Experiential techniques and therapeutic relationship in the treatment of narcissistic personality disorder: The case of Laura.

Experiential techniques can be used to address maladaptive interpersonal patterns in patients with personality disorders (PDs) as long as they are delivered minding about the therapeutic relationship. We present the case study of Laura, a 38-year-old woman presenting with covert narcissism, generalized anxiety disorder, depression, and complicated grief treated with metacognitive interpersonal therapy. Laura initially refused to engage in any experiential work out of fear of being judged and abandoned by her therapist. To navigate this therapeutic obstacle, the therapist focused on exploring and eventually repairing early alliance ruptures. Thereafter, Laura engaged in experiential work, which helped her address her narcissistic interpersonal patterns. After 2 years, Laura's symptoms and narcissistic problematic behaviors decreased. This case study can help us understand how experiential techniques can be successfully used in PD psychotherapy as long as attention to the therapy relationship is paid.

Mentalization-oriented psychodynamic group therapy for patients with personality disorders: a naturalistic prospective cohort study.

OBJECTIVES: Patients with personality disorders (PDs) are often treated with non-manualized psychodynamic group therapy (PDT) lasting for several years. Non-manualized PDT often combines a variety of therapeutic approaches from different PDT traditions, including mentalization-based therapy. Currently, little is known about the effect of this long-term, costly treatment. This study investigated the extent to which patients with different PDs benefit from mentalization-oriented PDT as it is implemented in clinical practice in terms of symptom severity, interpersonal problems, and general functioning. METHODS: The design was a naturalistic, prospective cohort study. Seventy-five consecutive PD patients were assessed before treatment with the Symptom Checklist-90 Revised (SCL-90-R) as the primary outcome measure and the Inventory of Interpersonal Problems (IIP) and Global Assessment of Functioning (GAF) as secondary outcome measures. The sample was repeatedly assessed every 12 months for up to 36 months. Paired t-tests were applied to examine the effectiveness of the intervention. RESULTS: Among completers (n = 42; 56%), improvement was observed on the SCL-90-R: Global Severity Index (mean change = -0.45 [95% CI = -0.72, -0.19]; Cohen's d = -0.55), Positive Symptom Distress Index (-0.40 [-0.63, -0.17]; -0.56); Positive Symptoms Total (-10.70 [-17.31, -4.09]; -0.52). Secondary outcomes also improved: IIP-total (mean change = -0.50 [95%CI = -0.74, -0.25]; Cohen's d = -0.66); GAF-Functioning (8.79 [6.32, 11.27]; 1.15); and GAF-Symptoms (10.67 [8.09, 13.25]; 1.34). CONCLUSIONS: Completers improved on symptom severity, interpersonal problems, and general functioning, with within-group effect sizes ranging from medium to large. Approximately half the sample dropped out, suggesting that mentalization-oriented PDT spanning several years may be unrealistic for many patients with PD. Significant outcomesThere are no clear guidelines for psychological interventions targeting personality disorders (PDs), and currently eclectic and non-manualized psychodynamic approaches lasting for up to 3 years are prevailing in some clinical practices.Although this treatment approach may have an effect on compliant patients, the high drop-out rate indicates that it may not be suitable for a large proportion of PD patients since it requires long-term commitment. Furthermore, it is difficult to identify the content of the non-manualized psychodynamic therapy and what helps the patients.More specific clinical guidelines emphasizing the application of evidence-based treatments or at least manualized treatments are warranted for the treatment of emotionally unstable PDs and other PDs. LimitationsThe naturalistic study design, without any control group, limits conclusions about mechanisms of action of the intervention.Since the intervention was not manualized, it is unknown exactly which treatment was actually administered, which reduces external validity.The outcomes are based on completer data of a relatively small sample size with high drop-out rate.

Hypnotizability and psychopathology of patients with personality disorders.

