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.

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.

Individuals with single versus multiple suicide attempts over 10years of prospective follow-up.

BACKGROUND: The study attempted to identify characteristics that differentiate multiple suicide attempters from single attempters in individuals with personality disorders (PDs) and/or major depression. METHOD: Participants were 431 participants enrolled in the Collaborative Longitudinal Study of Personality Disorders from July 1996 to June 2008. Suicide attempts were assessed with the Longitudinal Interval Follow-up Evaluation at 6 and 12months, then yearly through 10years. Logistic regression was used to compare single attempters to multiple attempters on Axis I and II psychiatric disorders and personality trait variables. RESULTS: Twenty-one percent of participants attempted suicide during the 10years of observation, with 39 (9.0%) reporting a single suicide attempt and 54 (12.5%) reporting multiple suicide attempts. Although no significant differences in were found in baseline Axis I disorders, multiple attempters were significantly more likely to meet criteria for borderline personality disorder and to have higher impulsivity scores than single attempters. CONCLUSION: These results underscore the importance of considering both personality disorders and traits in the assessment of suicidality.

Ten-year rank-order stability of personality traits and disorders in a clinical sample.

OBJECTIVE: This study compares the 10-year retest stability of normal traits, pathological traits, and personality disorder dimensions in a clinical sample. METHOD: Ten-year rank-order stability estimates for the Revised NEO Personality Inventory, Schedule for Nonadaptive and Adaptive Personality, and Diagnostic Interview for DSM-IV Personality Disorders were evaluated before and after correcting for test-retest dependability and internal consistency in a clinical sample (N = 266). RESULTS: Dependability-corrected stability estimates were generally in the range of.60-.90 for traits and.25-.65 for personality disorders. CONCLUSIONS: The relatively lower stability of personality disorder symptoms may indicate important differences between pathological behaviors and relatively more stable self-attributed traits and imply that a full understanding of personality and personality pathology needs to take both traits and symptoms into account. The five-factor theory distinction between basic tendencies and characteristic adaptations provides a theoretical framework for the separation of traits and disorders in terms of stability in which traits reflect basic tendencies that are stable and pervasive across situations, whereas personality disorder symptoms reflect characteristic maladaptations that are a function of both basic tendencies and environmental dynamics.

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.

Borderline personality disorder: considerations for inclusion in the Massachusetts parity list of "biologically-based" disorders.

Borderline Personality Disorder (BPD) is a common and severe mental illness that is infrequently included under state mental health parity statutes. This review considers BPD parity, using the Massachusetts mental health parity statute as a model. While BPD can co-occur with other disorders, studies of its heritability, diagnostic validity/reliability, and response to specific treatments indicate it is best considered an independent disorder, one that negatively impacts the patient's treatment response to comorbid disorders, particularly mood disorders. Persons with BPD are high utilizers of treatment, especially emergency departments and inpatient hospitalizations-the most expensive forms of psychiatric treatment. While some patients remain chronically symptomatic, the majority improve. The findings from psychopharmacologic and other biologic treatment data, coupled with associated brain functioning findings, indicate BPD is a biologically-based disorder. Clinical data indicate that accurately diagnosing and treating BPD conserves resources and improves outcomes. Based on this analysis, insuring BPD in the same manner as other serious mental illnesses is well-founded and recommended.

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.

An experimental investigation of emotional reactivity and delayed emotional recovery in borderline personality disorder: the role of shame.

