Can Patients With Narcissistic Personality Disorder Change? A Case Series.

ABSTRACT: The study was set out to establish the potential for psychotherapy to effect improvements in patients with narcissistic personality disorder (NPD). Eight patients with NPD who improved in treatment were identified. Consensus clinician/investigator diagnostic scores from before and after the psychotherapies were retroactively established on the Diagnostic Interview for Narcissism (DIN) and the Diagnostic Statistic Manual for Psychiatric Disorders, 5th Edition (DSM-5) Personality Disorder Section II criteria. Psychosocial functioning (work or school, romantic relationships) before and after the psychotherapies was retroactively evaluated as well. At the completion of the therapies after 2.5 to 5 years, all patients had improved, no longer met DIN or DSM-5 criteria for NPD, and showed better psychosocial functioning. Symptomatic improvements were associated with large effect sizes. In conclusion, changes in NPD can occur in treatment after 2.5 to 5 years. Future research should identify patient characteristics, interventions, and common processes in such improved cases that could help with development of treatments.

Defining Borderline Patients: An Overview.

This review of the descriptive literature on borderline patients indicates that accounts of such patients vary depending upon who is describing them, in what context, how the samples are selected, and what data are collected. The authors identify six features that provide a rational means for diagnosing borderline patients during an initial interview: the presence of intense affect, usually depressive or hostile; a history of impulsive behavior; a certain social adaptiveness; brief psychotic experiences; loose thinking in unstructured situations; and relationships that vacillate between transient superficiality and intense dependency. Reliable identification of these patients will permit better treatment planning and clinical research. Reprinted from Am J Psychiatry 1975; 132:1-10, with permission from American Psychiatric Association Publishing. Copyright © 1975.

Attitudes of Mental Health Staff Toward Patients With Borderline Personality Disorder: An Italian Cross-Sectional Multisite Study.

Negative attitudes toward borderline personality disorder (BPD) can present a barrier to those seeking care. We explored caring attitudes toward BPD among 860 mental health professionals, including psychiatrists, psychologists, social health educators, nurses, and social workers. The results showed that social workers and nurses scored significantly lower on caring attitudes than psychiatrists, social health educators, and psychologists. Our analysis showed that the more BPD patients treated in the past year, more years of experience in mental health, and having prior BPD training were positively associated with caring attitudes scores. For all professional subgroups, except for social health educators, the caring attitudes score is higher in those who have had prior BPD training, and for professionals with low and medium level of experience in mental health. This result shows that training on BPD should target less experienced clinicians and those professional groups who had less opportunity to receive such education.

A Clinical Trial of a Psychoeducation Group Intervention for Patients With Borderline Personality Disorder.

OBJECTIVE: The objective of this study was to assess the impact of a 6-session psychoeducational group (PEG) intervention for borderline personality disorder (BPD) in an underserved community-based outpatient setting. METHODS: The study was conducted between July 2015 and January 2017. Of 96 outpatients who met DSM-IV criteria for BPD, the first 48 received the experimental treatment, whereas the next 48 were assigned to a wait list. All received non-intensive treatment as usual. The primary outcome measure, the Zanarini Rating Scale for DSM-IV Borderline Personality Disorder (ZAN-BPD), was administered at baseline, at the end of treatment, and 2 months after the end of treatment. RESULTS: The PEG intervention was associated with a significant improvement on all sectors of BPD (P < .001). Improvements were greater for the PEG on all sectors except impulsivity. Benefits remained stable during 2-month follow-up. The PEG intervention had a large effect size (Cohen d = -1.16), whereas the wait list effect size was small (Cohen d = -0.18). The between-arms effect size was 0.80 after treatment and 0.90 at follow-up. With full response defined as a decrease of ≥ 50% from baseline in ZAN-BPD total score, 22 patients (46%) in the psychoeducation group and 3 (6%) in the wait list group were considered full responders. CONCLUSIONS: This study shows that a PEG intervention can be an effective treatment for patients with BPD. The overall cost benefits of group interventions and the the applicability of a PEG intervention to underserved patients demonstrate its potential to address significant public health needs.

Borderline personality disorder.

Caretakers are often intimidated or alienated by patients with borderline personality disorder (BPD), compounding the clinical challenges posed by the severe morbidity, high social costs and substantial prevalence of this disorder in many health-care settings. BPD is found in ∼1.7% of the general population but in 15-28% of patients in psychiatric clinics or hospitals and in a large proportion of individuals seeking help for psychological problems in general health facilities. BPD is characterized by extreme sensitivity to perceived interpersonal slights, an unstable sense of self, intense and volatile emotionality and impulsive behaviours that are often self-destructive. Most patients gradually enter symptomatic remission, and their rate of remission can be accelerated by evidence-based psychosocial treatments. Although self-harming behaviours and proneness to crisis can decrease over time, the natural course and otherwise effective treatments of BPD usually leave many patients with persistent and severe social disabilities related to depression or self-harming behaviours. Thus, clinicians need to actively enquire about the central issues of interpersonal relations and unstable identity. Failure to correctly diagnose patients with BPD leads to misleading pharmacological interventions that rarely succeed. Whether the definition of BPD should change is under debate that is linked to not fully knowing the nature of this disorder.

