When Your Loved One Has Borderline Personality Disorder

Escape Plan From a Borderline Woman

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Escape Plan From a Borderline Woman Summary


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Assessment of Borderline Patients

In my experience, approximately 15 to 20 of patients are definitely extraction cases. Another 50 definitely do not require extraction. The critical area is the other 30 or so of patients who are borderline cases. In our practice, nearly all of these borderline patients are treated without extraction. Five factors allow the use of nonextraction therapy and enable the mandibular incisors to remain positioned upright over basal bone

An illustration borderline personality pathology

Many clinical theorists consider splitting, projective identification, and identity disturbance to be hallmarks of borderline personality pathology (e.g., Clarkin, Yeomans, & Kernberg, 2006 Kernberg, 1975, 1984 Linehan, 1993 McWilliams, 1994). Consider, for example, the items reproduced below from the original SWAP-200 item set. The three items, taken in combination, convey something of the defensive splitting seen in patients with borderline personality pathology The next group of items helps flesh out a picture of a certain kind of borderline patient, addressing issues of affect regulation, interpersonal relations, cognition, and so on The last group of items, below, includes descriptors that might apply to a more disturbed type of borderline patient, perhaps one likely to be seen in an inpatient setting (Gunderson, 2001) The items reproduced here are illustrative only and are not intended to describe the borderline patient or any particular borderline patient. They are intended...

Borderline Personality Disorder Somatization Symptoms or Disorder

Borderline patients, many of whom also have somatization disorders, frequently become dependent on their physicians in an extremely demanding, clinging, helpless, or self-destructive manner. Physicians may feel manipulated, angry, depleted, exhausted, or self-doubting. They may want to end the patient relationship or rescue the patient from herself, or they can be drawn into a cycle of extensive medical testing to try and explain many somatic complaints. These patients fear separation or abandonment and may react to potential losses with panic, emotional instability, anger, or impulsive (suicidal or self-destructive) actions. They may seek care and utilize defenses, which appears as a somatization disorder. These somatic symptoms and borderline personality structure often represent the sequelae of childhood abuse, sexual abuse, or other trauma (Kernberg, 1975 Sansone et al., 2001). Use of parallel inquiry to uncover a history of trauma is often most helpful for the patient complaining...

The Borderline Patient

Borderline patients are defined as individuals with a personality disorder who have an instability in their personal relationships, engage in impulsive behavior, and have unstable moods. Intense, fluctuating emotions of love and hate are typical of borderline patients. They need emotional support because they are constantly threatened by people and circumstances. It is often very difficult to develop a good doctor-patient relationship with borderline patients because the swings of affect are rapid. Borderline patients are always afraid, but this fear may be masked by outbreaks of anger. These patients are best handled with reassuring words.

The Patient with Posttraumatic Stress Disorder

Many trauma-related disorders have been recognized and include brief reactive psychosis, multiple personality disorder, dissociative fugue, dissociative amnesia, conversion disorder, depersonalization disorder, dream anxiety disorder, summarization disorder, borderline personality disorder, and antisocial personality disorder. Many other trauma-related disorders have been postulated. These disorders and the trauma that may precede them are indicated as follows Somatization disorder early childhood abuse Borderline personality disorder early childhood trauma Antisocial personality disorder early childhood abuse

Neurotransmitter Correlates

In addition to examining the effects of serotonin agonists on neuroendocrine indices, a few studies have examined the effects of these agents on brain function. For instance, investigators have observed lower levels of resting prefrontal glucose metabolism in borderline personality-disordered subjects relative to healthy volunteers with positron emission tomography (PET). The magnitude of these reductions in pre-frontal cortical activity was inversely correlated with life history of aggression (Goyer et al., 1994). The cause of these reductions is unclear since some evidence suggests that reduced frontal metabolism may result from prior trauma (e.g., due to physical abuse, accidental injury, or other insults), which has frequently been observed in murderers and other violent individuals (Brower and Price, 2001). While injection of Although no neuroendocrine challenge studies involving dopamine agonists have involved schizotypal patients, behavioral responses to injections of the...

