FOCUS Current Issue

From the Guest Editors

Oldham JM, Fowler J. — Fri, 01 Mar 2013 00:00:00 GMT

Personality disorders (PDs) have been identified in every edition of the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association (APA). Specific diagnostic criteria were identified to define each of the PDs in 1980 in DSM-III, and the PDs were placed on Axis II in this first multiaxial version of the DSM. It is interesting that the two main diagnostic categories on Axis II were the PDs and, so called at the time, mental retardation. Although placement of these two groups on Axis II was multidetermined, it is easy to imagine that they were both seen as “life sentences”—one thought to be “psychogenic” and the other “biological” and heritable but both being longstanding and unlikely to change. We know now that some of these distinctions and assumptions are inaccurate. The PDs are moderately heritable conditions, comparably so to such disorders as major depression and schizophrenia. As is true in all of medicine, the combination of heritable risk and environmental stress can lead to the development of an illness, a formula that applies to the PDs as well as to other psychiatric disorders. The PDs generally have their onset in late adolescence or early adulthood, and it is often early life trauma or neglect that impairs the normal attachment process, thus interfering with the development of a healthy sense of self and of healthy and mutually rewarding interpersonal relationships.

Alternative DSM-5 Model for Personality Disorders

Fri, 01 Mar 2013 00:00:00 GMT

The current approach to personality disorders appears in Section II of DSM-5, and an alternative model developed for DSM-5 is presented here in Section III. The inclusion of both models in DSM-5 reflects the decision of the APA Board of Trustees to preserve continuity with current clinical practice, while also introducing a new approach that aims to address numerous shortcomings of the current approach to personality disorders. For example, the typical patient meeting criteria for a specific personality disorder frequently also meets criteria for other personality disorders. Similarly, other specified or unspecified personality disorder is often the correct (but mostly uninformative) diagnosis, in the sense that patients do not tend to present with patterns of symptoms that correspond with one and only one personality disorder. In the following alternative DSM-5 model, personality disorders are characterized by impairments in personality functioning and pathological personality traits. The specific personality disorder diagnoses that may be derived from this model include antisocial, avoidant, borderline, narcissistic, obsessive-compulsive, and schizotypal personality disorders. This approach also includes a diagnosis of personality disorder—trait specified (PD-TS) that can be made when a personality disorder is considered present but the criteria for a specific disorder are not met.(Reprinted from American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th Ed. Washington, DC,APA, 2013. Copyright © 2013, American Psychiatric Association. Used with permission.)

Antisocial Personality Disorder: A Mentalizing Framework

Bateman A, Bolton R, Fonagy P. — Fri, 01 Mar 2013 00:00:00 GMT

Antisocial personality disorder (ASPD) is a common condition with major public health implications. Yet effective treatment remains elusive. In this paper the major descriptive symptoms of ASPD are considered using a mentalizing framework. Mentalizing is the implicit or explicit perception or interpretation of the actions of others or oneself as intentional, that is, mediated by mental states or mental processes. It is considered as four intersecting dimensions: automatic/controlled or implicit/explicit; internally/externally based; self/other orientated; and cognitive/affective process. People with ASPD show problems with self/other mentalizing particularly in terms of empathic understanding of others. Their focus is biased toward external mentalizing with little regard for the internal mentalizing of others. The translation of this understanding into a clinical treatment program is discussed. The program is based on the current, evidence-based, mentalization-based treatment (MBT) for borderline personality disorder but with adaptations targeting the mentalizing difficulties of people with ASPD. A group and individual program is used. Some clinical interventions are exampled in the paper.

Ask the Expert: Personality Disorders

Michels R. — Fri, 01 Mar 2013 00:00:00 GMT

A 17-year-old male student was asked to take a leave of absence from school after being caught using marijuana. As a consultant for the secondary school, I was asked to assess him on consideration for readmission. The drug issue was trivial; he was no more involved than his classmates. However his leave of absence resulted from his apparent disinterest in concealing his behavior. Our interview revealed that he had a serious narcissistic personality disorder with grandiosity, little capacity for empathy, and a general aura of haughty disdain. He had no sense of any personal problem, no desire for help, and he made clear that he viewed me as a minor bureaucrat whom he had to suffer because of a silly rule. However, his pathology was serious. What should I do?