Competing Theories of Borderline Personality Disorder.

The authors review four theories that propose different conceptualizations of borderline personality disorder's (BPD) core psychopathology: excess aggression, emotional dysregulation, failed mentalization, and interpersonal hypersensitivity. The theories are compared in their ability to explain BPD's coaggregation of four usually distinct sectors of psychopathology, their high overlap with other disorders, their ability to distinguish BPD from other disorders, their integration of heritability, and their clinical applicability. The aims of this review are to increase awareness of these theories, to stimulate improved theories, and to f ster testable hypotheses so that research can advance our knowledge about BPD's core.

Mechanisms of Change in Treatments of Personality Disorders: Commentary on the Special Section.

Ueli Kramer has assembled an eclectic and original set of articles on mechanisms of change in the treatment of borderline personality disorder. They largely focus on patient variables. Several authors make the point that developmentally based variables may have more predictive power than symptom-based variables. Several other articles illustrate that changes occur early in treatments and studying their mechanisms is a promising approach that could have longer term significance. These articles document the variety of research methodologies that can be used to study mechanisms of change and the potential clinical significance of doing this. For showing the field the potential of such research, we owe Dr. Kramer our gratitude.

Functional outcomes in community-based adults with borderline personality disorder.

Many individuals in clinical samples with borderline personality disorder (BPD) experience high levels of functional impairment. However, little is known about the levels of functional impairment experienced by individuals with BPD in the general community. To address this issue, we compared overall and domain-specific (educational/occupational; social; recreational) functioning in a sample of community-based individuals with BPD (n = 164); community-based individuals without BPD (n = 901); and clinically-ascertained individuals with BPD (n = 61). BPD diagnoses and functional outcomes were based on well-accepted, semi-structured interviews. Community-based individuals with BPD were significantly less likely to experience good overall functioning (steady, consistent employment and ≥1 good relationship) compared to community-based individuals without BPD (BPD: 47.4%; Non- BPD: 74.5%; risk difference -27.1%; p < 0.001), even when compared directly to their own non-BPD siblings (risk difference -35.5%; p < 0.001). Community-based individuals with BPD versus those without BPD did not differ significantly on most domain-specific outcomes, but the former group experienced poorer educational/occupational performance and lower quality relationships with parents, partners, and friends. However, community-based individuals with BPD were significantly more likely to experience good overall functioning than clinically-based individuals with BPD (risk difference -35.2%; p < 0.001), with the latter group more likely to experience reduced employment status, very poor quality relationships with partners, and social isolation. In conclusion, community-based individuals with BPD experienced marked functional impairment, especially in the social domain, but were less likely to experience the more extreme occupational and social impairments seen among patients with BPD.

Personality and life events in a personality disorder sample.

Individuals with a personality disorder (PD) tend to experience more negative life events (NLEs) than positive life events (PLEs). In community samples, the Five Factor Model of personality (FFM) predicts both positive and negative life events. The present research examined whether FFM normal personality traits were associated with positive and negative life events among individuals with 1 of 4 PDs: avoidant, borderline, schizotypal, and obsessive-compulsive, and tested whether associations between the FFM of personality and PLEs and NLEs were similar across the 4 PD groups and a control group. Among aggregated PDs, neuroticism was positively associated with NLEs, whereas extraversion, openness to experience, and conscientiousness were positively associated with PLEs. Comparisons of each PD group to a control group of individuals with a major depressive disorder indicated that the FFM traits operated similarly across clinical samples with and without PD. Our findings indicate that normal personality traits can be used to help understand the lives of individuals with PD. (PsycINFO Database Record

Evidence-Based Treatments for Borderline Personality Disorder: Implementation, Integration, and Stepped Care.

LEARNING OBJECTIVE: After participating in this activity, learners should be better able to:• Evaluate evidence-based therapies for borderline personality disorder ABSTRACT: Several manualized psychotherapies for treating borderline personality disorder (BPD) have been validated in randomized, controlled trials. Most of these approaches are highly specialized, offering different formulation of BPD and different mechanisms by which recovery is made possible. Mental health clinicians are challenged by the degree of specialization and clinical resources that these approaches require in their empirically validated adherent forms. While these effective treatments have renewed optimism for the treatment of BPD, clinicians may feel limited in their ability to offer any of them or may integrate an eclectic assortment of features from the different treatments. This article will evaluate four major evidence-based treatments for BPD-dialectical behavioral therapy, mentalization-based treatment, transference-focused psychotherapy, and General Psychiatric Management-and possible modes of implementation in adherent and integrative forms. Models of implementing these diverse treatment approaches will be evaluated, and the potential advantages of combining evidence-based treatments will be discussed, along with some cautionary notes. A proposal for providing stepwise care through assessment of clinical severity will be presented as a means of achieving system-wide changes and greater access to care.