Assessment of hypnotizability is useful in research and predicting the effects of hypnosis in clinical practice. There are few contemporary scientific reports examining the relationship between hypnotizability and psychopathological personality dimensions. The current study explores the connections between abnormal personality in psychiatric patients and the hypnotizability level. Fifty-five patients with anxiety and personality disorders who previously completed the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) were invited to undergo the Elkins Hypnotizability Scale - Clinical Form (EHS-CF). The hypnotizability scores comprise a normal distribution but shifted toward low scores. Twenty-seven patients were included in the low hypnotizability (LOW) group, and 28 patients in the medium to high (MID-HIGH) group. The number of participants with high scores on the Psychopathic Deviate and Paranoia MMPI-2 clinical scales was significantly higher in the LOW than in the MID-HIGH group. Patterns of associations between hypnotizability and psychopathology differed in the two groups. The results indicate that moderate hypnotizability should be considered a normal trait that has no meaningful relationship with psychopathology, but certain dysfunctional symptoms of personality disorders may entail resistance and a defensive attitude toward the hypnotherapy, resulting in a tendency to obtain lower hypnotizability.

A Mentalizing Approach for Narcissistic Personality Disorder: Moving From "Me-Mode" to "We-Mode".

Narcissistic personality disorder (NPD) is a prevalent condition that frequently co-occurs with other diagnoses that bring patients into treatment. Narcissistic disturbances are not often the chief complaint, but they complicate the development of an adequate therapeutic alliance. Typical countertransference challenges, combined with stigma related to NPD, result in difficulty for the therapist to relate to these patients empathically. Mentalization-based treatment provides a means for therapists to reach these patients by taking a "not-knowing" stance with interest and curiosity in clarifying and expanding a shared awareness of the patient's emotional experiences. By understanding the attachment functions, mentalizing imbalances, and problems of epistemic disregard among patients with NPD, therapists can break through the self-centered "me-mode" of the therapeutic dyad, where the typical lack of engagement or power struggles prevail, to a "we-mode," where the patient and therapist are joined in attention to what happens in the patient's mind and in interactions with others.

Treating Avoidant Personality Disorder With Combined Individual Metacognitive Interpersonal Therapy and Group Mentalization-Based Treatment: A Pilot Study.

ABSTRACT: Avoidant personality disorder (AvPD) is a severe but understudied condition. The current pilot project reports data on acceptability and outcomes of a novel treatment combining biweekly individual metacognitive interpersonal therapy (MIT) and weekly mentalization-based therapy (MBT) group therapy. A total of 30 patients with AvPD were consecutively included in the program. The primary outcome was AvPD-specific personality functioning measured by self-report after treatment. Secondary outcomes were symptom distress, interpersonal problems, quality of life, and psychosocial functioning. Twenty-two patients completed treatment, with a mean duration of 13 months. On the primary outcome, effect sizes were generally moderate to large (effect size range: 0.59-1.10). On secondary outcomes, effect sizes were large (effect size range: 0.77-2.3). Both in terms of acceptability and outcomes, results are promising for the combination of MIT and MBT for AvPD. The approach is a strong candidate for further investigation in future large-scale randomized controlled trial.

Building the alliance and using experiential techniques in the early phases of psychotherapy for avoidant personality disorder.

Individuals experiencing avoidant personality disorder (AvPD) tend to make sense of social interactions via maladaptive self-and other attributions. They also experience difficulties in recognizing emotions. A further feature of AvPD psychopathology is the tendency to resort to maladaptive coping strategies, such as behavioral avoidance and perfectionism. Despite its impact, psychological treatments for AvPD remains poorly investigated. Herein, we describe the first five sessions of Metacognitive Interpersonal Therapy with a 28-year-old woman, whose treatment goal was to reduce social avoidance. We describe how this goal was achieved through a combination of working through the therapeutic relationship, alongside experiential techniques such as guided imagery, rescripting, and bodily work. Through this treatment configuration, the patient was able to increase self-awareness of her own emotions, enabling her to realize that she was guided by rigid schemas; specifically seeing herself as inadequate and others as judgmental. Finally, implications for the treatment of AvPD are discussed.

Validity of the Self-Expression and Emotion Regulation in Art Therapy Scale (SERATS).