How Can Disordered Personality Be Treated

Studies of physiological correlates of personality disorder symptoms cannot establish causality. They leave open the question of whether the physiological correlate leads to symptoms, whether the symptoms perturb the physiological correlate, or both. Causal evidence for a physiological effect on personality disorder symptoms might come from double-blind studies in which neurotransmitter function is selectively manipulated and changes in specific symptoms are monitored. A few relevant studies have been conducted in humans. Based on the evidence presented above, one might hypothesize that serotonergic interventions should ameliorate symptoms related to impulsive aggression that are commonly observed in personality disorders such as borderline personality disorder, while dopaminergic interventions might reduce psychotic symptoms that sometimes accompany schizotypal personality disorders. Four placebo-controlled double-blind studies have examined the effects of selective serotonin...

Prevalence and incidence of secondary organic personality change following TBI

Streeter, van Reekum, Shorr and Bachman (1995) noted that in a comparison of 54 males with borderline personality disorder to 49 psychiatric control patients there was a much higher incidence (42 ) of TBI in the borderline group as compared to the controls (4 ). As the TBI had occurred before the full expression of the personality disorder, the authors felt that the TBI had been a cause rather than a result of the TBI. Hibbard, Bogdany et al. (2000) noted that using the Structured Clinical Interview for the DSM-IV on 100 participants recruited from a larger pool of 438 TBI patients, 24 of the sample could be diagnosed with a personality disorder prior to the TBI, whereas 66 met the diagnostic criteria for at least one personality disorder after the injury. The most common forms of post-TBI personality disorder were borderline (34 ), avoidant (26 ), paranoid (26 ), obsessive-compulsive (27 ), and narcissistic (14 ). Those patients who had had personality disorder before the TBI were...

Impact of Comorbidity

This tendency toward splitting is largely a result of the descriptive atheoretical stance taken by the DSM. Given the limited understanding about the relationship between symptomatic presentation and underlying pathophysiology, the most conservative and neutral strategy is to split the symptom clusters into the smallest most diagnostically homogeneous entries possible rather than assuming that the symptoms fit together into a coherent whole. It is thus important to understand that the high rates of comorbidity often encountered during epidemio-logical surveys are almost certainly artificial and do not represent separate disease processes (Frances et al., 1990). For example, although a patient with binge eating purging, depression, panic attacks, substance abuse, and a lifelong pattern of stormy relationships might have symptoms that meet the DSM-IV criteria for five disorders (i.e., Bulimia Nervosa, Major Depressive Disorder, Panic Disorder, Substance Dependence, and...

Clinical Presentation

The differential diagnosis of OCD includes other psychiatric disorders that are characterized by repetitive behaviors and thoughts. To appropriately diagnose OCD, the content of the obsessions and or compulsions cannot be completely attributed to another psychiatric illness. For example, a diagnosis of anorexia nervosa should be made if a person has only obsessive worries about gaining weight and compulsions that are centered on not allowing the consumption of calorie-containing foods. By the same token, all obsessions or compulsions revolve around a fear of a specific animal, situation, or object, a simple phobia should be diagnosed. The obsessions of OCD must be distinguished from the ruminations of major depression, racing thoughts of mania, and psychotic symptoms of schizophrenia. The compulsions of OCD must be distinguished from the stereotypic movements found in individuals with mental retardation or autism, the tics of Tourette syndrome, the stereotypies of complex partial...

Intersubjectivity Theory Mentalization and the Theory of Other Minds

Some clinical innovators are proposing novel syntheses of varied clinical techniques. Psychotherapy strategies have been standardized and validated as effective treatments for posttraumatic stress disorders and borderline personality disorders, both of which have been linked to deficits in reflective functioning (see, e.g., Clarkin et al. 1999 Fonagy and Bateman 2008). An array of innovators have proposed syntheses of psychodynamic approaches with infant development information so as to intervene with serious relationship problems in infancy and early childhood (see, e.g., Seligman 1994).