Attachment and Personality Disorders: A Short Review

Lorenzini N, Fonagy P. — Fri, 01 Mar 2013 00:00:00 GMT

Attachment theory is a biopsychosocial model referring to a person’s characteristic ways of relating in close relationships, such as with parents, children, and romantic partners. These ways of relating are learned during early infancy and mold subsequent intimate relationships. An adult who is securely attached has internalized a reliable relationship to his/her caregivers in infancy, and thus is capable of adapting to different social contexts and, more importantly, of maintaining an adequate equilibrium between self-regulation and interpersonal regulation of stress. Insecure adult attachment styles are divided into 1) anxious/preoccupied (individuals are hypersensitive to rejection and show compulsive care- and attention-seeking behavior); 2) avoidant/dismissing (individuals are hyposensitive to social interactions, and are socially isolated); and 3) unresolved/disorganized (individuals are unable to cope under stress, thus suffering pervasive affective dysregulation). This review discusses the theoretical, psychological, neuroscientific, and developmental aspects of attachment from an evidence-based perspective. It provides an updated account of the science regarding attachment and its relevance to the etiology, diagnosis, and treatment of mental illness. It examines the privileged relation between attachment and personality disorders (PDs) from multiple angles in order to introduce the most recent psychotherapeutic advances, based on attachment research, for the treatment of PDs, particularly borderline PD. Three effective, evidence-based psychotherapeutic interventions are described: Mentalization-Based Treatment, Transference-Focused Psychotherapy and Schema-Focused Therapy.

Biological Advances in Personality Disorders

Perez-Rodriguez M, Zaluda L, New AS. — Fri, 01 Mar 2013 00:00:00 GMT

Neurobiological studies have focused primarily on DSM-IV axis I disorders, as they display extensive, and often severe and episodic symptomatology. However, there is an emerging focus on the neurobiology of personality disorders, consisting largely of maladaptive traits that impair functioning and adaptation to the environment. These clusters of maladapative traits are partially heritable, associated with specific candidate genes that are beginning to be identified by preliminary genetic studies, and are grounded in specific neurocircuitry changes; borderline personality disorder (BPD), antisocial personality disorder (ASPD), and schizotypal personality disorder (STPD) have been the most studied and have the largest empirical evidence. Greater understanding of the neurobiological grounding of these disorders will in part inform the conceptualization of personality disorders in the new nonaxial diagnostic system in DSM−5.

Borderline Personality Disorder

Gunderson JG, Weinberg I, Choi-Kain L. — Fri, 01 Mar 2013 00:00:00 GMT

This review summarizes the current body of knowledge about borderline personality disorder (BPD). Each section describes the development of BPD’s knowledge base in the 33 years since the diagnosis became part of the American Psychiatric Association’s standard diagnostic classification system. The changes in our understanding are remarkable with respect to virtually every consideration of BPD’s etiology, course, and treatment. This expansion of knowledge has forced the authors to have to choose what we deem is most important, and thereby this review may overlook or underrepresent other significant developments. Nonetheless, we expect readers will share our excitement about what’s been learned. Throughout our review we will highlight very interesting and distinctly different questions that now surround this diagnosis.

Communication Commentary: Effective Communication Under Stress: Personality Disorder and Treatment Engagement

Stubbe DE. — Fri, 01 Mar 2013 00:00:00 GMT

Co-Occurring Disorders and Treatment Complexity Within Personality Disorders

Fowler J, Oldham JM. — Fri, 01 Mar 2013 00:00:00 GMT

Excessive comorbidity within personality disorders and other psychiatric disorders is a perennial problem in psychiatric diagnosis and treatment. Questions of etiology, disorder hierarchies, and treatment decisions are problems clinicians face on a daily basis. From a pragmatic view, the presence of multiple psychiatric disorders co-occurring within the context of a personality disorder can be viewed as proxy for psychiatric severity particularly as it relates to impairments in interpersonal relating, affective instability, and impulsivity. By extension, impairments in the above facets of functioning can alert clinicians to a range of potential treatment challenges including forming and maintaining a treatment alliance, sustaining treatment adherence, and targeting symptoms for medication treatment. Evidence from high-quality efficacy studies demonstrate significant, and in some cases lasting, symptom and behavioral change, especially for patients diagnosed with borderline personality disorder.