BACKGROUND: The Self-Expression Emotion Regulation in Art Therapy Scale (SERATS) was developed as art therapy lacked outcome measures that could be used to monitor the specific effects of art therapy. Although the SERATS showed good psychometric properties in earlier studies, it lacked convergent validity and thus construct validity. METHOD: To test the convergent validity of the SERATS correlation was examined with the EES (Emotional Expressivity Scale), Emotion Regulation Strategies for Artistic Creative Activities Scale (ERS-ACA) and Healthy-Unhealthy Music Scale (HUMS). Patients diagnosed with a Personality Disorder, and thus having self-regulation and emotion regulation problems (n = 179) and a healthy student population (n = 53) completed the questionnaires (N = 232). RESULTS: The SERATS showed a high reliability and convergent validity in relation to the ERS-ACA approach strategies and self-development strategies in both patients and students and the HUMS healthy scale, in patients. Hence, what the SERATS measures is highly associated with emotion regulation strategies like acceptance, reappraisal, discharge and problem solving and with improving a sense of self including self-identity, increased self-esteem and improved agency as well as the healthy side of art making. Respondents rated the SERATS as relatively easy to complete compared to the other questionnaires. CONCLUSION: The SERATS is a valid, useful and user-friendly tool for monitoring the effect of art therapy that is indicative of making art in a healthy way that serves positive emotion regulation and self-development.

Group schema therapy for patients with cluster-C personality disorders: A case study on avoidant personality disorder.

This article presents a clinical illustration of group schema therapy (GST) for cluster-C personality disorders (CL-C PDs) to provide therapists an example on how one can perform GST for CL-C PDs and break through persistent avoidance and control mechanisms. A summary of evidence supporting the effectiveness of GST for CL-C PD's is given followed by an overview of basic principles of schema therapy and GST. A case presentation next illustrates the application of GST principles and interventions in the GST CL-C protocol, which improve clients understanding of emotional core needs and development of adaptive ways of getting needs better met, instead of avoiding life. Implications of the case for future applications of GST for CL-C PDs are discussed.

Does the Homo Hypnoticus Exist? Personality Styles of People Interested in Hypnosis.

It may be that individuals who are interested in hypnosis will volunteer for hypnosis experiments or practice hypnosis. Do these "hypnosis-prone" individuals differ from hypno-neutral, nonhypnosis-prone individuals? If so, could one speak of a personality type, the homo hypnoticus? This study reports on 3 samples of individuals where there was no indication of hypnosis or no interest in hypnosis (NONHYP: N = 1426) and 4 samples of individuals who were interested in hypnosis (HYP: N = 1048). Using the Personality Styles and Disorders Inventory, we calculated contrast analyses for the contextual effect of HYP vs. NONHYP and gender effects. Results suggested there may be a homo hypnoticus personality style with the characteristics of intuitive-schizotypal, rhapsodic-optimistic, and charming-histrionic. These distinctions appear mostly in women.

Assessing Autism Spectrum Disorder in Intellectually Able Adults with the Personality Assessment Inventory: Normative Data and a Novel Supplemental Indicator.

Differential diagnosis of autism spectrum disorder (ASD) among intellectually-able adults often presents a clinical challenge, particularly when individuals present in crisis without diagnostic history. The Personality Assessment Inventory (PAI) is a multiscale personality and psychopathology instrument utilized across clinical settings, but to date there are no published normative data for use of the PAI with adults with ASD. This study provides normative PAI data for adults diagnosed with ASD, with effect size comparisons to the PAI clinical standardization sample and an inpatient sample. Additionally, a discriminant function was developed and cross-validated for identification of ASD-like symptomatology in a clinical population, which demonstrates promise as a screening tool to aid in the identification of individuals in need of specialized ASD assessment.

Improving social functioning and life satisfaction among patients with personality dysfunction: Connectedness and engagement in integrative group treatment.

Reduced social impairment and improved life satisfaction are important objectives in group treatment for patients with personality dysfunction. Knowledge regarding patient characteristics and group treatment processes that contribute to these outcomes, however, remains limited. Dispositional connectedness, the valuing of interpersonal connections, may be an important patient factor that influences patients' experience of group treatment in ways that facilitate therapeutic benefits. The present study investigated the roles of dispositional connectedness and group engagement in contributing to improvement in social functioning and life satisfaction through integrative group treatment for personality dysfunction. Seventy-nine patients who completed an integrative group treatment programme were assessed for dispositional connectedness at baseline and social functioning and life satisfaction at pretreatment and posttreatment; each also provided ratings of group engagement during treatment. Regression analyses using bootstrap confidence intervals found significant indirect effects for dispositional connectedness regarding improvement in both social functioning and life satisfaction, through the mediating effect of group engagement. Thus, patients who entered treatment with tendencies towards interpersonal connectedness perceived a higher level of engagement in the group environment. Group engagement in turn contributed to greater improvement in social functioning and to greater improvement in life satisfaction following treatment. The findings indicate dispositional connectedness as a salient characteristic in selecting patients for group treatment and highlight the role of an engaged interpersonal climate in facilitating improvement in social functioning and life satisfaction.

