Case Report: Restitution 101.

The Case Report is a forum for distinguished clinicians representing a range of theoretical orientations to share diagnostic formulations and treatment recommendations of the same psychotherapy patient. The present case is that of Ms. S, a young woman with features of borderline personality disorder, mood disturbance, and posttraumatic stress disorder who was self-referred for individual outpatient psychotherapy. Treatment was precipitated by the sudden onset of vivid, snapshot-like memories of early childhood sexual abuse. Material from the initial weeks of therapy is presented, followed by a discussion of points of convergence and divergence from the expert therapists. Finally, a few closing comments are offered by the case contributor. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Restitution, Myth, and Reality.

Commenting on a case presentation entitled "Restitution 10," (see record 2005-02680-005), a number of problems are pointed out. The diagnosis of the patient is not properly documented, and the history is marred by probable false memories. The interpretation of Ornduff (2005) that understanding previous experiences of child abuse was helpful to the patient is questioned. An alternative approach, using both psychodynamic and cognitive principles, is suggested. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A Behavioral Approach to the Case of Ms.S.

This article provides a behavioral formulation and treatment plan for the case of Ms. S (see record 2005-02680-005). Given the complexity of Ms. S and the status of current research, interventions proposed emphasize empirically supported principles of change over any specific protocol. This particular behavioral approach incorporates aspects of dialectical behavior therapy and functional analytic psychotherapy in addition to more traditional behavior therapy. The utility of the therapeutic relationship in this approach is described (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Schema-Focused Cognitive Therapy and the Case of Ms. S.

The author looks at the case of Ms. S (see record 2005-02680-005), a 20 year old female with borderline personality disorder and posttraumatic stress disorder. The author discusses the symptoms leading to the diagnosis, and offers suggestions for the psychotherapeutic processes involved in schema-focused cognitive therapy. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Object Relations and the Nature of Therapeutic Interventions.

This discussion of a case (see record 2005-02680-005) addresses tailoring a multifaceted therapeutic intervention based on assessing the nature of the patient's object relations. In this case, the patient's ambivalent and confused sense of self and attachment that developed because of the history of abuse suggests an approach that aims to develop a "soft" attachment of the patient to the therapist. The nature of the attachment should be explored using interpersonal therapeutic techniques to understand current relationships rather than to depend on the development and analysis of transference. Cognitive-behavioral interventions will help limit distortions that occur because of an ego that weakens under stress. Though the therapist is thinking and analyzing the therapeutic data in terms of object relations, the interventions can come from a number of theoretical perspectives. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Points of Contention and Convergence.

In this portion of the clinical exchange, Drs. Kathleen Chard and Thomas Widiger, Joel Paris, Kenneth Silk, Amy Wagner, and Jeffrey Young discuss areas of agreement and disagreement about their concepts of the case, as described in their separate articles (see records 2005-02680-006; 2005-02680-007; 2005-02680-008; 2005-02680-009; 2005-02680-010) in this issue of the journal, of the patient with traits of borderline personality disorder described in "Restitution 101" (see record 2005-02680-005). Issues of diagnosis, phenomenology, case formulation, and treatment models and techniques are compared with an eye toward integrating the various viewpoints. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Randomized Trial of Cognitive-Behavioral Therapy for Chronic Posttraumatic Stress Disorder in Adult Female Survivors of Childhood Sexual Abuse.

The authors conducted a randomized clinical trial of individual psychotherapy for women with posttraumatic stress disorder (PTSD) related to childhood sexual abuse (n = 74), comparing cognitive-behavioral therapy (CBT) with a problem-solving therapy (present-centered therapy; PCT) and to a wait-list (WL). The authors hypothesized that CBT would be more effective than PCT and WL in decreasing PTSD and related symptoms. CBT participants were significantly more likely than PCT participants to no longer meet criteria for a PTSD diagnosis at follow-up assessments. CBT and PCT were superior to WL in decreasing PTSD symptoms and secondary measures. CBT had a significantly greater dropout rate than PCT and WL. Both CBT and PCT were associated with sustained symptom reduction in this sample. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Structural relations between borderline personality disorder features and putative etiological correlates.

This study assessed the structural relations between borderline personality disorder (BPD) features and purported etiological correlates. Approximately 5,000 18-year-old nonclinical young adults were screened for BPD features, and 2 cohorts of participants (total N?=?421; approximately one half of whom endorsed significant borderline features) completed the laboratory phase of the study. Measures included self-report and interview-based assessments of BPD psychopathology, personality, psychopathology in biological parents, and childhood physical and sexual abuse. Significant relations between BPD features and purported etiological correlates of BPD were found. A multivariate model that included parental psychopathology, childhood abuse, and personality factors provided an adequate fit to the data and supported the contention that the personality traits disinhibition and negative affectivity underlie BPD features. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Using feminist, emotion-focused, and developmental approaches to enhance cognitive-behavioral therapies for posttraumatic stress disorder related to childhood sexual abuse.