Narcissistic Personality Disorder: Progress in Recognition and Treatment

Ronningstam E, Weinberg I. — Fri, 01 Mar 2013 00:00:00 GMT

This review will address pathological narcissism and narcissistic personality disorder (NPD)—the clinical presentation, the challenges involved in diagnosing NPD, and significant areas of co-occurring psychopathology (i.e., affective disorder, substance usage, and suicide). Major depressive disorder is the most common comorbid disorder in patients with pathological narcissism or NPD. Need for self-enhancement and chronic disillusionment with self make these individuals particularly susceptible to substance use. Suicidal preoccupation in these patients is characterized by the absence of depression, lack of communication, self-esteem dysregulation, and life events that decrease self-esteem. The diagnostic focus on patients’ external characteristics and interpersonal behavior tends to dismiss the importance of their internal distress and painful experiences of self-esteem fluctuations, self-criticism, and emotional dysregulation. A collaborative and exploratory diagnostic approach to pathological narcissism and NPD is outlined that aims at engaging the patients and promoting their curiosity, narration, and self-reflection. Alliance building with a narcissistic patient is a slow and gradual process and mistakes are common. A central task is to balance these patients’ avoidance and sudden urges to reject the therapist and drop out of treatment with the goal of encouraging and enabling them to face and reflect upon their experiences and behavior. Implications for treatment and possible areas or indications of change include: interpersonal and vocational functioning; sense of agency and self-direction; emotion regulation and ability to understand, tolerate, and modulate feelings; reflective ability; and ability to mourn the loss of wished for or unreachable internal self-states, relationships, and external ideals.

Patient Management Exercises: Personality Disorders

Silk KR. — Fri, 01 Mar 2013 00:00:00 GMT

This exercise is designed to test your comprehension of material presented in this issue of FOCUS as well as your ability to evaluate, diagnose, and manage clinical problems. Answer the questions below, to the best of your ability, on the information provided, making your decisions as you would with a real-life patient.Questions are presented at “decision points” that follow a section that gives information about the case. One or more choices may be correct for each question; make your choices on the basis of your clinical knowledge and the history provided. Read all of the options for each question before making any selections. You are given points on a graded scale for the best possible answer(s), and points are deducted for answers that would result in a poor outcome or delay your arriving at the right answer. Answers that have little or no impact receive zero points. At the end of the exercise, you will add up your points to obtain a total score.

Personality Disorders in DSM-5 Section III

Skodol AE, Krueger RF, Bender DS, et al. — Fri, 01 Mar 2013 00:00:00 GMT

Despite long-recognized and significant shortcomings, the criteria for personality disorders in Section II of DSM-5 have not changed from those in DSM-IV. A new approach to the diagnosis of personality disorders was developed for DSM-5, however, which can be found in Section III. The DSM-5 Section III approach provides a clear conceptual basis for all personality disorder pathology and an efficient assessment approach with considerable clinical utility.

8-Year Follow-Up of Patients Treated for Borderline Personality Disorder: Mentalization-Based Treatment Versus Treatment as Usual

Bateman A, Fonagy P. — Fri, 01 Mar 2013 00:00:00 GMT

Objective

This study evaluated the effect of mentalization-based treatment by partial hospitalization compared to treatment as usual for borderline personality disorder 8 years after entry into a randomized, controlled trial and 5 years after all mentalization-based treatment was complete.

Method

Interviewing was by research psychologists blind to original group allocation and structured review of medical notes of 41 patients from the original trial. Multivariate analysis of variance, chi-square, univariate analysis of variance, and nonparametric Mann-Whitney statistics were used to contrast the two groups depending on the distribution of the data.

Results

Five years after discharge from mentalization-based treatment, the mentalization-based treatment by partial hospitalization group continued to show clinical and statistical superiority to treatment as usual on suicidality (23% versus 74%), diagnostic status (13% versus 87%), service use (2 years versus 3.5 years of psychiatric outpatient treatment), use of medication (0.02 versus 1.90 years taking three or more medications), global function above 60 (45% versus 10%), and vocational status (employed or in education 3.2 years versus 1.2 years).