Antisocial Impulsive And Borderlinenarcissistic Trends

A similar picture has emerged in relation to borderline personality disorder (BPD), which some scholars believe is simply a more disorganized manifestation of NPD. Research indicates that BPD is far more common in modern, as compared to traditional, societies and also that it is increasing within Western cultural settings.46 BPD is defined officially as a pervasive pattern of instability of interpersonal relationships, self-image, and emotion that is associated with high levels of impulsivity. It is this impulsivity that represents the core element of BPD.

Treatment Implications

DSM diagnostic criteria are largely descriptive, emphasizing behavioral signs and symptoms. They provide little guidance for the clinician trying to understand the meaning and function of the symptoms, or how to intervene. For example, DSM tells us that borderline patients are characterized by a pattern of unstable and intense interpersonal relationships. The statement is descriptively accurate, but why does the patient have unstable relationships and how can the clinician help Because the SWAP addresses underlying personality processes that give rise to these characteristics, it suggests some answers. Likewise, DSM tells us that borderline patients may have transient, stress-related paranoid ideation but leaves us in the dark about why this occurs or how to intervene. Suppose the patient has high scores on the following SWAP items Is prone to intense anger, out of proportion to the situation at hand (item 185) and Tends to see own unacceptable feelings or impulses in other people...

Developmental Research

Psychoanalytic developmental theories typically also have underestimated the enormous complexity of developmental processes by their overemphasis on early experience, although it must be said that several authors attempted to redress this balance. These include the work of Anna Freud (19811, who emphasized the importance of simultaneously considering different developmental lines and their complex interactions Erik Erikson (1959), who developed an epigenetic theory of human development across the life span and George Vail Ian t 11977), who was one of the first psychoanalytic investigators to embark on a series of longitudinal studies of adult development. Yet psychoanalytic theories have often been characterized by an unjustified confidence in tracing specific forms of psychopathology to specific (early) phases (examples are the link sometimes made between borderline personality disorder and the rapprochement subphase of separation and individuation, or between oedipal conflict and...

Psychoanalysis Medication or Both

Even without definitive proof that psychotherapy is efficacious for the treatment of specific mental disorders (Roth and Fonagy, 1996), there is widespread use of various forms of psychotherapy for typical problems presenting to mental health professionals, whether or not medication is prescribed. Based on expert consensus, the American Psychiatric Association has recommended a combination of psychotherapy and pharmacotherapy for the treatment of major depression, eating disorders, bipolar affective disorder, and borderline personality disorders (American Psychiatric Association, 2000a, 2000b, 2001, 2002). A recent randomized, controlled trial demonstrated that the combination of pharmacotherapy and a form of cognitive behavioral therapy was significantly more efficacious for chronic depression that either treatment alone (Keller et al., 2000). While supportive therapies combined with medication may be adequate for many patients, some individuals require psychoanalytic psychotherapy...

Specific Psychopharmacologic Considerations

From this vantage point, it became clear that her difficulties were not only the result of an untreated depression, but that her agitation, insomnia, and moodiness reflected a bipolar mood disorder. (Again, her mother's emotional instability, previously conceptualized as borderline personality disorder, may have been in part untreated bipolar affective disorder.) Dr. L had been seen at least twice weekly and had a trusting relationship with her therapist, yet even increasing the frequency of sessions did not stabilize the depression. The antidepressants were discontinued and Dr. L was started on carbamazepine, which enabled her to sleep regularly for the first time in years. She noted relief from the agitation but eventually required lamotrigine and quetiapine added to the carbamazepine for ongoing depression.

True Prevalence Studies

Tered the Personality Diagnostic Questionnaire (Hyler, 1983) to their subjects (Zimmerman and Coryell, 1990). Prevalence rates were fairly similar, but the PDQ produced higher rates of schizotypal, compulsive, dependent, and borderline personality disorders. The SIDP yielded higher rates of antisocial and passive-aggressive personality disorders. More individuals were diagnosed with a personality disorder by the SIDP, but the PDQ diagnosed multiple personality disorders more often. The results of the PDQ are not tabulated separately because the same sample was utilized for both instruments.

