Clinical Components of Borderline Personality Disorder and Personality Functioning.

BACKGROUND: Impairment in personality functioning (PF) represents a salient criterion of the DSM-5 alternative diagnostic model for personality disorders (AMPD). The main goal of this study is to analyze the relationship of the borderline personality disorder (BPD) clinical components derived from the DSM-5 categorical diagnostic model (affective dysregulation, behavioral dysregulation, and disturbed relatedness) with personality organization (PO), i.e., PF, assessed by the Structured Interview of Personality Organization (STIPO). METHODS: STIPO and the Structured Clinical Interviews for DSM-IV (SCID-I and -II) were administered to 206 BPD patients. The relationship between PO and BPD components were studied using Spearman correlations and independent linear regression analyses. RESULTS: Significant positive correlations were observed between STIPO scores and several DSM-5 BPD criteria and comorbid psychiatric disorders. STIPO dimensions mainly correlated with disturbed relatedness and, to a lesser extent, affective dysregulation components. Each BPD clinical component was associated with specific STIPO dimensions. CONCLUSIONS: Both diagnostic models, DSM-5 BPD criteria and PO, are not only related but complementary concepts. The results of this study particularly recommend STIPO for the assessment of relational functioning, which is a major domain of the Personality Functioning Scale Levels of the DSM-5 AMPD.

Transference-focused psychotherapy for borderline personality disorder: change in reflective function.

Borderline personality disorder is associated with deficits in personality functioning and mentalisation. In a randomised controlled trial 104 people with borderline personality disorder received either transference-focused psychotherapy (TFP) or treatment by experienced community therapists. Among other outcome variables, mentalisation was assessed by means of the Reflective Functioning Scale (RF Scale). Findings revealed only significant improvements in reflective function in the TFP group within 1 year of treatment. The between-group effect was of medium size (d = 0.45). Improvements in reflective function were significantly correlated with improvements in personality organisation.

Attachment and mentalization in female patients with comorbid narcissistic and borderline personality disorder.

We investigated attachment representations and the capacity for mentalization in a sample of adult female borderline patients with and without comorbid narcissistic personality disorder (NPD). Participants were 22 borderline patients diagnosed with comorbid NPD (NPD/BPD) and 129 BPD patients without NPD (BPD) from 2 randomized clinical trials. Attachment and mentalization were assessed on the Adult Attachment Interview (AAI; George, Kaplan, & Main, 1996). Results showed that as expected, compared with the BPD group, the NPD/BPD group was significantly more likely to be categorized as either dismissing or cannot classify on the AAI, whereas the BPD group was more likely to be classified as either preoccupied or unresolved for loss and abuse than was the NPD/BPD group. Both groups of patients scored low on mentalizing, and there were no significant differences between the groups, indicating that both NPD/BPD and BPD individuals showed deficits in this capacity. The clinical implications of the group differences in AAI classification are discussed with a focus on how understanding the attachment representations of NPD/BPD patients helps to illuminate their complex, contradictory mental states.

Self-report and observer ratings of personality functioning: a study of the OPD system.

Recent considerations around DSM-5 criteria of personality disorders (PDs) demand new concepts of assessing levels of personality functioning. Of special interest are multiperspective approaches accounting for clinicians' as well as patients' points of view. The study investigates observer-rated and self-assessed levels of personality functioning measured by the level of structural integration as defined by the Operationalized Psychodynamic Diagnosis System (OPD). Both perspectives were positively related. The combination of both measures was most efficient in discriminating among 3 diagnostic groups of varying degrees of personality dysfunction. Future studies should take into account expert ratings as well as self-report data.

Psychiatric comorbidity and personality structure in patients with polyvalent addiction.

