Effectiveness of time-limited cognitive analytic therapy of borderline personality disorder: factors associated with outcome.

Most patients with borderline personality disorder receive no formal treatment for their personality disorder and psychotherapy is widely believed to be necessarily intensive, of long duration and of uncertain effect. This study seeks to demonstrate the scope and limits of time-limited outpatient cognitive analytic psychotherapy. Cases were identified by standard diagnostic procedures. Most were referred from psychiatrists and were typical of inner city patient populations. At an assessment 6 months after therapy the 27 patients completing therapy were divided into 'improved' and 'unimproved' groups. The patients classified as improved no longer met diagnostic criteria for borderline personality disorder. The two-thirds still traceable were re-tested at 18 months. These groups were compared in terms of a number of pre-therapy measures and features. Poorer outcome was associated with greater severity of borderline features, a history of self-cutting, alcohol abuse and unemployment.

The identification and characteristics of the partially dissociated states of patients with borderline personality disorder.

A developmental and structural model of borderline personality disorder is described. Partial dissociation provoked by trauma and deprivation in childhood is seen to result in the persistence of separate self states. The characteristics of these and alternations between them are seen to account for the main features of the condition. The identification and characterization of states through clinical procedures and the use of the states grid are described and case illustrations are given. The states identified by the grid method in a series of 20 borderline patients are described and classified into six groups, named abuser rage, victim rage, passive victim, ideal, coping and zombie. The clinical value and nosological implications of the model and these findings are briefly discussed.

A trial of cognitive analytic therapy in poorly controlled type I patients.

OBJECTIVE: This study compared the effect of cognitive analytic therapy (CAT), a focused time-limited psychotherapy, and diabetes specialist nurse education (DSNE) in a controlled trial of 26 chronically poorly controlled adult type I patients. RESEARCH DESIGN AND METHODS: Patients were randomized to either 16 sessions of CAT (treatment) or 14-18 sessions of DSNE (control). Pre- and post-treatment blood glucose control (HbA1), interpersonal difficulties, and diabetes knowledge were measured before and up to 9 months after treatment was completed. RESULTS: Although HbA1 levels improved in the DSNE group, at the end of treatment (mean fall 1.2%, P = 0.004) this was not maintained; so by the 9-month follow-up, the overall net fall was limited to 0.9% (P = 0.03 vs. entry value). There were no significant improvements in interpersonal difficulties in DSNE subjects at any retest point (P > 0.05). In contrast, glycemic control and interpersonal difficulties both improved after CAT. In contrast to DSNE, this improvement continued so that at the 9-month follow-up visit, the changes were significant (mean fall in HbA1 = 2%, P = 0.002 and P = 0.03 for the Inventory of Interpersonal Problems [IIP] scores). CONCLUSIONS: These results suggest that although there is no statistical difference between CAT and DSNE, the effects of CAT produce a more prolonged effect on glycemic control. If psychological difficulties underlying problems with self-care in a type I population are addressed, then improvements in diabetes control are likely to continue.

The structure and development of borderline personality disorder: a proposed model.

BACKGROUND: The theory of cognitive analytic therapy is extended to offer an understanding of borderline personality disorder (BPD). METHOD: A structural model (the multiple self states model) and a classification of different levels of developmental damage are proposed. RESULTS: The model offers an explanation of the phenomenology of BPD. CONCLUSIONS: The multiple self states model provides insights that will be useful for clinicians involved in the psychotherapy and management of BPD patients.

Ogden's autistic-contiguous position and the role of interpretation in psychoanalytic theory building.

Ogden's proposed addition of the 'autistic-contiguous' position to the existing P-S and D positions is critically examined. It is concluded that it is not an equivalent concept to the existing positions. The case vignettes offered by Ogden as illustrations of his proposed position are analysed and doubt is thrown on the way in which interpretations may be used to elicit apparent confirmation of theoretical positions.

Transference and counter-transference variations in the course of the cognitive-analytic therapy of two borderline patients: the relation to the diagrammatic reformulation of self-states.

The cognitive-analytic therapy of two patients with borderline personality disorder is described. Patients and therapists completed post-sessional questionnaires which yielded measures of transference and counter-transference. The relation of changes in these to the sequential diagrammatic reformulation of the patients' self-states is considered.

Projective identification: a particular form of reciprocal role procedure.

Certain aspects of the phenomena considered under the concept of projective identification, notably those concerned with the relationship between intrapsychic and interpersonal phenomena and with indirect forms of communication and influence, are discussed in relation to an alternative theoretical framework. It is argued that these clinically important phenomena are best understood as particular forms of the more general processes involved in interpersonal relating.

Consciousness and psychotherapy.

The origins and resistance to change of neurotic procedures are considered with particular reference to the nature and role of consciousness. It is argued that the traditional opposition between conscious and unconscious systems provides an unsatisfactory model. The crucial role of language in the formation of human self-consciousness is emphasized. The restricted procedural repertoire of neurotic subjects, and their deficient self-consciousness, can be attributed to a number of factors. It is argued that the main use of consciousness in therapy should be to heighten the patient's awareness of his or her damaging or restricting procedural repertoire through the process of reformulation, which allows recognition, and in due course revision to be achieved.

The integrative effect of reformulation: cognitive analytic therapy with a patient with borderline personality disorder.

