Is self disturbance the core of borderline personality disorder? An outcome study of borderline personality factors.

OBJECT: To determine which constellation of clinical features constitutes the core of borderline personality disorder (BPD). METHOD: The criterion of endurance was used to identify the constellation of features which are most basic, or core, in borderline personality disorder. Two sets of constellations of DSM-III features were tested, each consisting of three groupings. The first set of constellations was constructed according to Clarkin's factor analysis; the second was theoretically derived. Broadly speaking, the three groupings concerned 'self', 'emotional regulation', and 'impulse'. Changes of these constellations were charted over one year in a comparison of the effect of treatment by the Conversational Model (n = 29) with treatment as usual (n = 31). In addition, measures of typical depression (Zung) were scored before and after the treatment period. The changes in the constellations were considered in relation to authoritative opinion. RESULTS: The changes in the two sets of constellations were similar. In the treatment as usual (TAU) group, 'self' endured unchanged, while 'emotional regulation' and 'impulse' improved. In the Conversational Model cohort, 'self' improved, 'emotional regulation' improved more greatly than the TAU group, while 'impulse' improved but not more than the treatment as usual group. Depression scores were not particularly associated with any grouping. CONCLUSIONS: A group of features including self/identity disturbance, emptiness and fear of abandonment may be at the core of BPD. Correlations between the three groupings and Zung scores favoured the view that the core affect is not typical depression. Rather, the central state may be 'painful incoherence'. It is suggested that the findings have implications for the refinement and elaboration of treatment methods in borderline personality disorder.

A university psychotherapy training program in a psychiatric hospital: 25 years of the conversational model in the treatment of patients with borderline personality disorder.

OBJECTIVE: The aim of this paper is to describe the development, delivery and experience of a university psychotherapy training program for psychiatry trainees in a public psychiatric hospital, demonstrating that patients with severe borderline personality disorder can be treated successfully with psychodynamic psychotherapy and stressing the need for structured psychodynamic psychotherapy training in psychiatry. METHOD: Two of the authors (JH and JS) were part of the first group of eight trainees supervised by Professor Russell Meares and several other experienced psychiatrists. RESULTS: Ninety trainees have successfully completed the course. Two hundred and forty patients have been treated by trainees in this program to date; 49 patients have dropped out. CONCLUSIONS: The training program provided a sound psychodynamic base and an improved capacity to relate with our patients, not only in the program but also in our routine work as psychiatrists. An important public health issue and community need was addressed, which also proved to make sound economic sense as the number of patients who were treated might not have otherwise received long-term psychotherapy. An integrated process model of psychoanalytic psychotherapy--the conversational model--has evolved and continues to be offered as a 3-year part-time clinically oriented course leading to a Masters in Medicine, Psychotherapy at the University of Sydney. Several outcome studies and papers have been published and workshops have been presented both in Australia and overseas. The patients improved considerably--their self harming behaviour stopped within 6 months and they were no longer clinically depressed at the end of 1 year.

The beneficial effect on family life in treating borderline personality.

The harmful effect of borderline patients on their families is an important but relatively neglected aspect of outcome studies. This study concerns changes in perceived quality of relationships with partners and children of 24 patients suffering Borderline Personality Disorder (BPD) after 12 months of treatment with the Conversational Model (CM). They were compared to 21 parents with BPD receiving "Treatment as Usual" (TAU) from their referring clinicians for the same period. Both groups developed naturalistically giving the study a quasi-experimental design. The Social Adjustment Scale (SAS-SR) was administered on intake and again after 12 months. The subscales dealing with relationships with children, with partners and with the family unit were scored and compared between groups. It was found that the perceived relationships with children and partners improved significantly for the CM group but not for the TAU group.

Somatization and stimulus entrapment.

A "vicious circle" hypothesis is put forward for the common kind of somatization which forms the basis of the DSM's "somatization disorder." Two compounding mechanisms are seen to be operative: (1) a failure of higher order inhibitory systems involved in the "medial pain system"; (2) amplification of stimulus intensity produced by the effect of attention. Attentional failure is produced not only by social factors but also by failure of sensory intensity modulation consequent upon (1). The argument focuses on data from borderline patients in whom the unusual prominence of pain may be due, at least in part, to incompetence of the "medial pain system." This is reflected in enlarged P3a components of the event-related potential suggesting diminished inhibitory function involving prefrontal connections. Two studies are briefly presented in summary form suggesting that somatization may be ameliorated by a form of therapy which focuses on "inner" material as a means of overcoming "stimulus entrapment."

The nothing that is something: core dysphoria as the central feature of borderline personality disorder. Implications for treatment.

People with borderline personality disorder (BPD) often describe a longstanding depression or dysphoria central to the disorder. The dimension of chronic inner dysphoria is reflected in the DSM criterion of "emptiness" and is demonstrated on self-report measures of depression. In this paper, we report on outcomes for patients with BPD treated with outpatient psychodynamic psychotherapy based on the Conversational Model. Data were collected using the Zung depression scale and the Westmead severity scale at 1 year and at 2 years from two groups of patients. One group had 1 year in psychotherapy, the other had 2 years in therapy. While general symptom scores improved steadily over time in the two-year group, gains for the one-year group tapered off in the second year. Change in depression scores continued at an unchanged rate in the second year for the two-year group compared to a leveling out of gains in the group treated for one year. Gains in general symptom scores were more substantial, suggesting that change in affect occurs more slowly than other symptomatic changes. Drawing upon our findings and those of others in the field, it appears that this slowness of affective change may reflect that patients with BPD have an inner world where predominant negative affectivity became established early in life in the context of disturbances of relatedness. This has implications for the appropriate duration of psychotherapeutic engagement with this group. We argue for more prolonged psychotherapy in this group, which is consistent with current understanding of processes of attachment and development.

Harm avoidance, self-harm, psychic pain, and the borderline personality: life in a "haunted house".

This article investigates the pattern of temperament for patients with borderline personality disorder and the impact of psychotherapeutic treatment on temperamental variables. A cohort of patients treated in the Westmead Borderline Personality Disorder Psychotherapy research project completed the Tridimensional Personality Questionnaire. All patients had a diagnosis of borderline personality disorder according to the Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition, criteria. This group scored highly on novelty-seeking and harm avoidance scales and moderately on reward dependence. There was a significant reduction in harm avoidance after 12 months of psychotherapy with a further reduction after 2 years in therapy. Although at variance with Cloninger's original prediction of low harm avoidance in histrionic and borderline patients, results are consistent with other studies in this patient group. The paradox of "self-harmers" scoring highly on harm avoidance may be explained by recognition of the intensity of "psychic pain" in this group. Self-harming behaviors may frequently be motivated by avoidance of a "greater harm" in terms of the inner psychic reality for these patients. Reduction in harm avoidance with psychotherapy could suggest an impact of treatment on temperament or may indicate that the harm avoidance construct is influenced by state variables such as mood.

Mother knows best: effects of maternal modelling on the acquisition of fear and avoidance behaviour in toddlers.

The present study was conducted to investigate the influence of parental modelling on the acquisition of fear and avoidance towards novel, fear-relevant stimuli in a sample of 30 toddlers. The toddlers were shown a rubber snake and spider, which were alternately paired with either negative or positive facial expressions by their mothers. Both stimuli were presented again after a 1- and a 10-min delay, while mothers maintained a neutral expression. The children showed greater fear expressions and avoidance of the stimuli following negative reactions from their mothers. This was true for both genders although the degree of modelled avoidance was greater in girls than in boys. The strong observational learning results are consistent with views that modelling constitutes a mechanism by which fear may be acquired early in life.