Diagnosis, Comorbidity, and Psychodynamic Psychotherapy in Borderline Personality

1
Diagnosis, Comorbidity, and Psychodynamic
Psychotherapy in Borderline Personality

• Allan Tasman, M.D.

2
Impact of Systems of Psychiatric Diagnosis

• DSM and ICD are still non-etiologic approaches
  based on symptom clusters
• DSM revisions were designed to stimulate
  research, which has occurred
• No provision for role of psychological conflict
  or developmental distress
• No provision for symbolic meaning of symptoms
• When role of empathic listening for trauma,
  transference, cultural influences, and symbolic
  meanings are omitted, we cannot fully understand
  our patients

3
Personality Temperament Character
4
The Five-Factor Model of Personality

• Neuroticism
• Calm Worrying
• Even-tempered Temperamental
• Self-satisfied Self-pitying
• Comfortable Self-conscious
• Unemotional Emotional
• Hardy Vulnerable
• Extraversion
• Reserved Affectionate
• Loner Joiner
• Quiet Talkative
• Passive Active
• Sober Fun-loving
• Unfeeling Passionate
• Openness to Experience
• Down-to-earth Imaginative
• Uncreative Creative
• Conventional Original
• Prefer routine Prefer variety

• Agreeableness
• Ruthless Soft-hearted
• Suspicious Trusting
• Stingy Generous
• Antagonistic Acquiescent
• Critical Lenient
• Irritable Good-natured
• Conscientiousness
• Negligent Conscientious
• Lazy Hardworking
• Disorganized Well-organized
• Late Punctual
• Aimless Ambitious
• Quitting Persevering

Adapted from Costa McCrae 1986
5
Three Major Brain Systems Influencing Stimulus
Response Characteristics
6
Cloningers Seven-Factor Model

• Temperament Domains (Moderately heritable, not
  greatly influenced by family environment)
• Novelty Seeking
• Harm Avoidance
• Reward Dependence
• Persistence
• 2. Character Domains (Moderately influenced by
  family environment, only weakly heritable)
• Self-transcendence
• Cooperativeness
• Self-directedness

7
DSM-IV Definition of Personality Disorder

• An enduring pattern of inner experience and
  behavior that deviates markedly from the
  expectations of the individuals culture. This
  pattern is manifested in two (or more) of the
  following areas
• Cognition (i.e., ways of perceiving and
  interpreting self, other people, and events)
• Affectivity (i.e., the range, intensity, ability,
  appropriateness of emotional response)
• Interpersonal functioning
• Impulse control
• The Enduring pattern is inflexible and pervasive
  across a broad range of personal and social
  situations.

8
DSM-IV Definition of Personality Disorder

• C. The enduring pattern leads to clinically
  significant distress or impairment in social,
  occupational, or other important areas of
  functioning.
• The pattern is stable and of long duration and
  its onset can be traced back at lease to
  adolescence or early adulthood.
• The enduring pattern is not better accounted for
  as a manifestation or consequence of another
  mental disorder.
• The enduring pattern is not due to the direct
  physiological effects of a substance (e.g., a
  drug of abuse, a medication) or a general medical
  condition (e.g., head trauma).

9
Phenomenologically Corresponding Axis I Axis II
Disorders, Potential Biological Indexes, and
Characteristic Traits (Core Vulnerabilities),
Defenses and Coping Strategies of Dimensions of
Personality Disorders
Preliminary data are available in patients with
personality disorder (PD)
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Impulsive Disorders

• Axis II
• Borderline Personality Disorder
• Antisocial Personality Disorder
• Axis I
• Psychoactive Substance Use Disorder
• Bulimia
• Paraphilias
• Impulsive Control Disorder NEC

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STPD
Bip-II
MDD
PTSD
BPD
Severity of social dysfunction
SPD
ASPD
NPD
AVPD
HPD
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Concepts of Borderline Disorders
Affective Disorders
Borderline Schizophrenia (Kety) (Schizotypal PD -
Rado, Meehl)
Atypical Affective Disorders (D.Klein)
Schizophrenia
Borderline Personality Organization (Kernberg)
Borderline Personality Disorder
Borderline Syndrome (Grinker)
Neuroses
13
Theories of Etiology of BPD

• 1. Affective/impulsive dysregulation (Klein,
  Akiskal)
• 2. Excessive aggression (Kernberg)
• A. Primary (constitutional)
• B. Secondary (reaction to frustration or trauma)
• 3. Maternal withdrawal (Masterson, Rinsley)
• 4. Introjective failure (Mahler, Kohut)
• 5. Neurological dysfunction (Andrulonis)
• Gunderson and Zanarini