BACKGROUND: This study focuses on the systematic psychiatric evaluation of polydrug-using opiate-dependent patients, using the standard DSM-IV diagnostic interviews and a new psychodynamic instrument operationalizing personality organization (Structured Interview of Personality Organization, STIPO). SAMPLING AND METHOD: 50 patients were interviewed with the Structured Clinical Interview for DSM-IV Disorders (SCID) I and II and the STIPO by two independent researchers at a detoxification treatment unit. RESULTS: According to the SCID I and II, all patients had at least one axis I disorder, 90% at least one axis II disorder. A correspondence was found between STIPO and SCID results, in that more pathology in the SCID coincided with more severity in the STIPO. According to the STIPO, 100% of the patients were located at the level of borderline personality organization, indicating identity pathology according to Kernberg's model. CONCLUSION: Given the fact that comorbid psychiatric disorders compromise the outcome of detoxification and dehabituation treatments, it is highly relevant to diagnose these disorders and to assess underlying personality pathology. While the evidence of psychosocial treatments in addiction therapy is still weak, the integration of syndrome-tailored treatment modules may help improve the treatment of patients with this chronically relapsing condition. LIMITATION: small sample size.

Reliability and validity of the German version of the Structured Interview of Personality Organization (STIPO).

BACKGROUND: The assessment of personality organization and its observable behavioral manifestations, i.e. personality functioning, has a long tradition in psychodynamic psychiatry. Recently, the DSM-5 Levels of Personality Functioning Scale has moved it into the focus of psychiatric diagnostics. Based on Kernberg's concept of personality organization the Structured Interview of Personality Organization (STIPO) was developed for diagnosing personality functioning. The STIPO covers seven dimensions: (1) identity, (2) object relations, (3) primitive defenses, (4) coping/rigidity, (5) aggression, (6) moral values, and (7) reality testing and perceptual distortions. The English version of the STIPO has previously revealed satisfying psychometric properties. METHODS: Validity and reliability of the German version of the 100-item instrument have been evaluated in 122 psychiatric patients. All patients were diagnosed according to the Diagnostic and Statistical Manual for Mental Disorders (DSM-IV) and were assessed by means of the STIPO. Moreover, all patients completed eight questionnaires that served as criteria for external validity of the STIPO. RESULTS: Interrater reliability varied between intraclass correlations of .89 and 1.0, Crohnbach's α for the seven dimensions was .69 to .93. All a priori selected questionnaire scales correlated significantly with the corresponding STIPO dimensions. Patients with personality disorder (PD) revealed significantly higher STIPO scores (i.e. worse personality functioning) than patients without PD; patients cluster B PD showed significantly higher STIPO scores than patients with cluster C PD. CONCLUSIONS: Interrater reliability, Crohnbach's α, concurrent validity, and differential validity of the STIPO are satisfying. The STIPO represents an appropriate instrument for the assessment of personality functioning in clinical and research settings.

Internal structure of the Reflective Functioning Scale.

The Reflective Functioning Scale (RFS) was developed to assess individual differences in the ability to mentalize attachment relationships. The RFS assesses mentalization from transcripts of the Adult Attachment Interview (AAI). A global score is given by trained coders on an 11-point scale ranging from antireflective to exceptionally reflective. Coding procedures rely on a distinction of demand and permit questions during the AAI. Demand questions directly probe for reflective functioning (RF), whereas permit questions do not. Coding focuses on detecting qualitative markers of RF and qualitative markers of absent RF, respectively. Despite its relevant empirical contributions in clinical research, several psychometric properties of the RFS are still unclear. In this article, we present data on the reliability and internal structure of the RFS based on a combined sample of 196 subjects. We were able to show that (a) the global score can be assessed with good interrater reliability, is relatively stable across time, and is significantly reduced in persons with mental disorders; (b) demand questions are based on a single latent factor; (c) demand questions do not differ in terms of difficulty; (d) all demand questions but 1 are incrementally predictive of the global score; (e) 5 permit questions contribute to the global score over and above demand questions; and (f) the number of qualitative markers of RF is also predictive of the global score. Our results have important conceptual and methodological implications for future studies using the RFS.

The relationship between personality organization and psychiatric classification in chronic pain patients.

