Therapist interpretation, patient-therapist interpersonal process, and outcome in psychodynamic psychotherapy for avoidant personality disorder.

[Correction Notice: An erratum for this article was reported in Vol 43(3) of Psychotherapy: Theory, Research, Practice, Training (see record 2006-12148-017). The correct legend for Figure 1 on page 500 should read as follows: Figure 1. The SASB circumplex model, cluster version, interpersonal surfaces. Adapted from Benjamin (1993), Interpersonal diagnosis and treatment of personality disorders. New York: Guilford Press, copyright Guilford Press, and from: Benjamin (1987), Use of the SASB dimensional model to develop treatment plans for personality disorders, I: Narcissism. Journal of Personality Disorders, 1, 43-70, copyright Guilford Press.] The authors examined the link between interpretive techniques, the therapeutic relationship, and outcome in psychodynamic psychotherapy. Two independent teams of judges each coded one early session from patients diagnosed with avoidant personality disorder. Results revealed (a) an inverse association between concentration of interpretation and favorable patient outcome; (b) that small amounts of disaffiliative patient-therapist transactions before, during, and after interpretations were reliably or meaningfully associated with negative patient change; and (c) concentration of interpretation was positively associated with disaffiliative therapy process before and during interpretation and negatively associated with affiliative patient responses to interpretation. The results suggest that therapists who persisted with interpretations had more hostile interactions with patients and had patients who reacted with less warmth than therapists who used interpretations more judiciously. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Speed and accuracy of facial expression classification in avoidant personality disorder: A preliminary study.

The aim of this preliminary study was to examine whether individuals with avoidant personality disorder (APD) could be characterized by deficits in the classification of dynamically presented facial emotional expressions. Using a community sample of adults with APD (n = 17) and non-APD controls (n = 16), speed and accuracy of facial emotional expression recognition was investigated in a task that morphs facial expressions from neutral to prototypical expressions (Multi-Morph Facial Affect Recognition Task; Blair, Colledge, Murray, & Mitchell, 2001). Results indicated that individuals with APD were significantly more likely than controls to make errors when classifying fully expressed fear. However, no differences were found between groups in the speed to correctly classify facial emotional expressions. The findings are some of the first to investigate facial emotional processing in a sample of individuals with APD and point to an underlying deficit in processing social cues that may be involved in the maintenance of APD. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Co-occurrence of avoidant personality disorder and child sexual abuse predicts poor outcome in long-standing eating disorder.

Few consistent predictive factors for eating disorder have been identified across studies. In the current 5-year prospective study, the objective was to examine whether (a) personality disorder and child sexual abuse predict the course of severity of eating disorder symptoms after inpatient treatment and (b) how the predictors interact. A total of 74 patients with long-standing eating disorder and mean age of 30 years were assessed at the beginning and end of inpatient therapy and at 1-, 2-, and 5-year follow-up. A mixed model was used to examine the predictors. Avoidant personality disorder and child sexual abuse interacted in predicting high levels of eating disorder over a long-term course. These results suggest that eating disorder, avoidant personality disorder, and sequelae after child sexual abuse are potential targets for treatment that need further investigation. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Shame aversion and shame-proneness in Cluster C personality disorders.

The associations between shame and Cluster C personality disorders (PDs) were examined in 237 undergraduates, 35 of whom met at least subthreshold criteria for Cluster C PDs assessed using the Personality Disorder Interview–IV. Shame-proneness (the propensity to experience shame across many situations) was measured using the Test of Self-Conscious Affect–3, and shame aversion (the tendency to perceive shame as especially painful and undesirable) was measured using the Shame-Aversive Reactions Questionnaire. A go/no-go association task was used to assess the strength of implicit mental representations of the association between shame and pain, relative to that between shame and pleasure. Shame-proneness and shame aversion were associated with Cluster C PD symptoms over and above trait positive and negative affect. Further, shame-proneness was found to be associated with Cluster C PDs among individuals with high but not low levels of shame aversion. Finally, shame–pain associations were uniquely associated with dependent personality disorder. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The interpersonal problems of the socially avoidant: Self and peer shared variance.

We demonstrate a means of conservatively combining self and peer data regarding personality pathology and interpersonal behavior through structural equation modeling, focusing on avoidant personality disorder traits as well as those of two comparison personality disorders (dependent and narcissistic). Assessment of the relationship between personality disorder traits and interpersonal problems based on either self or peer data alone would result in counterintuitive findings regarding avoidant personality disorder. In contrast, analysis of the variance shared between self and peer leads to results that are more in keeping with hypothetical relationships between avoidant traits and interpersonal problems. Similar results were found for both dependent personality disorder traits and narcissistic personality disorder traits, exceeding our expectations for this method. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Dialectical behavior therapy for borderline personality disorder: A meta-analysis using mixed-effects modeling.