The impact of 26 sessions of Cognitive Analytic Therapy on a patient with a borderline personality disorder is presented, largely through the patient's account given at a follow-up assessment interview. It is suggested that the account raises questions of practical and theoretical interest.

Secretion of mucus proteinase inhibitor and elafin by Clara cell and type II pneumocyte cell lines.

The regulation of proteinases secreted by neutrophils is very important for the prevention of tissue injury. We recently described the isolation of elafin from bronchial secretions, a new elastase-specific inhibitor that is also found in the skin of patients with psoriasis. In this study, we investigated the secretion of elafin and mucus proteinase inhibitor (MPI), another inhibitor showing sequence similarity with elafin, in two lung carcinoma cell lines, NCI-H322 and A549, which have features of Clara cells and type II alveolar cells, respectively. The results presented show that the two inhibitors are produced when the cells are cultured either in serum-free or in serum-containing media. MPI was detected immunologically as a unique molecule of M(r) 14 kD, in accordance with previous studies. Conversely, one or two elafin-immunoreactive species were detected depending on the cell line: a 12- to 14-kD species was observed in the A549 cell line, regardless of the culture conditions, whereas in the NCI-H322 cell line we detected a 6-kD species in serum-containing (10% fetal calf serum) conditions and a 12- to 14-kD species in serum-free conditions. The 12- to 14-kD molecule probably represents an active precursor of elafin. Whether the cleavage of the 12- to 14-kD precursor giving rise to the elafin molecule is of any physiologic significance is not known. In showing for the first time that MPI and elafin (and its precursor) are secreted by the A549 cell line, this report implicates the type II alveolar cell in the defense of the peripheral lung against the neutrophil elastase secreted during inflammation.

Critique of a Kleinian case presentation.

An account of Kleinian analysis illustrating the concept of the pathological organization is discussed from an alternative theoretical position, that of cognitive analytic therapy. It is suggested that the alternative model of development, while still essentially an object relations theory, produces a different understanding and that the therapeutic method associated with it offers a more powerful means of aiding personality integration.

Isolation of elafin and elastase-specific inhibitor (ESI) from bronchial secretions. Evidence of sequence homology and immunological cross-reactivity.

Evidence is presented that the elastase-specific inhibitor of Mr 2500 (Sallenave, J.-M. & Ryle, A.P. (1991) Biol. Chem. Hoppe-Seyler 372, 13-21) is a biologically active fragment of a larger molecule described in the skin of patients with psoriasis (Wiedow, O., Shroder, J.-M., Gregory, H., Young, J.A. & Christophers, E. (1990) J. Biol. Chem. 265, 14791-14795) which the authors called elafin. We also describe the purification of the complete elafin molecule from bronchial secretions from a patient suffering from bronchial carcinoma, thus showing that the elafin, like the mucus proteinase inhibitor (MPI), is not of single origin but is probably a marker of inflammation (chronic obstructive pulmonary diseases, psoriasis...) present in different tissues.

Object relations theory and activity theory: a proposed link by way of the procedural sequence model.

An account of object relations theory (ORT), represented in terms of the procedural sequence model (PSM), is compared to the ideas of Vygotsky and activity theory (AT). The two models are seen to be compatible and complementary and their combination offers a satisfactory account of human psychology, appropriate for the understanding and integration of psychotherapy.

Some meanings of body and self in eating-disordered and comparison subjects.

A new repertory grid was used to compare a group of 27 eating-disordered women (EDS) with a group of 20 women of normal weight without eating disorders (NWC) on contrasts from theories which link abnormalities in the perception of body and self to the eating disorders. No evidence was found for greater polarization of either self or body images in the EDS. A negative connotation of the body at normal weight and overweight was specific to EDS, but the underweight body did not have a more positive connotation. Negative connotation of normal weight is shown to be more specific for EDS than is negative connotation of the overweight body. There was no evidence for specific implications of weight for sexuality nor for family pressures against sexuality or femininity in EDS although they did construe themselves as less sexual than the NWC.

Differential inhibition of rat mast cell proteinase I and II by members of the alpha-1-proteinase inhibitor family of serine proteinase inhibitors.

Rat mast cell proteinase II (RMCP II) from mucosal mast cells was titrated into rat serum, and the resulting serine proteinase inhibitor (serpin)-enzyme complex was purified by affinity chromatography on anti-RMCP II-Sepharose 4B and by Mono-Q anion-exchange. The purified complex was used to raise polyclonal antibodies which, after cross-absorption against RMCP II-Sepharose 4B, were specific for serpin and were used to affinity purify two rat serpin molecules (RSI and RSII) that inhibit RMCP II in rat serum. The kinetic constants characterizing the interaction between RMCP II and RSI and RSII are ka, 2.2 x 10(5) and 1.65 x 10(5) M-1 s-1, respectively; Ki, 3.6 x 10(-10) and 1.0 x 10(-9) M; and kd, 7.9 x 10(-5) and 1.65 x 10(-4) s-1. Amino-terminal sequence analysis indicated that RSI and RSII are distinct, differing at the amino-terminal residues, and are products of the rat Spi-1 locus. Rat mast cell proteinase I (RMCP I) from connective tissue mast cells cleaved both RSI and RSII and was not inhibited.