What's old is new again: updated findings on personality disorders and substance use disorders.

PURPOSE OF REVIEW: Personality disorders, mental disorders marked by long-term deviations from societal expectations that cause distress, and substance use and related disorders (SUDs), mental disorders marked by engaging with substances or behaviors that activate the brain's reward system to the point that normal activities are neglected, are common debilitating conditions. Personality disorders and SUDs are highly comorbid, potentially resistant to treatment, and their presence increases all-cause mortality, particularly when found together. RECENT FINDINGS: The present review highlights the most notable findings on prevalence, comorbidity, biological and behavioral pathways between the disorders, impact on incarcerated people and treatment for the disorders. SUMMARY: Personality disorders and SUDs are relatively common, highly comorbid, and increase the risk of all-cause mortality: particularly in those who have both conditions. Possible shared pathways between personality disorders and SUDs include emotional dysregulation, shared genes, and certain neurotransmitters. Personality disorders and SUDs are common in people who have been incarcerated, and this morbidity and comorbidity has been found throughout the world. Finally, comorbidity between personality disorders and SUDs greatly complicates treatment, with emerging treatment modalities such as mentalization-based treatment, schema modes, and attentional training showing potential, but lacking strong evidence of efficacy.

Metacognitive Interpersonal Mindfulness-Based Training for Worry About Interpersonal Events: A Pilot Feasibility and Acceptability Study.

Individuals with personality disorders experience worry and repetitive thoughts regarding interpersonal scenarios. Mainstream mindfulness-based approaches may be insufficient to soothe these individual's distress due to difficulties in letting thoughts go and refocusing attention to the present moment. For this reason, we devised an adapted form of mindfulness-based program called Metacognitive Interpersonal Mindfulness-Based Training (MIMBT) for personality disorders. In this pilot study, 28 individuals attended nine weekly sessions to evaluate the feasibility and acceptability, and to establish preliminary outcomes. All individuals completed the program. Attendance was very high (96%). Significant changes were observed on the primary outcome of reduction in repetitive thinking, measured using the Metacognition Questionnaire-30. We also observed a decrease in depression severity. Despite important limitations, this pilot study suggests that MIMBT has the potential to be a viable and well-accepted option for increasing positive outcomes in the treatment of personality disorders. Clinical considerations and directions for future research are discussed.

Interprofessional team-based approach to patients with chronic hepatitis C and personality disorder: Three case studies.

Hepatitis C virus is a blood borne pathogen that infects 130 million people worldwide. After a prolonged period of slowly progressive liver injury, those infected are at risk of advancing to end stage liver disease, with its associated complications, and hepatocellular carcinoma. Rates of past and/or current substance use and behavioral comorbidities are higher among those infected with hepatitis C compared to the general population. A number of patient, provider and system barriers to care and treatment have led to low rates of treatment initiation in this population despite pharmacologic advances that have made hepatitis C a curable disease. Innovation in care delivery is considered a key strategy that will help reach more patients. We present three case studies of patients with chronic hepatitis C and multiple psychiatric comorbidities who were successfully engaged in care and treated for their chronic hepatitis C in our multidisciplinary primary care-based program.

Self-Knowledge in Personality Disorders: An Emotion-Focused Perspective.

Emotional knowledge about one's own and others' emotional experience are central features of mental health and may be characteristic of therapeutic processes leading to good outcome. Clients with personality disorders (PDs) often lack in their ability to access and accept emotional experiences, or to reflect on emotion and use it in adaptive ways. The present theoretical and clinical review discusses self-knowledge, and lack thereof, in personality disorders, from an emotion-focused perspective. A first section differentiates between two fundamental types of meaning construction processing. The second section describes, from an integrative therapy perspective, how self-knowledge may be facilitated in psychotherapy by the client-therapist interaction. A subsequent section discusses lack of awareness of one's own emotions in the construction of meaning associated with PDs. The final section describes initial studies that demonstrate change occurring in constructing emotional self-knowledge as a correlate of treatment. The concepts of the review are illustrated throughout with three clinical cases of PD.

Inhibitors and facilitators of compassion-focused imagery in personality disorder.