A body of research indicates the efficacy of cognitive-behavioral interventions for the treatment of posttraumatic stress disorder (PTSD) subsequent to sexual assault in adulthood. The generalizability of these treatments to women who present with trauma symptoms associated with childhood sexual abuse (CSA) has yet to be shown, however. A number of characteristics and dynamics of CSA that make it unique from sexual assault in adulthood are described, specifically its disruption of normal childhood development, its impact on attachment style and interpersonal relationships, its inescapability, and the stigma attached to it. Then, drawing on the developmental, emotion-focused, and feminist literatures, a number of considerations that would enhance the application of cognitive- behavioral trauma therapies to the treatment of women with PTSD related to CSA are delineated. These considerations relate to providing clients with corrective interpersonal experiences, creating new relationship events, enhancing affect regulation skills before initiating exposure therapy, considering the time elapsed since the abuse, addressing themes of power, betrayal, self-blame, stigma, and sex-related cognitions and emotions, and helping clients develop a feminist consciousness. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

An evaluation of cognitive processing therapy for the treatment of posttraumatic stress disorder related to childhood sexual abuse.

This study compared the effectiveness of cognitive processing therapy for sexual abuse survivors (CPT-SA) with that of the minimal attention (MA) given to a wait-listed control group. Seventy-one women were randomly assigned to 1 of the 2 groups. Participants were assessed at pretreatment and 3 times during posttreatment: immediately after treatment and at 3-month and 1-year follow-up, using the Clinician-Administered Posttraumatic Stress Disorder (PTSD) Scale (D. Blake et al., 1995), the Beck Depression Inventory (A. T. Beck, R. A. Steer, & G. K. Brown, 1996), the Structured Clinical Interview for the DSM-IV (R. L. Spitzer, J. B. W. Williams, & M. Gibbon, 1995; M. B. First et al., 1995), the Dissociative Experiences Scale-II (E. M. Bernstein & F. W. Putnam, 1986), and the Modified PTSD Symptom Scale (S. A. Falsetti, H. S. Resnick, P. A. Resick, & D. G. Kilpatrick, 1993). Analyses suggested that CPT-SA is more effective for reducing trauma-related symptoms than is MA, and the results were maintained for at least 1 year. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Abuse, Coping, and Treatment.

The authors were asked to provide in this commentary a discussion of the psychotherapy case of Ms. S, including a consideration of diagnosis, therapeutic relationship, treatment methods, and therapy process. In this paper, they recommend a possible treatment plan for Ms. S using cognitive behavioral techniques, and provide a diagnostic conceptualization in terms of the Five Factor Model of general personality functioning. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Review of Dynamic psychotherapy of the borderline patient.

Reviews the book, Dynamic psychotherapy of the borderline patient by William Goldstein (1996). The reviewer notes that The Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994) defines the essential feature of borderline personality disorder as a pervasive pattern of instability of interpersonal relationships, self-image, and affects, along with marked impulsivity that begins by early adulthood and is present in a variety of contexts. This pattern is observable in many kinds of DSM-IV personality disorders, and as a result: the borderline personality diagnosis overlaps with many other types of DSM-IV disorders. This has led to a plethora of theories, techniques, and suggestions regarding the borderline patient. Goldstein has made an effort in this book to present a primer outlining some of the basic approaches along with his own approach to treatment: of borderline patients. His orientation is said to be pragmatic, much like the reviewer's, except that he has a Kernberg-influenced penchant for distinctions and categories which perhaps will help some beginners to organize the variety of their patients who tend to get labeled as borderline. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Nontraumatic pathways to borderline personality disorder.

Clinicians who treat borderline personality disorder (BPD) generally assume that this disorder is caused by childhood abuse. This assumption is strongly supported in the BPD literature, which indicates that the majority of individuals with BPD have suffered emotional, physical, and sexual abuse. What is often missed or simply ignored in discussions of BPD is that this same body of research also suggests that a significant minority of borderline individuals have not suffered childhood abuse. This article reviewed the literature on the prevalence of childhood abuse and BPD, offered a number of hypotheses about nontraumatic pathways to BPD, and briefly considered treatment implications for nontraumatized BPD individuals. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A controlled trial of psychodynamic psychotherapy for co-occurring borderline personality disorder and alcohol use disorder.

A randomized controlled trial was conducted to determine whether a manual-based psychodynamic treatment, labeled dynamic deconstructive psychotherapy (DDP), would be feasible and effective for individuals with co-occurring borderline personality disorder (BPD) and alcohol use disorder. Thirty participants were assessed every 3 months during a year of treatment with either DDP or treatment as usual (TAU) in the community. DDP participants showed statistically significant improvement in parasuicide behavior, alcohol misuse, institutional care, depression, dissociation, and core symptoms of BPD, and treatment retention was 67% to 73%. Although TAU participants received higher average treatment intensity, they showed only limited change during the same period. The results support the feasibility, tolerability, and efficacy of DDP for the co-occurring subgroup and highlight the need for further research. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The impact of antisocial personality characteristics on anger management treatment for veterans with PTSD.