Objective: At present, the most frequently investigated psychosocial intervention for borderline personality disorder (BPD) is dialectical behavior therapy (DBT). We conducted a meta-analysis to examine the efficacy and long-term effectiveness of DBT. Method: Systematic bibliographic research was undertaken to find relevant literature from online databases (PubMed, PsycINFO, PsychSpider, Medline). We excluded studies in which patients with diagnoses other than BPD were treated, the treatment did not comprise all components specified in the DBT manual or in the suggestions for inpatient DBT programs, patients failed to be diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders, and the intervention group comprised fewer than 10 patients. Using a mixed-effect hierarchical modeling approach, we calculated global effect sizes and effect sizes for suicidal and self-injurious behaviors. Results: Calculations of postintervention global effect sizes were based on 16 studies. Of these, 8 were randomized controlled trials (RCTs), and 8 were neither randomized nor controlled (nRCT). The dropout rate was 27.3% pre- to posttreatment. A moderate global effect and a moderate effect size for suicidal and self-injurious behaviors were found, when including a moderator for RCTs with borderline-specific treatments. There was no evidence for the influence of other moderators (e.g., quality of studies, setting, duration of intervention). A small impairment was shown from posttreatment to follow-up, including 5 RCTs only. Conclusions: Future research should compare DBT with other active borderline-specific treatments that have also demonstrated their efficacy using several long-term follow-up assessment points. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Transitional relatedness and borderline personality disorder.

This study examined various aspects of transitional relatedness among individuals diagnosed as borderline or antisocial personality disorder. This study was a follow-up to an earlier report (Cooper, 1983) using the Rorschach Transitional Object Scale, which found only marginal support for Modell's clinical hypothesis that the borderline personality disorder involves a developmental arrest at the stage of the transitional object. The authors approached the concept of transitional relatedness as a series of external and internalized modes of relating including the perceptual capacity to distinguish between object and symbol on the Rorschach as well as self-reported current and past reliance on transitional objects and self-soothing activities. The study failed to provide evidence to suggest that reliance on a past or present transitional object per se is a unique or diagnostic feature of the borderline personality disorder. Particular aspects of current transitional relatedness, however, were strongly associated with borderline psychopathology. The clinical and research implications of these findings are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Correction to Schut et al. (2005).

Reports an error in "Therapist Interpretation, Patient-Therapist Interpersonal Process, and Outcome in Psychodynamic Psychotherapy for Avoidant Personality Disorder" by Alexander J. Schut, Louis G. Castonguay, Kelly M. Flanagan, Alissa S. Yamasaki, Jacques P. Barber, Jamie D. Bedics and Tracey L. Smith (Psychotherapy: Theory, Research, Practice, Training, 2005 Win, Vol 42(4), 494-511). The correct legend for Figure 1 on page 500 should read as follows: Figure 1. The SASB circumplex model, cluster version, interpersonal surfaces. Adapted from Benjamin (1993), Interpersonal diagnosis and treatment of personality disorders. New York: Guilford Press, copyright Guilford Press, and from: Benjamin (1987), Use of the SASB dimensional model to develop treatment plans for personality disorders, I: Narcissism. Journal of Personality Disorders, 1, 43-70, copyright Guilford Press. (The following abstract of the original article appeared in record 2006-03309-008.) The authors examined the link between interpretive techniques, the therapeutic relationship, and outcome in psychodynamic psychotherapy. Two independent teams of judges each coded one early session from patients diagnosed with avoidant personality disorder. Results revealed (a) an inverse association between concentration of interpretation and favorable patient outcome; (b) that small amounts of disaffiliative patient-therapist transactions before, during, and after interpretations were reliably or meaningfully associated with negative patient change; and (c) concentration of interpretation was positively associated with disaffiliative therapy process before and during interpretation and negatively associated with affiliative patient responses to interpretation. The results suggest that therapists who persisted with interpretations had more hostile interactions with patients and had patients who reacted with less warmth than therapists who used interpretations more judiciously. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The stability of personality traits in individuals with borderline personality disorder.

Although stability and pervasive inflexibility are general criteria for Diagnostic and Statistical Manual of Mental Disorders, 4th edition (American Psychiatric Association, 1994) personality disorders (PDs), borderline PD (BPD) is characterized by instability in several domains, including interpersonal behavior, affect, and identity. The authors hypothesized that such inconsistencies notable in BPD may relate to instability at the level of the basic personality traits that are associated with this disorder. Five types of personality trait stability across 4 assessments over 6 years were compared for BPD patients (N = 130 at first interval) and patients with other PDs (N = 302). Structural stability did not differ across groups. Differential stability tended to be lower for 5-factor model (FFM) traits in the BPD group, with the strongest and most consistent effects observed for Neuroticism and Conscientiousness. Growth curve models suggested that these 2 traits also showed greater mean-level change, with Neuroticism declining faster and Conscientiousness increasing faster, in the BPD group. The BPD group was further characterized by greater individual-level instability for Neuroticism and Conscientiousness in these models. Finally, the BPD group was less stable in terms of the ipsative configuration of FFM facet-level profiles than was the other PD group over time. Results point to the importance of personality trait instability in characterizing BPD. (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 manual-based psychodynamic therapy for treatment-resistant borderline personality disorder.