BACKGROUND: Compassion-focused therapy (CFT) has potential to benefit clients with a personality disorder (PD), given the inflated levels of shame and self-criticism in this population. However, clinical observation indicates that clients with PD may find techniques from this approach challenging. AIMS: The aim of this study is to trial one aspect of CFT, compassion-focused imagery (CFI), with this population, and identify factors that predict clients' ability to generate CFI and experience self-compassion during the task, including type of CFI exercise and, second, to establish whether CFI outcomes increase with practice. METHOD: In Study 1, 53 participants with a diagnosis of PD completed measures of self-compassion, self-reassurance, shame, self-criticism, fear of self-compassion, affect, anxious and avoidant attachment, and mental imagery abilities. Participants were assigned to trial CFI from memory (n = 25) or from imagination (n = 28), then rated their image's vividness, its compassionate traits, and ease of experiencing compassion. A negative mood manipulation was carried out, and CFI tasks and outcome measures were repeated. For Study 2, self-compassion and self-criticism were measured before and after 1 week of daily CFI practice. RESULTS: Study 1 found that negative mood and low mental imagery ability are significant inhibitors to generating compassionate images and affect. The 2 CFI exercises were equally effective. Study 2 suffered from high attrition, but regular practice was associated with significant improvement in self-compassion (though not self-criticism). CONCLUSIONS: CFI appears to be effective in improving self-compassion for some clients. However, it is less effective in the presence of negative affect. Clients with low mental imagery ability may benefit more from alternative CFT techniques.

Schema therapy for emotional dysregulation in personality disorders: a review.

PURPOSE OF REVIEW: To give an update on the most recent studies regarding the role of schema therapy in the treatment of emotion dysregulation related to personality disorders. RECENT FINDINGS: In personality disorders, a lack of emotion regulation can be found. Schema therapy treats emotion dysregulation with a series of techniques, such as imagery rescripting, limited reparenting, chairwork, and cognitive restructuring to remove dysregulatory mechanism. SUMMARY: Schema therapy is one of the most efficient therapies for personality disorders. However, there is a lack of recent studies on how it treats emotion dysregulation. Although the treatment of emotional dysregulation is not the core of schema therapy, it is certainly important inside this theoretical framework. The mode model helps clinicians address their work toward the reduction of dysfunctional modes, whereas fostering functional modes.

Efficacy of Art Therapy in Individuals With Personality Disorders Cluster B/C: A Randomized Controlled Trial.

Multidisciplinary treatment programs for patients with personality disorders (PDs) often include art therapy, but the efficacy of this intervention has hardly been evaluated. The objective of this study is to evaluate the effects of an art therapy intervention on psychological functioning of patients with a PD. In this randomized controlled trial, 57 adult participants diagnosed with a PD cluster B/C (SCID-II) were randomly assigned to either weekly group art therapy (1.5 hours, 10 weeks) or a waiting list group. Outcome measures OQ45, AAQ-II, and SMI were assessed at baseline, at post-test (10 weeks after baseline), and at follow-up (5 weeks after post-test). The results show that art therapy is an effective treatment for PD patients because it not only reduces PD pathology and maladaptive modes but it also helps patients to develop adaptive, positive modes that indicate better mental health and self-regulation.

Assessing Narcissism Using Rorschach-Based Imagery and Behavior Validated by Clinician Reports: Studies With Adult Patients and Nonpatients.

We evaluate 11 Rorschach variables with potential for assessing grandiosity and narcissism. Seven of these variables were drawn from previous literature: Omnipotence, Idealization, Reflection, Personal Knowledge Justification, Exhibitionism, Magic, and Elevated Mood States; four were developed for this research: Expanded Personal Reference, Narcissistic Devaluation, Narcissistic Deflation, and Narcissistic Denial. Using Rorschach protocols from American normative adults and Italian adult outpatients, the dimensional structure of these variables was evaluated by principal components analysis, and validity was tested by correlations with clinician ratings of narcissism on two scales from the Shedler-Westen Assessment Procedure-200 that were made after at least five sessions with the primary clinician. A cohesive dimension was found in both data sets defined by Expanded Personal Reference, Personal Knowledge Justification, Omnipotence, and Idealization, and it was meaningfully correlated with the clinician ratings of narcissism ( M r = .41). Implications of the findings include the applicability of these variables in clinical practice and research for assessing narcissistic personality dynamics.