BACKGROUND: The present study investigated the relationship between psychiatric classification and personality organization (PO) in a secondary/tertiary clinical sample of chronic pain patients (CPPs). SAMPLING AND METHODS: Forty-three patients were administered the Structured Clinical Interview for DSM-IV (SCID I+II) and the Structured Interview of Personality Organization (STIPO). The prevalence of axis I and axis II disorders was correlated with the STIPO level of PO. The STIPO dimensional ratings of patients without personality disorder (PD) were compared to those of patients diagnosed with one or more PDs. RESULTS: Axis I comorbidity was high (93%), and 63% of the patients met the criteria for at least one axis II diagnosis. Twenty-five patients (58%) were diagnosed as borderline PO, with high-level impairments in the dimensions 'coping/rigidity', 'primitive defenses' and 'identity'. Higher axis I and axis II comorbidity corresponded with greater severity of PO impairment. No difference was found between the dimensional ratings of patients without PD and those of patients with one or more PDs. CONCLUSIONS: The assessment of PO is a crucial issue for diagnosis and treatment planning in CPPs, since it represents a measure of structural impairment that is to a considerable extent independent of axis I and II diagnoses. Moreover, the STIPO dimensional rating focuses on the most salient dysfunctions at a given time.

Patients with borderline personality disorder not participating in an RCT: are they different?

BACKGROUND: Despite the notion that randomized controlled trials are regarded as the gold standard in psychotherapy research, questions about their generalizability have been raised. This paper focuses on the differences between participants and eligible nonparticipants of a randomized controlled trial for patients with borderline personality disorder (BPD). SAMPLING AND METHODS: One hundred forty-two patients were screened, and 122 were found eligible for study participation. Out of these, 64 patients (52.5%) gave informed consent and were included in the study. RESULTS: The 58 eligible nonparticipants showed a lower level of functioning (global assessment of functioning score), had a history of more outpatient treatment attempts and were living alone more often. Regarding acute symptoms and severity of BPD as indexed by suicide attempts, inpatient treatments, substance abuse and history of trauma, no differences between the groups could be detected. Moreover, participants showed significantly more eating disorders, whereas nonparticipants presented more affective and anxiety disorders. CONCLUSIONS: The results indicate that lower psychosocial functioning and comorbid affective and anxiety disorders decrease BPD patients' willingness to participate in an RCT.

[Personality structure and clinical severity of borderline personality disorder]. / Strukurniveau und klinischer Schweregrad der Borderline-Persönlichkeitsstörung.

OBJECTIVES: To correlate personality structure and clinical severity of borderline personality disorder. METHODS: Based on data from a sample of 104 female patients with borderline personality disorder, we computed bivariate correlations and group comparisons using the scales from the Structured Interview of Personality Organization (STIPO) as well as indicators of clinical severity of the disorder (axis-II comorbidity, suicide attempts, self-destructive behaviour, service utilization). RESULTS: Patients with a clinically more severe disorder revealed a worse level of personality structure. Specific associations between dimensions of personality structure and phenomenology were found. CONCLUSIONS: The diagnoses of personality structure and of phenomenology complement each other and should be combined in clinical settings as well as for research purposes.

Ten-year use of mental health services by patients with borderline personality disorder and with other axis II disorders.

OBJECTIVE: The study determined the prevalence of use of three treatment modalities (individual therapy, medication, and hospitalization) reported over a ten-year period by patients with borderline personality disorder and by those in a comparison group with other axis II disorders. Time to cessation and time to resumption for each modality among patients with borderline personality disorder were also determined. METHODS: Treatment history of inpatients with a reliable diagnosis of borderline personality disorder (N=290) and of other axis II disorders (N=72) was assessed with an interview of proven reliability during the index admission. Treatment history was reassessed at two-year intervals for ten years. RESULTS: For all three treatment modalities, prevalence of use declined significantly among patients with borderline personality disorder and among those in the comparison group. Among patients with borderline personality disorder, 52% reported having stopped individual therapy and 44% reported having stopped medication at one or more of the follow-up interviews over ten years. However, 85% of those who had stopped psychotherapy and 67% of those who stopped taking medication resumed these treatments during a subsequent two-year period. In contrast, 88% had experienced at least one two-year period without a psychiatric hospitalization by the time of the ten-year follow-up; however, almost half of these patients were subsequently rehospitalized. CONCLUSIONS: The results suggest that patients with borderline personality disorder tend to use outpatient treatments without interruption over prolonged periods. They also suggest that inpatient treatment is used far more intermittently by patients with borderline personality disorder.

Transference-focused psychotherapy v. treatment by community psychotherapists for borderline personality disorder: randomised controlled trial.

