Beyond the ICD and DSM: Diagnosis, Comorbidity, and the Therapeutic Alliance in Severe Personality Disorders with an Emphasis on Borderline Personality Allan Tasman, M.D.
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
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 Uncurious – Curious Conservative – Liberal 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 The Five-Factor Model of Personality Adapted from Costa & McCrae 1986
Three Major Brain Systems Influencing Stimulus – Response Characteristics
Cloninger’s 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
DSM-IV Definition of Personality Disorder • An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s 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.
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).
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)
Impulsive Disorders Axis II • Borderline Personality Disorder • Antisocial Personality Disorder Axis I • Psychoactive Substance Use Disorder • Bulimia • Paraphilias • Impulsive Control Disorder NEC
STPD Bip-II MDD PTSD BPD Severity of social dysfunction SPD ASPD NPD AVPD HPD
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
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
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
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
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)
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)
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
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.
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
Pharmacotherapy Type 1 (Affective) Type 2 (Impulsive) Type 3 (Aggressive) Type 4 (Dependent) Type 5 (Empty) B P D T y p e Psychotherapy
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
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 treatmentcontinuity quality-of-life interfering behaviors dishonesty or deliberatewithholding contract breaches in-session acting out between-session acting out nonaffective or trivial themes
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
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”
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
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
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; 160:1223-1232
Summary • Present diagnostic classification systems are inadequate for severe personality disorders • Alternative models assess interaction of temperament and developmental experience • Research evidence for borderline personality emphasizes psychotherapeutic interventions • Development and maintenance of an effective therapeutic alliance is critical for success no matter what form of psychotherapy is utilized