14
Etiology of BPD

• Type 1 Affective (Akiskal, Klein)
• A moderately heritable subaffective
  vulnerability, precipitated by environmental
  stress
• Prototypic Criteria
• 6 affective instability due to marked
  reactivity of mood (dysphoria or anxiety)
• 5 recurrent suicidal behavior, gestures or
  threats, or self-mutilating behavior

15
Etiology of BPD

• Type 2 Impulsive (Zanarini, Hollander, Siever)
• A moderately heritable impulse spectrum
  disorder, precipitated by environmental stress
• Prototypic Criteria
• 4 impulsivity in at least two areas that are
  potentially self-damaging
• 5 recurrent suicidal behavior, gestures or
  threats, or self-mutilating behavior

16
Etiology of BPD

• Type 3 Aggressive (Kernberg)
• A primary moderately heritable aggressive
  temperament, or a secondary reaction to early
  trauma and/or abuse
• Prototypic Criteria
• 8 inappropriate, intense anger or difficulty
  controlling anger
• 6 affective instability due to marked
  reactivity of mood (irritability)

17
Etiology of BPD

• Type 4 Dependent (Masterson and Rinsley
  Gunderson)
• intolerance of aloneness, and impaired
  autonomy, possibly secondary to parental
  separation-resistance
• Prototypic Criteria
• 1 frantic efforts to avoid real or imagined
  abandonment
• 6 affective instability due to marked
  reactivity of mood (anxiety)

18
Etiology of BPD

• Type 5 Empty (Mahler Adler and Buie)
• failure to develop an evocative memory
  secondary to lack of empathy and inconsistency in
  early parenting
• Prototypic Criteria
• 7 chronic feelings of emptiness
• 3 identity disturbance markedly and
  persistently unstable self-image or sense of self

19
APA Practice Guidelines Work Group on Borderline
Personality Disorders

• John Oldham, M.D. (Chair)
• Glen Gabbard, M.D.
• Marcia Goin, M.D., Ph.D.
• John Gunderson, M.D.
• Paul Soloff, M.D.
• David Spiegel, M.D.
• Michael Stone, M.D.
• Katherine Phillips, M.D.

20
Part A Treatment Recommendations for Patients
with Borderline Personality Disorder

• II. Formulation and Implementation of a Treatment
  Plan
• E. Specific Treatment Strategies for the Clinical
  Features of Borderline Personality Disorder
• 1. Psychotherapy
• 2. Pharmacotherapy and other somatic treatments

21
Pharmacotherapy

• Type 1 (Affective)
• Type 2 (Impulsive)
• Type 3 (Aggressive)
• Type 4 (Dependent)
• Type 5 (Empty)

B P D T y p e
Psychotherapy
22
Common Features of Recommended Psychotherapy for
BPD

• 1. Non-brief
• 2. Strong therapeutic alliance
• 3. Establishment of clear roles and
  responsibilities of patient and therapist
• 4. Active therapist
• 5. Hierarchy of priorities
• 6. Empathic validation need for patient to
  control behavior
• 7. Flexibility
• 8. Limit-setting
• 9. Concomitant individual and group approaches

23
Table 2. The Hierarchy of Priorities in
Therapeutic Sessions
Dialectical Behavior Therapy (Linehan 1993)
Psychoanalytic/Psychodynamic Therapies (Kernberg
et al. 1989 Clarkin et al. 1999)
suicidal behaviors
suicide or homicide threats
therapy-interfering behaviors
overt threats to treatment continuity
quality-of-life interfering behaviors
dishonesty or deliberate withholding
contract breaches
in-session acting out
between-session acting out
nonaffective or trivial themes
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Part A Treatment Recommendations for Patients
with Borderline Personality Disorder

• IV. Risk Management Issues in Treating Borderline
  Patients
• A. General Considerations
• 1. Good collaboration and communication
• 2. Assessment of risk, careful documentation
• 3. Attention to problems in the transference or
  countertransference
• 4. Consultations
• 5. Psychoeducation

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Part A Treatment Recommendations for Patients
with Borderline Personality Disorder

• IV. Risk Management Issues in Treating Borderline
  Patients
• B. Suicide
• 1. Monitor for suicide risk
• 2. Take suicide threats seriously
• 3. Address chronic suicidality without acute
  risk, in therapy
• 4. Actively treat comorbid Axis I conditions
• 5. Consultation
• 6. Involvement of family
• 7. Non-reliance on suicide contract

26
Part A Treatment Recommendations for Patients
with Borderline Personality Disorder

• IV. Risk Management Issues in Treating Borderline
  Patients
• C. Anger, Impulsivity, and Violence
• 1. Monitor for impulsive or violent behavior
• 2. Address abandonment/rejection issues, anger,
  impulsivity, in therapy
• 3. Careful coverage arrangement and documentation
  when away
• 4. Take action if necessary to protect self or
  others