Conclusions

Patients with 18 months of mentalization-based treatment by partial hospitalization followed by 18 months of maintenance mentalizing group therapy remain better than those receiving treatment as usual, but their general social function remains impaired.(Reprinted with permission from The American Journal of Psychiatry 2008; 165:631–638)

A Prototype Approach to Personality Disorder Diagnosis

Westen D, Shedler J, Bradley R. — Fri, 01 Mar 2013 00:00:00 GMT

Objective

Virtually no research has tested alternatives to the diagnostic method used since DSM-III, which requires decisions about the presence/absence of individual diagnostic criteria, followed by counting symptoms and applying cutoffs (the count/cutoff method). This study tested an alternative, prototype matching procedure designed to simplify diagnosis. The procedure was applied to personality disorders.

Method

A random national sample of psychiatrists and clinical psychologists (N=291) described a randomly selected patient in their care. Clinician-provided diagnostic data were used to generate categorical and dimensional DSM-IV diagnoses (number of symptoms present per disorder). Clinicians also used one of two prototype matching systems to provide a diagnosis for the selected patient.

Results

Prototype diagnosis led to reduced comorbidity relative to DSM-IV diagnosis, yielded similar estimates of validity in predicting criterion variables (adaptive functioning, treatment response, and etiology), and outperformed DSM-IV diagnosis in ratings of clinical utility and ease of use. Adding a personality health prototype further increased prediction.

Conclusions

A simple prototype matching procedure provides a viable alternative for improving diagnosis of personality disorders in clinical practice. Prototype diagnosis has multiple advantages, including ease of use, minimization of artifactual comorbidity, compatibility with naturally occurring cognitive processes, and ready translation into both categorical and dimensional diagnosis.(Reprinted with permission from The American Journal of Psychiatry 2006; 163:846–856)

Abstracts: Personality Disorders

Fri, 01 Mar 2013 00:00:00 GMT

Bibliography: Personality Disorders

Fri, 01 Mar 2013 00:00:00 GMT

This section contains a compilation of recent publications that have shaped the thinking in the field as well as classic works that remain important to the subject reviewed in this issue. This bibliography has been compiled by experts in the field and members of the editorial and advisory boards. Entries are listed chronologically and within years by first author. Articles from the bibliography that are reprinted in this issue are in bold type.

Borderline Personality Disorder

Leichsenring F, Leibing E, Kruse J, et al. — Fri, 01 Mar 2013 00:00:00 GMT

Recent research findings have contributed to an improved understanding and treatment of borderline personality disorder. This disorder is characterised by severe functional impairments, a high risk of suicide, a negative effect on the course of depressive disorders, extensive use of treatment, and high costs to society. The course of this disorder is less stable than expected for personality disorders. The causes are not yet clear, but genetic factors and adverse life events seem to interact to lead to the disorder. Neurobiological research suggests that abnormalities in the frontolimbic networks are associated with many of the symptoms. Data for the effectiveness of pharmacotherapy vary and evidence is not yet robust. Specific forms of psychotherapy seem to be beneficial for at least some of the problems frequently reported in patients with borderline personality disorder. At present, there is no evidence to suggest that one specific form of psychotherapy is more effective than another. Further research is needed on the diagnosis, neurobiology, and treatment of borderline personality disorder.(Reprinted with permission from Lancet 2011;377:74–84)

Borderline Personality Disorder and Suicidality

Oldham JM. — Fri, 01 Mar 2013 00:00:00 GMT

A 35-year-old woman, an academic professional, sought outpatient treatment for chronic dysphoria, a pattern of turbulent and unsuccessful interpersonal relationships, and a state of barely concealed rage that she attributed to the shortcomings and failures of others. She received a diagnosis of borderline personality disorder and began twice weekly psychotherapy. About 1 year into treatment, a stormy but long-term relationship with a man broke up, and the patient became angry and agitated. Although she blamed the man for the failed relationship and chronicled his many shortcomings, her mood shifted over several weeks and she reported feeling depressed and suicidal, hopeless about her future, and uninterested in work, friends, or family. How common and how serious is suicidal ideation and/or behavior in patients with borderline personality disorder? How should it be evaluated and managed? What is the appropriate role of hospitalization in such cases?(Reprinted with permission from The American Journal of Psychiatry 2006; 163:20–26)