BACKGROUND: Transference-focused psychotherapy is a manualised treatment for borderline personality disorder. AIMS: To compare transference-focused psychotherapy with treatment by experienced community psychotherapists. METHOD: In a randomised controlled trial (NCT00714311) 104 female out-patients were treated for 1 year with either transference-focused psychotherapy or by an experienced community psychotherapist. RESULTS: Significantly fewer participants dropped out of the transference-focused psychotherapy group (38.5% v. 67.3%) and also significantly fewer attempted suicide (d = 0.8, P = 0.009). Transference-focused psychotherapy was significantly superior in the domains of borderline symptomatology (d = 1.6, P = 0.001), psychosocial functioning (d = 1.0, P = 0.002), personality organisation (d = 1.0, P = 0.001) and psychiatric in-patient admissions (d = 0.5, P = 0.001). Both groups improved significantly in the domains of depression and anxiety and the transference-focused psychotherapy group in general psychopathology, all without significant group differences (d = 0.3-0.5). Self-harming behaviour did not change in either group. CONCLUSIONS: Transference-focused psychotherapy is more efficacious than treatment by experienced community psychotherapists in the domains of borderline symptomatology, psychosocial functioning, and personality organisation. Moreover, there is preliminary evidence for a superiority in the reduction of suicidality and need for psychiatric in-patient treatment.

[The psychic structure of chronic pain patients]. / Psychische Struktur bei chronischen Schmerzpatienten.

OBJECTIVES: The study investigates the psychic structure and psychiatric comorbidity of chronic pain patients according to Kernberg's concept of personality organization. METHODS: We assessed 48 chronic pain patients attending the Behavioural Medicine Pain Clinic in the Department of Psychiatry. Patients were diagnosed using the SCID (DSM-IV). Psychic structure was assessed using the Structured Interview of Personality Organization (STIPO). RESULTS: At least one psychiatric diagnosis was found in 94 % of the patients, and 63 % of the patients met the criteria of at least one diagnosis of a personality disorder. In 58 % of the patients, we diagnosed a borderline personality organization, with high deficits in the dimensions of coping, defence mechanisms and identity. CONCLUSIONS: The high prevalence of borderline personality organization confirms the importance of a diagnostic investigation of the psychic structure and the necessity for psychotherapeutic treatment in chronic pain patients.

Structured Interview of Personality Organization (STIPO): preliminary psychometrics in a clinical sample.

In this article, we describe the development and preliminary psychometric properties of the Structured Interview of Personality Organization (STIPO), a semistructured interview designed for the dimensional assessment of identity, primitive defenses, and reality testing, the three primary content domains in the model of personality health and disorder elaborated by Kernberg (1984; Kernberg & Caligor, 2005). Results of this investigation, conducted in a clinical sample representing a broad range of personality pathology, indicate that identity and primitive defenses as operationalized in the STIPO are internally consistent and that interrater reliability for all 3 content domains is adequate. Validity findings suggest that the assessment of one's sense of self and significant others (Identity) is predictive of measures of positive and negative affect, whereas the maladaptive ways in which the subject uses his or her objects for purposes of regulating one's self experience (Primitive Defenses) is predictive of measures of aggression and personality disorder traits associated with cluster B personality disorders. We discuss implications of these findings in terms of the theory-driven and trait-based assessment of personality pathology.

[Psychotherapists' attitudes towards the treatment of patients with borderline personality disorder]. / Einstellung von Psychotherapeuten gegenüber der Behandlung von Patienten mit Borderline Persönlichkeitsstörung.

A questionnaire was sent to a representative sample of 300 psychotherapists working in Munich, consisting of a short case report on a prototypical BPD patient, 21 questions on sociodemographic data and suggestions on the treatment of BPD. 58% replied to the questionnaire. 22% of the therapists stated not to treat BPD patients on principle. 66% declared not to offer therapy to new patients, due to being booked out. Specific therapeutic approaches for the treatment of BPD were recommended by 51%, but only offered by 3%. Psychotherapists in private practice often experience anxiety and show some prejudice towards the treatment of patients with BPD. The introduction of specialized treatment programs like DBT and TFP has led to a high degree of publicity and acceptance, but the number of trained therapists is still low even in a city like Munich.