Despite the emphasis on emotional reactivity and delayed emotional recovery in prominent theoretical accounts of borderline personality disorder (BPD), research in this area remains limited. This study sought to extend extant research by examining emotional reactivity (and recovery following emotional arousal) to 2 laboratory stressors (one general, and the other involving negative evaluation) and exploring the impact of these stressors on subjective responding across the specific emotions of anxiety, irritability, hostility, and shame. We hypothesized that outpatients with BPD (compared to outpatients without a personality disorder; non-PD) would demonstrate heightened subjective emotional reactivity to both stressors, as well as a delayed return to baseline levels of emotional arousal. Results provide evidence for context- and emotion-specific reactivity in BPD. Specifically, BPD participants (compared to non-PD participants) evidenced heightened reactivity to the negative evaluation but not the general stressor. Furthermore, results provide support for shame-specific reactivity in BPD, with BPD participants (vs non-PD participants) evidencing a significantly different pattern of change in shame (but not in reported anxiety, irritability, or hostility) across the course of the study. Specifically, not only did BPD participants report higher levels of shame in response to the negative evaluation, their levels of shame remained elevated following this stressor (through the post-recovery period at the end of the study). Findings suggest the importance of continuing to examine emotional reactivity in BPD within specific contexts and across distinct emotions, rather than at the general trait level.

Ethnicity in trauma and psychiatric disorders: findings from the collaborative longitudinal study of personality disorders.

The study's aims are to explore ethnic differences in rates of adverse childhood experiences and lifetime traumatic events and in rates of psychiatric disorders for patients exposed to similar traumas. Rates of these events and rates of major depressive disorder, posttraumatic stress, substance use, and borderline personality disorders were compared among 506 non-Hispanic Whites (N-HW), 108 Latina(o)s, and 94 African Americans (AA) participating in the Collaborative Longitudinal Personality Disorder Study. We found that Whites reported higher rates of neglect than African Americans and Latina(o)s, higher rates of verbal/emotional abuse than African Americans, and higher rates of accidents and injuries/feared serious injury than Latina(o)s. African Americans had higher rates of seeing someone injured/killed than Whites. No significant interaction was observed between adverse events and ethnicity for mental disorders.

The relationship between self-reported attachment styles, interpersonal dysfunction, and borderline personality disorder.

Clinical theories of borderline personality disorder (BPD) identify attachment insecurity as the basis of its characteristic disturbed interpersonal functioning. The purpose of this study was to compare attachment ratings in rigorously diagnosed BPD, depressed (MDD), and nonborderline comparison groups and their correlations to features of interpersonal disturbance. Subjects self-reported ratings on attachment styles using the relationship questionnaire. BPD subjects reported higher scores on both preoccupied and fearful attachment styles than both MDD and nonborderline comparison groups. A mixed model of preoccupied and fearful attachment was more prevalent in the BPD group and was associated with 3 to 20 times greater risk for diagnosis of BPD. Scores on preoccupied and fearful attachment styles were correlated with features of interpersonal disturbance in BPD. A combination of preoccupied and fearful self-reported attachment styles is more specific to BPD than either style alone or attachment insecurity in general.

The construct validity of passive-aggressive personality disorder.

Although Passive Aggressive personality disorder (PAPD) plays an important role in many theories of personality pathology, it was consigned to the appendix of the fourth edition of the DSM. The scientific basis of this decision has been questioned, but several controversies persist regarding PAPD, including its structure, content validity, overlap with other PDs, and relations to validating variables such as personality traits, childhood experiences, and clinically relevant correlates. This study examined these facets of PAPD's construct validity in a large clinical sample. Results suggest that the construct is unidimensional, internally consistent, and reasonably stable. Furthermore, PAPD appears systematically related to borderline and narcissistic personality disorders, sets of personality traits, and childhood experiences consistent with several theoretical formulations, dysfunction, substance abuse disorders, and history of hospitalizations. Overall, results support the construct validity of PAPD.

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.

Preliminary data on the relationship between anxiety sensitivity and borderline personality disorder: the role of experiential avoidance.