Using multilevel modeling, the authors examined the impact of antisocial personality characteristics on the effectiveness of cognitive–behavioral anger management group treatment among 86 veterans with posttraumatic stress disorder. A wide range of forms of anger, as well as use of physical aggression, decreased during treatment. As predicted, antisocial personality characteristics were associated with smaller decreases in trait anger, anger expression, and use of physical aggression during treatment. Conversely, these characteristics were associated with a greater decrease in state anger. Mechanisms of action and implications for the role of anger and antisocial personality in treatment are proposed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A comparison of trauma-focused and present-focused group therapy for survivors of childhood sexual abuse: A randomized controlled trial.

This randomized controlled trial compared trauma-focused group psychotherapy (TFGT) with present-focused group psychotherapy (PFGT) and a waitlist condition for 166 survivors of childhood sexual abuse who were at risk for HIV infection. Primary outcomes included risk for HIV infection (based on sexual revictimization, drug and alcohol use, and risky sex) and posttraumatic stress disorder (PTSD) symptoms. It was hypothesized that TFGT would be superior to the PFGT and waitlist conditions and that receiving either treatment (combining both TFGT and PFGT) would be superior to no treatment (waitlist condition). Intention-to-treat analyses for HIV risk found that all conditions reduced risk; however, there was no effect for condition on HIV risk. Intention-to-treat analyses for PTSD symptoms found a reduction for all conditions. There was no advantage for either TFGT or PFGT in reducing PTSD symptoms; however, there was an effect for treatment compared with the waitlist condition. On secondary outcomes, there was a greater reduction in anger for TFGT compared with PFGT, and when comparing treatment with the waitlist condition, there was a greater reduction in hyperarousal, reexperiencing, anger, and impaired self-reference for the treatment condition. Adequate dose analyses generally confirmed the intention-to-treat findings and additionally found that treatment led to reductions in depression, dissociation, and sexual concerns. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Treating co-occurring Axis I disorders in recurrently suicidal women with borderline personality disorder: A 2-year randomized trial of dialectical behavior therapy versus community treatment by experts.

This study evaluated whether dialectical behavior therapy (DBT) was more efficacious than treatment by nonbehavioral psychotherapy experts in reducing co-occurring Axis I disorders among suicidal individuals with borderline personality disorder (BPD). Women with BPD and recent and repeated suicidal and/or self-injurious behavior (n = 101) were randomly assigned to 1 year of DBT or community treatment by experts (CTBE), plus 1 year of follow-up assessment. For substance dependence disorders (SDD), DBT patients were more likely to achieve full remission, spent more time in partial remission, spent less time meeting full criteria, and reported more drug- and alcohol-abstinent days than did CTBE patients. These findings suggest that improvements in co-occurring SDD among suicidal BPD patients are specific to DBT and cannot be attributed to general factors associated with nonbehavioral expert psychotherapy. Further, group differences in SDD remission were not explained by either psychotropic medication usage or changes in BPD criterion behaviors. DBT and CTBE did not significantly differ in the reduction of anxiety disorders, eating disorders, or major depressive disorder. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Posttraumatic stress symptoms mediate the relation between childhood sexual abuse and nonsuicidal self-injury.

Prior research consistently has shown a strong relation between childhood abuse and nonsuicidal self-injury (NSSI), yet it is unclear why this relation exists. The authors examined 2 specific posttraumatic stress disorder (PTSD) symptom clusters as potential mechanisms through which childhood abuse may be related to NSSI. Participants were 86 adolescents (78% female, 22% male; 73% Caucasian, 27% other races/ethnicities; mean age = 17.03 years, range = 12-19 years) who completed measures of childhood abuse, Diagnostic and Statistical Manual of Mental Disorders (4th ed.) PTSD symptoms, and NSSI. Analyses revealed a significant relation between childhood sexual abuse in particular and the presence and frequency of NSSI. Moreover, data supported a theoretical model in which PTSD reexperiencing and avoidance/numbing symptoms independently mediate this relation. Future research must test the temporal relation between childhood sexual abuse, PTSD symptoms, and NSSI and identify additional pathways to engagement in NSSI. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Skills training in affective and interpersonal regulation followed by exposure: A phase-based treatment for PTSD related to childhood abuse.

Fifty-eight women with posttraumatic stress disorder (PTSD) related to childhood abuse were randomly assigned to a 2-phase cognitive-behavioral treatment or a minimal attention wait list. Phase 1 of treatment included 8 weekly sessions of skills training in affect and interpersonal regulation; Phase 2 included 8 sessions of modified prolonged exposure. Compared with those on wait list, participants in active treatment showed significant improvement in affect regulation problems, interpersonal skills deficits, and PTSD symptoms. Gains were maintained at 3- and 9-month follow-up. Phase 1 therapeutic alliance and negative mood regulation skills predicted Phase 2 exposure success in reducing PTSD, suggesting the value of establishing a strong therapeutic relationship and emotion regulation skills before exposure work among chronic PTSD populations. (PsycINFO Database Record (c) 2010 APA, all rights reserved)