Prevalence of Specific Dsmiii Dsmiiir or Dsmiv Personality Disorders

Baron et al. (1985) conducted a family study of the transmission of schizotypal and borderline personality disorder. They identified a control group of 90 subjects and subsequently included 376 of their relatives. Their findings on the relatives of controls is relevant for inferring prevalence in a nonclinical sample. Seventy percent of the relatives of controls were personally interviewed by mental health professionals using the Schedule for Affective Disorders and Schizophrenia (Spitzer and Endicott, 1978) for axis I and with the Schedule for Interviewing Borderlines (Gunderson, 1982) which yields diagnoses for DSM-III schizotypal and borderline personality disorders. Data were obtained on 30 of the relatives using a family history version of the Schedule for Interviewing Borderlines (the family history method refers to obtaining information from an informant rather than through a direct interview). Seventy-five percent of the relatives of controls were studied blind to the...

Methodological Issues Diagnostic Issues

Another central issue in diagnosing personality disorders is the occurrence of certain spectrum relationships that exist between personality disorders and axis I disorders, which are thought to represent phenotypic variations of the same underlying pathology. Such relationships have been suggested to exist between borderline personality disorder and depression, depressive personality disorder and depression, schizotypal personality disorder and schizophrenia, avoidant personality disorder and social phobia, cluster B personality disorders and substance use, cluster B and C personality disorders and eating disorders, cluster C personality disorders and anxiety disorders and cluster A and schizophrenia (Tyrer et al., 1997). There is evidence that the co-occurrence of personality disorders with axis I disorders predicts worse outcome than an axis I disorder alone (Reich and Green, 1991) and that personality disorders may impair subsequent axis I treatment response. However,...

Comorbidity and Diagnostic Overlap

Skodol et al. (1999) found that certain clinical characteristics of major depressive disorder and dysthymia disorder predicted personality disorder co-occurrence. For major depression, the greater the number of prior episodes, the more likely the patient was to receive a diagnosis of borderline personality disorder. However, dependent personality disorder was associated with fewer episodes. Earlier onset dysthymia also signified an increased likelihood of borderline personality disorder however, no evidence was found that early onset of major depressive disorder increased the likelihood of any other personality disorders.

Defenses and Coping Styles

By understanding the constellation of defenses and coping styles used by difficult patients, the physician may be able to modify the pathologic defense or coping style that is interfering with the patient-physician alliance and the delivery of medical care. A physician can use clarification, confrontation, and interpretation (see Table 46-1). For example, a borderline patient may feel hurt and abandoned by the physician's vacation and accuse the physician of not caring. This patient may use a defense mechanism called devaluation (physician is deprecated as uncaring) and a coping style of manipulation (threatens suicide). With this understanding, the physician can begin to help the patient by not taking the patient's efforts to devalue or manipulate personally. The physician can respond to the patient by empathizing with the patient's fears of abandonment. The physician may clarify that the patient has a distorted belief, and that the vacation is being incorrectly experienced as a...

Improving the Capacity to Test Reality

Difficult patients often have distorted views of realty. Stressed patients with cluster A and B personality disorders may transiently hear voices, hallucinate, have brief episodes of delusional thinking, or have other severe distortions in perception of reality (e.g., paranoia). This can occur with paranoid, schizotypal, and borderline personality disorders. If psychotic disturbances in reality are present, assess and treat these first before providing the requested medical care. Mobilizing external supports, using medications, or placing the patient in a safe and calm environment is often sufficient.

Dependent Personality Disorder and Somatization Disorder

Although both borderline patients and dependent patients are extremely dependent on others, they react very differently to the threat of losing a significant other. The borderline patient becomes angry or enraged, whereas the dependent patient becomes submissive and obsequious. Dependent personality disorder patients use defenses that include regression, passive-aggression, and reaction formation.