The authors introduce a manual-based treatment, labeled dynamic deconstructive psychotherapy, developed for those patients with borderline personality disorder who are most difficult to engage in therapy, such as those having co-occurring substance use disorders. This treatment model is based on the hypothesis that borderline pathology and related behaviors reflect impairment in specific neurocognitive functions, including association, attribution, and alterity that form the basis for a coherent and differentiated self. Dynamic deconstructive psychotherapy aims to activate and remediate neurocognitive self-capacities by facilitating elaboration of affect-laden interpersonal experiences and integration of attributions, as well as providing novel experiences in the patient-therapist relationship that promote self-other differentiation. Treatment involves weekly individual sessions for a predetermined period of time and follows sequential stages. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The undisordered personality: Normative assumptions underlying personality disorder diagnoses.

Clinical diagnoses are impossible without referring to normative assumptions about what is desirable functioning. In this paper, the authors explicate the implicit normative assumptions that seem to have guided the formulation of the Diagnostic and Statistical Manual of Mental Disorders (DSM–IV) personality disorder (PD) criteria. Then the authors discuss various conceptual reference frames in which such assumptions may be grounded: (1) a given diagnostician’s personal value system, (2) the expectations of the culture in which a person currently lives, (3) the expectations of the culture in which a person was raised, (4) models of “natural” personality functioning that are rooted in evolution theory, and (5) the presence of distress and/or impairment. In accordance with Wakefield (1992a, 2006), the authors argue that PD diagnoses necessarily involve both an evolutionary and a cultural component. If PDs were defined completely in cultural terms, investigating their biological underpinnings would be nonsensical. In addition, the values of any specific culture should not be given too much weight, because cultural expectations may themselves be harmful. Future editions of DSM should define personality pathology in less culture-relative terms, and address the inevitable issue of values more explicitly. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Shorter term treatment of borderline personality disorder: A developmental, self-, and object relations approach.

After a brief summary of J. F Masterson's developmental, self-, and object relations approach to long-term, intensive psychotherapy of the borderline personality disorder, an adaptation of this approach to shorter term treatment is proposed. The time constraints of abbreviated treatment require the following limited goals for the patient: (a) increased control of maladaptive defenses, (b) learning about the fundamental dynamics related to the focal symptom or problematic behavior, and (c) improved adaptation. Requisite modifications of technique include (a) limited frequency of sessions, (b) focalized treatment, (c) an emphasis on adaptation, and (d) a reliance on confrontation as the primary therapeutic intervention. A brief case study is presented for illustrative purposes. (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)     

Pharmacologic treatment of personality disorder.

This article reviews the recent literature on pharmacologic treatment of personality disorders, discusses the existing models that pharmacotherapy of these disorders, and reviews specific classes of medication that appear to play a beneficial role. Antipsychotics, mood stabilizers. antidepressants, benzodiazepines, and opioid antagonists are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The construct validity of depressive personality disorder.

This study examined the construct validity of depressive personality disorder (DPD; American Psychiatric Association, 1994). Adult Psychiatric outpatients (N=900) underwent comprehensive Axis I and II evaluations and provided data on 4,768 of their 1st-degree relatives. Despite modest overlap, DPD was not redundant with any Axis I or II disorder. Participants with DPD exhibited more Axis I and Axis II comorbidity, and greater psychosocial dysfunction, than participants without DPD. Relatives of participants with DPD had higher rates of mood disorders, alcohol abuse, and antisocial personality. Results are consistent with findings of several other similar investigations. The authors argue that DPD is a valid construct and should be conceptualized as a personality disorder as opposed to a mood disorder. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A dimensional model of personality disorder: Incorporating DSM Cluster A characteristics.

The authors articulate an expanded dimensional model of personality pathology to better account for symptoms of DSM-defined Cluster A personality disorders. Two hundred forty participants (98 firstdegree relatives of probands with schizophrenia or schizoaffective disorder, 92 community control participants, and 50 first-degree relatives of probands with bipolar disorder) completed a dimensional personality pathology questionnaire, a measure of schizotypal characteristics, and Chapman measures of psychosis proneness. Scales from all questionnaires were subjected to an exploratory factor analysis with varimax rotation. A 5-factor structure of personality pathology emerged from the analyses, with Peculiarity forming an additional factor to the common 4-factor structure of personality pathology (consisting of Introversion, Emotional Dysregulation, Antagonism, and Compulsivity). These results support a 5-factor dimensional model of personality pathology that better accounts for phenomena encompassed by the Cluster A personality disorders in DSM-IV-TR (4th ed., text revised; American Psychiatric Association, 2000). This study has implications for the consideration of a dimensional model of personality disorder in DSM-V by offering a more comprehensive structural model that builds on previous work in this area. (PsycINFO Database Record (c) 2010 APA, all rights reserved)