Ethics Commentary: The Psychotherapeutic Relationship

Roberts L, Dyer AR. — Fri, 01 Mar 2013 00:00:00 GMT

(Reprinted with permission from Roberts LW, Dyer AR: Concise Guide to Ethics in Mental Health Care. Arlington, VA, American Psychiatric Publishing Inc., 2004.)

Evaluating Three Treatments for Borderline Personality Disorder: A Multiwave Study

Clarkin JF, Levy KN, Lenzenweger MF, et al. — Fri, 01 Mar 2013 00:00:00 GMT

Objective

The authors examined three yearlong outpatient treatments for borderline personality disorder: dialectical behavior therapy, transference-focused psychotherapy, and a dynamic supportive treatment.

Method

Ninety patients who were diagnosed with borderline personality disorder were randomly assigned to transference-focused psychotherapy, dialectical behavior therapy, or supportive treatment and received medication when indicated. Prior to treatment and at 4-month intervals during a 1-year period, blind raters assessed the domains of suicidal behavior, aggression, impulsivity, anxiety, depression, and social adjustment in a multiwave study design.

Results

Individual growth curve analysis revealed that patients in all three treatment groups showed significant positive change in depression, anxiety, global functioning, and social adjustment across 1 year of treatment. Both transference-focused psychotherapy and dialectical behavior therapy were significantly associated with improvement in suicidality. Only transference-focused psychotherapy and supportive treatment were associated with improvement in anger. Transference-focused psychotherapy and supportive treatment were each associated with improvement in facets of impulsivity. Only transference-focused psychotherapy was significantly predictive of change in irritability and verbal and direct assault.

Conclusions

Patients with borderline personality disorder respond to structured treatments in an outpatient setting with change in multiple domains of outcome. A structured dynamic treatment, transference-focused psychotherapy was associated with change in multiple constructs across six domains; dialectical behavior therapy and supportive treatment were associated with fewer changes. Future research is needed to examine the specific mechanisms of change in these treatments beyond common structures.(Reprinted with permission from The American Journal of Psychiatry 2007; 164:922–928)

Evidence-Based Pharmacotherapy for Personality Disorders

Ripoll LH, Triebwasser J, Siever LJ. — Fri, 01 Mar 2013 00:00:00 GMT

Patients with personality disorders are prescribed psychotropic medications with greater frequency than almost any other diagnostic group. Prescribing practices in these populations are often based on anecdotal evidence rather than rigorous data. Although evidence-based psychotherapy remains an integral part of treatment, Axis II psychopathology is increasingly conceptualized according to neurobiological substrates that correspond to specific psychopharmacological strategies. We summarize the best available evidence regarding medication treatment of personality disordered patients and provide optimal strategies for evidence-based practice. Most available evidence is concentrated around borderline and schizotypal personality disorders, with some additional evidence concerning the treatment of avoidant and antisocial personality disorders. Although maladaptive personality symptoms respond to antidepressants, antipsychotics, mood stabilizers, and other medications, evidence-based pharmacotherapy is most useful in treating circumscribed symptom domains and induces only partial improvement. Most available evidence supports use of medication in reducing impulsivity and aggression, characteristic of borderline and antisocial psychopathology. Efforts have also begun to reduce psychotic-like symptoms and improve cognitive deficits characteristic of schizotypy. Indirect evidence is also provided for psychopharmacological reduction of social anxiety central to avoidant personality disorder. Evidence-based practice requires attention to domains of expected clinical improvement associated with a medication, relative to the potential risks. The development of future rational pharmacotherapy will require increased understanding of the neurobiological underpinnings of personality disorders and their component dimensions. Increasing efforts to translate personality theory and social cognitive neuroscience into increasingly specific neurobiological substrates may provide more effective targets for pharmacotherapy.(Reprinted with permission from Internationl Journal of Neuropsychopharmacology 2011;14:1257–1288)