Alcohol Use Disorder in Women

Nonmedical use of prescription drugs in general and opioids in particular has been identified as a significant problem since the late 1990s. Women also have higher associated rates with first use of illicit drugs after age 24, serious mental illness, and cigarette smoking (Tetrault et al., 2008). Comorbid conditions for women include drug addiction, sexual abuse, intimate partner violence, borderline personality disorder, eating disorders, mood disorders and anxiety disorders, and HIV infection. Women who drink alcohol may be more sensitive to the behavioral effects of concomitant cocaine use (Zweben, 2009).

Role of Technique in Treatment

Another illustrative study was conducted by Gabbard et al. ( 1994)r who examined upward and downward shifts in collaboration between patient and therapist as an indicator of the therapeutic alliance following transference interpretations. Examining three patients diagnosed with borderline personality disorder in long-term dynamic therapy, the researchers found that the patients responded quite differently to transference interventions. In one patient, only 29 of all upward shifts in collaboration were linked to transference work, whereas the second patient responded positively 63 of the time and the third patient 81 of the time. All in all, transference interpretations were found to have a greater impact than other interventions, both positive and negative, which indeed suggests that transference work is a high-risk, high-gain enterprise, at least with patients with borderline disorders.

Psychodynamic Therapy With Diagnostically Specific Samples

Particular attention, at least in Europe, has been paid to the development of ment aliza tion - based treatment MBT Bateman and Fonagy 2004, 2006). Although derived in part from attachment and cognitive theories, MBT is basically psychodynamic in its approach. There is evidence accumulating for the efficacy of MBT protocols with quite disturbed borderline patients. Especially interesting, Bateman and Fonagy 2008 followed up on a patient sample 5 years after treatment discharge. The outcome parameters were socially obtrusive yet nonreactivc criteria like suicide attempts, hospitalization, emergency visits, medication, and employment. On all parameters, the MBT group was still significantly and clearly superior to the comparison group whose members had undergone so-called treatment as usual TAU). Bateman and Fonagy 2009 recently reported findings from a randomized controlled trial of MBT in comparison with structured clinical management with outpatients with a diagnosis of borderline...

Effects Of Child Sexual Abuse Across The Life Span

Disruption in their ability to regulate their affect,47 many are at risk for developing substance abuse or substance dependence disorders.48 In addition, child sexual abuse survivors may develop PTSD, experience intrusive thoughts about their abuse, become hypervigilant to abuse-related stimuli, and develop avoidance strategies such as numbing and dissociation. There are also those survivors whose trauma experiences may have put them at risk for developing borderline personality disorder.49 Although the negative consequences of child sexual abuse are important to understand thoroughly, there has been a recent focus over the past ten years on the resilience experiences of survivors.50,51,5 Resilience may be understood as a survivor's ability to bounce back from adversity despite difficult experiences and may include both individual and collective components of resilience that may assist survivors in healing from child sexual abuse.32

The Hierarchy Of Treatment Evidence

There are a number of pre-post design studies that have been carried out with borderline patients (e.g., Blum et al., 2002 Brown et al., 2004 Clarkin et al., 1992 Clarkin et al., 2001 Low, Jones, Duggan, Power, & MacLeod, 2001 Cookson, Espie, & Yates, 2001 Miller, Wyman, Huppert, Glassman, & Rathus, 2000 Ryle & Golynkina, 2000 Smith, Koenigsberg, Yeomans, Clarkin, & Selzer, 1995 Stevenson & Meares, 1992 Telch, Agras, & Linehan, 2000 Trupin, Stewart, Beach, & Boesky 2002 Wildgoose, Clark, & Waller, 2001 Yeomans et al., 1994 Mental Health Center of Greater Manchester, 1998). Stevenson and Meares (1992) conducted a pre-post study that evaluated the effects of a nonmanualized psychodynamic treatment (based on the ideas of Kohut, Winnocott, and Hobson's conversational model) for patients with BPD. They found that compared to pre-therapy, patients at the end of treatment showed an increase in time employed and decreases in number of medical visits, number of self-harm episodes, and number...

