. We identified three distinct RSB profiles: (1) a Low RSB profile that was manifested by the majority (77.7%) of youth; (2) an Unprotected Sex in Relationships profile (13.3%) and; (3) an Impulsive Sex Outside Relationships profile (12%) which was manifested by youth with significantly higher BPD features. The findings shed light on the difficulties youth with BPD manifest around integrating sexuality, intimacy, fidelity, and love. This contrasts with the majority of youth who are sexually active in the context of relationships and engage in little or no RSB. The findings have important clinical implications. Adolescent sexuality is frequently in the blind spot of clinicians. To address the elevated risk of RSB in adolescents with BPD, interventions are needed to help adolescents navigate this period and improve their understanding of the reasons for RSB while addressing difficulties in establishing sexual and attachment relationships.

Facial Affective Behavior in Borderline Personality Disorder Indicating Two Different Clusters and Their Influence on Inpatient Treatment Outcome: A Preliminary Study.

BACKGROUND: The purpose of the present study was threefold: first, to investigate the facial affective behavior in patients with a borderline personality disorder (BPD); second, to examine whether these patients could be divided into clusters according to facial affective behavior; and third, to test whether these clusters would influence the inpatient treatment outcome. METHODS: Thirty inpatients with BPD were assessed with the Structured Clinical Interviews for DSM-IV Axis I and II Disorders (SCID I, SCID II) and had to complete a series of questionnaires before and directly after the 12-week long inpatient treatment. Facial affective behavior was recorded during the structured interview for personality organization (STIPO) and afterward coded with the emotional facial action coding system (EMFACS). Measures on psychopathology [beck depression inventory (BDI), Spielberger state and trait anxiety inventory (STAI), Spielberger state and trait anger inventory (STAXI), and symptom cheklist-90-revised (SCL-90-R)], interpersonal problems [Inventory of Interpersonal Problems (IIP)], and personality organization [inventory of personality organization (IPO)] were administered. RESULTS: Cluster analysis before the treatment yielded two groups that differed in general facial expressivity, and regarding the display of anger, contempt, and disgust. The effect sizes of the repeated measures ANOVAs showed that persons with higher scores on the affective facial expressions benefitted more from the treatment in terms of STAI state anxiety, STAXI state and trait anger, IIP total, and the two scales primitive defenses and identity diffusion of the IPO, whereas persons with lower scores benefitted more on the scale IPO reality testing. CONCLUSION: Our results indicated some initial trends for the importance of facial affective behavior in patients with BPD and their treatment outcome.

An Object Relations Model Perspective on the Alternative Model for Personality Disorders (DSM-5).

The Alternative Model of DSM-5 combines dimensional ratings of self-functioning, interpersonal functioning, and traits with categorical classification. The object relations model has a long tradition pre-dating the Alternative Model and, in part, has been incorporated into the Alternative Model. The object relations model provides a theoretical background (generally missing in the Alternative Model) that enhances the clinical assessment of personality pathology and its relationship to treatment planning.

Conformity to prototypical therapeutic principles and its relation with change in reflective functioning in three treatments for borderline personality disorder.

OBJECTIVE: To examine conformity to prototypical therapeutic principles and its relation with change in reflective functioning in 3 treatments for borderline personality disorder (BPD). METHOD: Early phase videotaped sessions from a randomized-controlled trial of year-long transference-focused psychotherapy (TFP; n = 27), dialectical behavior therapy (DBT; n = 26), and supportive psychodynamic therapy (SPT; n = 29) were coded using the Psychotherapy Q-sort (Jones, 1985). Ratings were compared to experts' ratings of ideal TFP, DBT, and mentalizing-enhancing principles to quantify conformity to ideal treatments. Reflective functioning was assessed at pre- and posttreatment. Differences among treatments in conformity and its relation with change in reflective functioning were examined. RESULTS: Conformity to TFP and mentalizing-enhancing principles was highest in TFP (ps < .01) while conformity to DBT principles was high in DBT and SPT (DBT vs. SPT: p > .40), but lower in TFP (ps < .01). Larger improvements in reflective functioning were predicted by higher conformity to TFP principles during TFP (p = .04) and higher conformity to mentalizing-enhancing principles during SPT (p = .02). CONCLUSIONS: Treatments for BPD differ in conformity to unique principles of specific modalities. Treatments also differ in the processes that predict increase in reflective functioning. The findings point to specificity and multiple pathways in increasing reflective functioning in the treatment of BPD. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Complex depression: The treatment of major depression and severe personality pathology.

The intensive treatment of a patient presenting with major depression, chronic suicidal ideation, and a borderline personality disorder with narcissistic features is described as it developed over an 18-month treatment. The treatment approach is a transdiagnostic one with an emphasis on change in the patient's representation of self and others, identity and interpersonal functioning. The intended change is not only in the reduction of depression and suicidal ideation but also an improvement in interactions with others at work and intimate relations. The combination of rich clinical information from the therapist and independent research ratings of patient progress provide a complex picture of the treatment.