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Part A Treatment Recommendations for Patients
with Borderline Personality Disorder

• IV. Risk Management Issues in Treating Borderline
  Patients
• D. Boundary Violations
• 1. Monitor counter transference
• 2. Be alert to deviations from standard practice
• 3. Avoid boundary violations
• 4. Consultation

28
The Effectiveness of Psychodynamic Therapy and
Cognitive Behavior Therapy in the Treatment of
Personality Disorders A Meta-Analysis

• Both psychodynamic therapy and cognitive behavior
  therapy are effective treatments of personality
  disorders
• For psychodynamic therapy, the effect sizes
  indicate long-term rather than short-term change
  in personality disorders (mean follow-up period
  1.5 years 78 weeks vs CBT mean follow-up 13
  weeks)

Leichsenring F, Leibing E, Am J Psychiatry 2003
1601223-1232
29
Intensive Psychodynamic Psychotherapy in BPD

• Basic principles
• Stability of the framework of treatment
• Increased activity of the therapist
• Tolerance of negative transference
• Establishing a connection between the patients
  actions and feeling in the present
• Making self-destructive behaviors ungratifying

30
Intensive Psychodynamic Psychotherapy in BPD

• Basic principles continued
• Blocking acting out behaviors
• Focusing, clarifications, and interpretations on
  the here and now
• Paying careful attention to countertransference
  feelings
• Treatment goals are related to the position of
  the therapist regarding etiology and
  pathophysiology of BPD

31
Theories about Etiologies of BPD Pertinent to
Psychodynamic Psychotherapy

• Kernberg emphasizes the role of excessive
  aggression
• Aggression is seen to interfere with bringing
  together aggressive and loving internal images of
  the self or others so as to prevent the images of
  the good self and the good other from suffering
  the impact of aggression and hatred
• Primitive defenses such as splitting, projection,
  idealization, projective identification, and
  others are used to prevent obliteration of good
  self or other by the patients own aggression

32
Theories about Etiologies of BPD Pertinent to
Psychodynamic Psychotherapy

• Other authors emphasize deficits in patients
  ability to maintain internal images of holding or
  soothing, thus patient cannot evoke these images
  in a self-soothing way
• A vulnerability exists to painful experiences of
  aloneness, panic, or abandonment

33
Theories about Etiologies of BPD Pertinent to
Psychodynamic Psychotherapy

• Many psychoanalytic theoreticians emphasize
  problems during the separation individuation
  period
• A conflict exists between drive for autonomy and
  the need for continued care and support
• The infant may resort to using primitive defenses
  to preserve the illusion of symbiotic union with
  the mother

34
Goals and Phases of Psychodynamic Psychotherapy
Treatment in BPD

• The initial goal, which persists throughout
  therapy, is the creation of a positive emotional
  holding environment
• Patient uses the therapist for these functions as
  they are unavailable to the patient
• Another ongoing goal is to help patients develop
  images of self and others that are
  multidimensional, cohesive, and integrated
• Essential because BPD patients lack integrated
  representations of self and others, causing
  misperceptions and distortions in social
  interactions
• Therapists interventions serve the function of
  helping the patient learn self-reflective
  capacities

35
Goals and Phases of Psychodynamic Psychotherapy
Treatment in BPD

• Early and consistent interpretation of the
  patients aggression is essential
• Because of acting out and lack of
  self-reflection, suicide threats and behavior,
  threats to quit treatment, lying and withholding
  information may be prominent and disruptive
• Interpretation occurs most usefully within a
  holding therapeutic relationship
• Various forms of acting out frequently interfere
  with patients experience of this

36
Goals and Phases of Psychodynamic Psychotherapy
Treatment in BPD

• Extreme sensitivity to separation is prominent
  early and throughout treatment
• This includes therapist absences or vacations,
  termination, or even momentary withdrawal of
  attention during a treatment session
• As tolerance of ambivalence in the perception of
  self increases, the need to protect the self by
  primitive defenses decreases
• Therapy shifts from predominance of acting out to
  greater subjective awareness of interpersonal
  distortions increased use of language over
  behavior
• Ultimate goal is consolidation of ego or self
  with integration of representations of self and
  others

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Summary

• Psychotherapeutic interventions are ideally
  targeted to etiological issues - most present
  diagnostic systems are inadequate in this regard
  comorbidity may impair clear etiologic
  formulation
• In BPD standard therapeutic techniques are
  modified with greater therapist activity and here
  and now focus
• Creation of a holding and soothing environment is
  difficult, but critical to success
• Ultimate goals include resolution of split self
  and object representations, and decreased
  reliance on primitive defenses