Psychosocial Adjustment

Into the prefrontal anterior cingulate and the dor-solateral, orbitofrontal, and ventromedial cortices. The dorsolateral prefrontal cortex generates goal-directed behavior thus, lesions in this area lead to labile affect, depression, and poor executive functioning. Judgment and socialization are based in the orbitofrontal cortex, and patients with tumors in this area tend to be disinhibited, with a pseudopsy-chopathy that may include mood fluctuations, self-mutilation, antisocial behaviors, and personality traits characteristic of borderline personality (Berlin et al. 2004). Ventromedial prefrontal cortex is responsible for empathy, foresight, and reversal learning. Deficits that result from lesions in this area include the persistence of high-risk negative behaviors that in the past were rewarded but currently have severe and adverse consequences. The anterior cingu-late affects motivated attention and concentration along with the ability to recognize affect and mood conflicts....

Application to therapy

A central feature of CBT is the need to be able to share a clear, easily grasped, rationale with the person with whom you are working, and obviously the exposition of the Interacting Cognitive Subsystems model given above does not match that description However, it does lead to some very simple and user-friendly ideas that have been central to Helena's therapy. In summary, if the desynchrony between propositional and implicational levels, mediated by high arousal, is at the root of at least the psychotic symptom part of the problem, getting these to work together is at the heart of the solution. The ideas of shared and non-shared reality, the ability to hold two ideas at once, and the role of state of arousal in mediating access to the more rational explanation, as introduced above, all relate directly to this model. Fundamentally, being in the world is seen as a balancing act rather than a given. In most mental health problems the balance becomes tipped, but in psychosis it becomes...

Personality Style vs Personality Disorder

The distinction between personality style and a personality disorder is a matter of degree. Personality styles tend to be relatively stable over a lifetime but can be modified by psychotherapy or needs to adapt to the environment. Personality disorders are also stable, but are more difficult to modify, if at all, and then by long-term or special forms of psychotherapy or by life events. Personality styles that become rigid, extreme, maladaptive, or damaging to self or others, or that lead to social or occupational impairment, are called personality disorders. Although everyone is unique, there seems to be a set of personality styles and disorders that are commonly encountered. Some personality disorders can be recognized in the movies (schizotypal personality disorder, Robert DeNiro in Taxi Driver narcissistic personality disorder, Tom Cruise in Top Gun dependent-borderline personality disorder, Bill Murray in What About Bob ).

What patient psychosocial factors may negatively influence the decision to proceed with a spinal operation

Substance abuse (alcoholism, drug dependence), severe depression or other psychologic disturbance (e.g. borderline personality), secondary gain (litigation, financial, social), chronic pain, as well as childhood developmental risk factors (physical abuse, sexual abuse, abandonment, neglect, chemically dependent parents).

Kenneth N Levy And Lori N Scott

Borderline personality disorder (BPD) is characterized by affective instability, angry outbursts, frequent suicidality and parasuicidality, as well as marked deficits in the capacity to work and to maintain meaningful relationships. BPD has prevalence rates of nearly 1-4 in the general population, 10 in psychiatric outpatient samples, and up to 20 in psychiatric inpatient samples (e.g., Paris, 1999 Torgersen, Kringlen, & Cramer, 2001 Weissman, 1993 Widiger & Frances, 1989 Widiger & Weissman, 1991). In addition, BPD is frequently comorbid with depression, anxiety disorders, eating disorders, posttraumatic stress disorder, and substance abuse, often with detrimental effects on the treatment of these disorders (for a review, see Skodol, Gunderson, Pfohl, Widiger, Livesley, & Siever, 2002). Furthermore, patients with BPD typically experience profound impairment in general functioning and have an estimated suicide completion rate of 8-10 (Oldham et al., 2001). Thus, BPD is a debilitating...