Although research on the temperamental vulnerabilities associated with borderline personality disorder (BPD) has focused primarily on the role of impulsive-aggression, affective instability, and emotional vulnerability, growing evidence suggests that anxiety sensitivity (AS) also may increase vulnerability for BPD. This study provides preliminary data on the relationship between AS and BPD, examining whether AS distinguishes outpatients with BPD from outpatients without a personality disorder (non-PD), and whether the relationship between AS and BPD is mediated by experiential avoidance (i.e., attempts to avoid unwanted internal experiences, such as anxiety). Findings indicate that BPD outpatients reported higher levels of AS than non-PD outpatients and AS reliably distinguished between these two groups. Furthermore, the relationship between AS and BPD was mediated by experiential avoidance. Finally, results indicate that AS (and experiential avoidance as a mediator) accounted for a significant amount of additional variance in BPD status above and beyond both negative affect and two well-established temperamental vulnerabilities for BPD (affect intensity/reactivity and impulsivity). Findings suggest the need to further explore the role of AS in the pathogenesis of BPD.

New episodes and new onsets of major depression in borderline and other personality disorders.

BACKGROUND: In the context of much literature and conjecture about the relationship of personality disorders (PD) and major depressive disorder (MDD), this paper uses longitudinal data to assess the frequency with which PD patients, and especially those with borderline personality disorder (BPD), have recurrences (for patients with lifetime histories), or new onsets (for patients without lifetime histories) of MDD. METHODS: A sample of 478 PD patients received reliable repeated follow-up assessments over a period of 6 years. The rates of new onsets and recurrences of MDD in all PD patients, and in BPD patients compared to OPD patients were analyzed. Whether age, gender, GAF score, or the number and types of BPD criteria predict new onsets or recurrences of MDD was also examined. RESULTS: Eighty-five percent of PD subjects had episodes of MDD during the 6 year follow-up; of those with lifetime MDD, 85% had recurrences. Of the PD subjects without lifetime MDD, 44% had new onsets. BPD subjects were significantly more likely (p = .0036) to have recurrences of MDD but were about equally likely to have new onsets compared to OPD subjects. The number and types of BPD criteria were predictive of onsets and recurrences for all PDs, but were not more predictive for the BPD than OPD subsamples. LIMITATIONS: Longer term follow ups with a more epidemiologically representative sample of PDs would strengthen the generalizability of this study's findings. CONCLUSIONS: Having a comorbid PD confers significant risk for recurrences and for new onsets of MDD and confers a significantly negative effect on the course of MDD. BPD conferred more risk for recurrence than OPD.

BPD's interpersonal hypersensitivity phenotype: a gene-environment-developmental model.

This paper explores the development of BPD as it might emerge in the child's early interpersonal reactions and how such reactions might evolve into the interpersonal pattern that typifies BPD. It begins to bridge the relevant bodies of clinical literature on the borderline's prototypic interpersonal problems with the concurrently expanding relevant literature on early child development. We will start by considering how a psychobiological disposition to BPD is likely to include a constitutional diathesis for relational reactivity, that is, for hypersensitivity to interpersonal stressors. Data relevant to this disposition's manifestations in adult clinical samples and to its heritability and neurobiology will be reviewed. We then consider how such a psychobiological disposition for interpersonal reactivity might contribute to the development of a disorganized-ambivalent form of attachment, noting especially the likely contributions of both the predisposed child and of parents who are themselves predisposed to maladaptive responses, leading to an escalation of problematic transactions. Evidence concerning both the genetics and the developmental pathways associated with disorganized attachments will be considered. Emerging links between such developmental pathways and adult BPD will be described, in particular the potential appearance by early- to middle-childhood of controlling-caregiving or controlling-punitive interpersonal strategies. Some implications from this gene-environment interactional theory for a better developmental understanding of BPD's etiology are discussed.

A comparison of interview and self-report methods for the assessment of borderline personality disorder criteria.

Interview methods are widely regarded as the standard for the diagnosis of borderline personality disorder (BPD), whereas self-report methods are considered a time-efficient alternative. However, the relative validity of these methods has not been sufficiently tested. The current study used data from the Collaborative Longitudinal Personality disorder Study to compare diagnostic base rates and the relative validity of interview and self-report methods for assessing functional outcome in BPD. Although self-report yielded higher base rates of criteria endorsement, results did not support the common assumption that diagnostic interviews are more valid than self-reports, but instead indicated the combined use of these methods optimally identifies BPD criteria.

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.

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.