"Good Enough" Psychiatric Residency Training in Borderline Personality Disorder: Challenges, Choice Points, and a Model Generalist Curriculum.

While the public health burden posed by borderline personality disorder (BPD) rivals that associated with other major mental illnesses, the prevailing disposition of psychiatrists toward the disorder remains characterized by misinformation, stigma, aversive attitudes, and insufficient familiarity with effective generalist treatments that can be delivered in nonspecialized health care settings. Residency training programs are well positioned to better equip the next generation of psychiatrists to address these issues, but no consensus or guidelines currently exist for what and how residents should be taught about managing BPD. Instead, disproportionately limited curricular time, teaching of non-evidence-based approaches, and modeling of conceptually confused combinations of techniques drawn from specialty BPD treatments are offered. In this article, we (1) explain why training in a generalist model is sensible and why alternative approaches are not appropriate for residents, (2) propose a plan for giving residents adequate training via a generalist model, highlighting minimal didactic and clinical-training objectives (dubbed "core competencies" and "milestones") and a model curriculum developed at the Massachusetts General Hospital/McLean Hospital residency program, and (3) describe obstacles to implementation of effective generalist training posed by infrastructural, faculty-centered, and resident-centered variables.

The Effect of Attending Good Psychiatric Management (GPM) Workshops on Attitudes Toward Patients With Borderline Personality Disorder.

The effect that attending a 1-day workshop on Good Psychiatric Management (GPM) had on attitudes about borderline personality disorder (BPD) was assessed among 297 clinicians. Change was recorded by comparing before and after scores on a 9-item survey previously developed to assess the effects of workshops on Systems Training for Emotional Predictability and Problem Solving (STEPPS). Participants reported decreased inclination to avoid borderline patients, dislike of borderline patients, and belief that BPD's prognosis is hopeless, as well as increased feeling of competence, belief that borderline patients have low self-esteem, feeling of being able to make a positive difference, and belief that effective psychotherapies exist. Less clinical experience was related to an increased feeling of competence and belief that borderline patients have low self-esteem. These findings were compared to those from the STEPPS workshop. This assessment demonstrates GPM's potential for training clinicians to meet population-wide needs related to borderline personality disorder.

Promoting Good Psychiatric Management for Patients With Borderline Personality Disorder.

General psychiatric management for patients with borderline personality disorder was devised to be an outpatient intervention that could be readily learned and easily delivered by independent community mental health professionals. To disseminate the approach, Drs. Gunderson and Links developed the Handbook of Good Psychiatric Management for Borderline Personality Disorder (Gunderson & Links, ) that presented the basics of the approach, videos to illustrate the appropriate clinical skills, and case examples to practice adherence to the approach. Unfortunately, the inclusion of "psychiatric" in the treatment's name may discourage psychologists and other mental health professionals from using this therapy. In this article, we review the basic principles and approaches related to general psychiatric management. With a case example, we illustrate how psychologists can use all the general psychiatric management principles for their patients with BPD, except medications and, as a result, provide and deliver this approach effectively.

Interactions of borderline personality disorder and anxiety disorders over 10 years.

OBJECTIVE: This report examines the relationship of DSM-IV borderline personality disorder (BPD) to anxiety disorders using data on the reciprocal effects of improvement or worsening of BPD and anxiety disorders over the course of 10 years. METHOD: We reliably and prospectively assessed borderline patients (n = 164) with DSM-IV-defined co-occurring generalized anxiety disorder (GAD; n = 42), panic disorder with agoraphobia (n = 39), panic disorder without agoraphobia (n= 36), social phobia (n = 48), obsessive-compulsive disorder (OCD; n = 36), and posttraumatic stress disorder (PTSD; n = 88) annually over a period of 10 years between 1997 and 2009. We used proportional hazards regression analyses to assess the effects of monthly improvement or worsening of BPD and anxiety disorders on each other's remission and relapse the following month. RESULTS: BPD improvement significantly predicted remission of GAD (hazard ratio [HR] = 0.65, P <.05) and PTSD (HR = 0.57, P < .05), whereas BPD worsening significantly predicted social phobia relapse (HR = 1.87, P < .05). The course of anxiety disorders did not predict BPD remission or relapse, except that worsening PTSD significantly predicted BPD relapse (HR = 1.90, P < .05). CONCLUSION: BPD negatively affects the course of GAD, social phobia, and PTSD. In contrast, the anxiety disorders, aside from PTSD, had little effect on BPD course. For GAD and social phobia, whose course BPD unidirectionally influences, we suggest prioritizing treatment for BPD, whereas BPD should be treated concurrently with panic disorders, OCD, or PTSD. We discuss state/trait issues in the context of our findings.