George Stricker

The representativeness heuristic links judgments to signs that are representative of the group in general, so that it is assumed, once it is determined that a patient is a member of a particular diagnostic group (or has a particular set of psychodynamics), that the patient has all of the characteristics of that group. This is the object of the diagnostic procedure, but it is not always an accurate basis for individual judgment, as not all patients with borderline personality disorder, for example, have all of the characteristics of borderline personality disorder (e.g., not all cut themselves). It is also important to recognize that the representativeness heuristic is the source of much stereotyping and subsequent bias. The assumption, for example, that all members of a particular racial group, gender, or religious persuasion are characterized by specific features are examples of the representativeness heuristic at work, and must be guarded against.

The est approach

There are many assumptions inherent in the EST model. One is that random assignment of patients to treatments is neutral as to outcome and therefore provides the least biased results. This is not necessarily the case (see Blatt & Zuroff, 2005). Another assumption is that if an EST works, it does so because of the specific interventions detailed in the treatment manual. This also does not necessarily follow and we will have more to say about this later in this chapter. The assumption most relevant to the approach that we wish to consider as an alternative to ESTs (i.e., common factors) is that treatments need to be specifically tailored to the disorder under investigation. This leads to a myriad of ESTs, at least one for each disorder. That is, there would be an EST for depression, another for anxiety, a third for Borderline Personality Disorder, and so on. There are currently more ESTs than any one clinician could possibly learn, at latest count over 150 (Beutler & Johannsen, 2006)....

Factitious Disorder

With factitious disorder have severe personality disorders, most often borderline personality disorder (American Psychiatric Association 2000). According to the literature, 30 -55 of women with FDP also have factitious disorder (Ayoub 2006 Sheridan 2003) the presence of factitious disorder in a mother with FDP signals a poor prognosis for any reunification or contact between the mother and the abused child (Feldman et al. 1997 Jones 1987).


By initially giving the borderline patient 6 to 9 months in treatment, the orthodontist can determine if the nonex-traction therapy will be successful. If after that time the progress is not sufficient, extractions are recommended. Extraction choices in such cases are discussed in principle 18. A detailed description of treatment of borderline cases, which often includes expansion of both arches, will be presented in a future volume of this series.

Suicide and Teens

Suicide goes beyond young people who are dealing with a severe mental disorder. Only up to 41 percent of people who commit suicide meet diagnostic criteria for major depression. Substance abuse disorders, panic disorders, social phobias, gender identity disorders, and borderline personality disorders also account for many suicides. Mental health practitioners should screen for suicidal thoughts in anyone who expresses pervasive hopelessness regardless of their diagnosis. It is important to note that someone who is contemplating suicide (showing suicidal ideation and perhaps planning it) usually speaks about it to close friends or family members. Any comments made about suicide should be taken seriously. Listening is important. Referrals to a local suicide hotline or outreach program should follow.

Summary Of Rcts

Although there is accumulating evidence from outcome studies suggesting the effectiveness and efficacy of a number of different treatments for BPD, the probative importance of these studies for understanding a treatment's actual mechanisms of action are both indirect and limited (Garfield, 1990). Therefore, despite the support for the effectiveness and efficacy of existing treatments for borderline personality disorder, researchers are still confronted with a high degree of uncertainty about the underlying processes of change. Additionally, validation for the treatment occurs to the extent that the theoretically specified mechanisms of change are actually related to the treatments' effectiveness. It is very possible & Bohus, 2002) have suggested that the evidence contraindicates their use and shows them to be ineffective (Kroll, 2000). However, the Kroll (2000) study was designed to determine the extent that no-suicide contracts were employed (which was found to be 57 ) and, although...


Levy and Scott are a bit less favorably disposed to efficacy studies, seeing them as one tool in a multimethod toolbox. They discuss internal and external validity as the touchstones of the different methods available, with efficacy studies at one end (strong internal validity, relatively weak external validity) and case histories at the other (strong external validity, relatively weak internal validity). They provide an elegant review of different methodologies, describing the strengths and weaknesses of each and showing the values of each in a systematic research program. They apply their analysis to the study of Borderline Personality Disorder and

Emotional Disorders

Borderline Personality Disorder Child sexual abuse can contribute to the development of a borderline personality disorder in later life. This disorder results from projecting a part of oneself on to other persons and a lack of emotional control. As a result of this splitting off of a part of one's own self, persons with this disorder shift between idealizing and demonizing other persons. They may be loving and trustful one moment and raging and distrustful moments later toward the same person. They tend to be unable to sustain stable personal, social, or professional relationships. They also frequently display self-destructive and impulsive behaviors, for example, driving recklessly and engaging in promiscuous sex.

Treated Prevalence

Dahl (1986) reported results of the systematic assessment of DSM-III personality disorders in 231 consecutive admissions to a psychiatric inpatient unit in Norway. Chronic patients and those with organic disorders were excluded. Approximately 45 of the sample received a personality disorder diagnosis (40 of females and 49 of males). Forty-four percent of those with a personality disorder received one diagnosis, 36 had two diagnoses, 15 had three diagnoses, and 5 had four diagnoses. Schizotypal, histrionic, antisocial, and borderline personality disorders were each present in approximately 20 of the sample. Avoidant personality disorder was diagnosed in 9 of the sample and the remaining personality disorders were diagnosed much less frequently. In a series of 100 patients admitted with major psychiatric disorders (affective disorders, schizophrenia, and other functional psychosis), Cutting et al. (1986) found that 44 had an ''abnormal personality'' based on informant interviews about...

Antidotes to Stress

Skills Training Manual for Treating Borderline Personality Disorder. New York Guilford. Specific skills that are useful for functioning populations as well, including mindfulness, interpersonal effectiveness skills, emotion regulation skills, and distress tolerance skills.

Atypical Behaviors

Physicians can use the scope of patient-generated countertransferences (their feelings, fantasies, and atypical medical behaviors) as a valuable diagnostic aid, because difficult patients tend to provoke the same feelings in most physicians who deal with them. For example, a patient with a borderline personality disorder often leaves many physicians exhausted and worried about the patient's suicidal threats. A patient with multiple somatic complaints may leave physicians feeling frustrated that they cannot alleviate the patient's pain symptoms or suffering. Physicians who learn to recognize feelings provoked by patients will find it easier to identify the subtype of difficult patients according to the feelings elicited. More importantly, physicians who can recognize their unusual reactions will be better able to tolerate them and avoid acting out their feelings with a patient. This will improve the physician-patient relationship, medical decision making, and ultimately patient care...

Rc480a78 2007

13 The Art of Interpreting the Science and the Science of Interpreting the Art of the Treatment of Borderline Personality Kenneth N. Levy, Ph.D., is an assistant professor in the Department of Psychology at The Pennsylvania State University. Dr. Levy is also an adjunct assistant professor of psychology in psychiatry at the Joan and Sanford I. Weill Medical College of Cornell University. His primary interests are in attachment theory, social cognition, emotion regulation, borderline personality disorder, and mechanisms of change in psychotherapy. Lori N. Scott is a doctoral student in clinical psychology at The Pennsylvania State University. She is interested in social cognition, mechanisms of change in psychotherapy, and borderline personality disorder.

Mom Fctish Photos

Borderline personality organization A primitive character structure represented by a fluid and labile sense of identity a desperate fear of isolation and aloneness, along with chaotic intimate relationships in which the other is both intensely needed and experienced as toxic and rejecting and the use of archaic defenses of splitting and projective identification. This personality often manifests with eruptive anger in chaotic relationships, yet in nonintimate situations, these individuals often function well.

Case Illustration

The narrative description provides a detailed portrait of a severely troubled patient with borderline personality pathology. The description helps illustrate the difference between descriptive psychiatry (aimed at establishing a diagnosis) and clinical case formulation (aimed at understanding an individual). In this As the more severe aspects of borderline personality pathology have receded, other conflicts and symptoms have moved to the fore. For example,

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