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Beyond the ICD and DSM: Diagnosis, Comorbidity, and the Therapeutic Alliance in Severe Personality Disorders with an Emphasis on Borderline Personality

Allan Tasman, M.D.

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Impact of Systems of Psychiatric Diagnosis

DSM and ICD are still non-etiologic approaches based on symptom clusters

DSM revisions were designed to stimulate research, which has occurred

No provision for role of psychological conflict or developmental distress

No provision for symbolic meaning of symptoms

When role of empathic listening for trauma, transference, cultural influences, and symbolic meanings are omitted, we cannot fully understand our patients

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Personality =Temperament + Character

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The Five-Factor Model of PersonalityNeuroticism Calm – Worrying Even-tempered – Temperamental Self-satisfied – Self-pitying Comfortable – Self-conscious Unemotional – Emotional Hardy – Vulnerable

Extraversion Reserved – Affectionate Loner – Joiner Quiet – Talkative Passive – Active Sober – Fun-loving Unfeeling – Passionate

Openness to Experience Down-to-earth – Imaginative Uncreative – Creative Conventional – Original Prefer routine – Prefer variety Uncurious – Curious Conservative – Liberal

Agreeableness Ruthless – Soft-hearted Suspicious – Trusting Stingy – Generous Antagonistic – Acquiescent Critical – Lenient Irritable – Good-natured

Conscientiousness Negligent – Conscientious Lazy – Hardworking Disorganized – Well-organized Late – Punctual Aimless – Ambitious Quitting – Persevering

Adapted from Costa & McCrae 1986

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Three Major Brain Systems Influencing Stimulus – Response Characteristics

Brain System (Related Personality Dimension)

Principal Monoamine Neuromodulator

Relevant Stimuli Behavioral Response

Behavioral activation

(novelty seeking)

Dopamine Novelty Exploratory pursuit

Potential reward Appetitive approach

Potential relief of monotony or punishment

Active avoidance, escape

Behavioral inhibition

(harm avoidance)

Serotonin Conditioned signals for punishment, novelty, or frustrative nonreward

Passive avoidance, extinction

Behavioral maintenance

(reward dependence)

Norepinephrine Conditioned signals for reward or relief of punishment

Resistance to extinction

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Cloninger’s Seven-Factor Model

1. Temperament Domains (Moderately heritable, not greatly influenced by family environment)

a. Novelty Seekingb. Harm Avoidancec. Reward Dependenced. Persistence

2. Character Domains (Moderately influenced by family environment, only weakly heritable)

a. Self-transcendenceb. Cooperativenessc. Self-directedness

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DSM-IV Definition of Personality Disorder

A. An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture. This pattern is manifested in two (or more) of the following areas:

1. Cognition (i.e., ways of perceiving and interpreting self, other people, and events)

2. Affectivity (i.e., the range, intensity, ability, appropriateness of emotional response)

3. Interpersonal functioning

4. Impulse control

B. The Enduring pattern is inflexible and pervasive across a broad range of personal and social situations.

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DSM-IV Definition of Personality Disorder

C. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.

D. The pattern is stable and of long duration and its onset can be traced back at lease to adolescence or early adulthood.

E. The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder.

F. The enduring pattern is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., head trauma).

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DSM-IV Personality Disorders

A. Cluster A (odd/eccentric)

1. Paranoid

2. Schizoid

3. Schizotypal

B. Cluster B (dramatic/emotional/impulsive)

1. Antisocial

2. Borderline

3. Histrionic

4. Narcissistic

C. Cluster C (anxious/fearful)

1. Avoidant

2. Dependent

3. Obsessive-Compulsive

D. Personality Disorder Not Otherwise Specified

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Phenomenologically Corresponding Axis I & Axis II Disorders, Potential Biological Indexes, and Characteristic

Traits (Core Vulnerabilities), Defenses and Coping Strategies of Dimensions of Personality Disorders

Dimension Axis I Disorder Axis II Disorder Biological Indexes Characteristic Traits Defenses and Coping Strategies

Cognitive/ Perceptual Organization

Schizophrenia Odd cluster(schizotypal PD)

Eye movement dysfunction*, continuous performance task, backward masking test*, plasma HVA*, CSF HVA*, evoked potential response, VBR

Disorganization, psychotic-like symptoms

Social isolation, detachment, guardedness

Impulsivity/Aggression

Impulse disorders

Dramatic cluster(borderline & antisocial PDs)

CSF 5-HIAA*, responses to serotonergic challenge, galvanic skin response*, continuous performance task

Readiness to action, irritability/aggression

Externalization, dissociation, enactment, repression

AffectiveInstability

Major affective disorders

Dramatic cluster(borderline & possibly histrionic PDs)

REM latency, responses to cholinergic challenges*, responses to catecholamingeric challenges*

Environmentally responsive, transient affective shifts

Exaggerated affectivity, “manipulativeness”, “splitting”

Anxiety/ Inhibition

Anxiety disorders

Anxious cluster(avoidant PD)

Heart rate variability*, orienting responses, responses to lactate and yohimbine

Autonomic arousal, fearfulness, inhibition

Avoidant, compulsive, and dependent behaviors

* Preliminary data are available in patients with personality disorder (PD)

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Impulsive Disorders

Axis II Borderline Personality Disorder Antisocial Personality Disorder

Axis I Psychoactive Substance Use Disorder Bulimia Paraphilias Impulsive Control Disorder NEC

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ASPDASPD

SPDSPD

BPDBPD

AVPDAVPD

HPDHPD

NPDNPD

STPDSTPD

PTSDPTSDBip-II

MDDMDD

SeveritySeverityof socialof social

dysfunctiondysfunction

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Concepts of Borderline Disorders

SchizophreniaSchizophreniaAffective Affective DisordersDisorders

Borderline Borderline Schizophrenia (Kety)Schizophrenia (Kety)(Schizotypal PD - (Schizotypal PD - Rado, Meehl)Rado, Meehl)

Atypical Atypical Affective Affective Disorders Disorders (D.Klein)(D.Klein)

BorderlineBorderlinePersonalityPersonality

OrganizationOrganization(Kernberg)(Kernberg)

BorderlineBorderlinePersonalityPersonality

DisorderDisorder

BorderlineBorderlineSyndromeSyndrome(Grinker)(Grinker)

NeurosesNeuroses

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Theories of Etiology of BPD

1. Affective/impulsive dysregulation (Klein, Akiskal) 2. Excessive aggression (Kernberg)

A. Primary (constitutional) B. Secondary (reaction to frustration or trauma)

3. Maternal withdrawal (Masterson, Rinsley) 4. Introjective failure (Mahler, Kohut) 5. Neurological dysfunction (Andrulonis)

Gunderson and Zanarini

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Etiology of BPD

Type 1: Affective (Akiskal, Klein) **A moderately heritable “subaffective”

vulnerability, precipitated by environmental stress

Prototypic Criteria: #6: affective instability due to marked

reactivity of mood (dysphoria or anxiety);

#5: recurrent suicidal behavior, gestures or threats, or self-mutilating behavior

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Etiology of BPD

Type 2: Impulsive (Zanarini, Hollander, Siever) **A moderately heritable impulse spectrum

disorder, precipitated by environmental stress

Prototypic Criteria: #4: impulsivity in at least two areas that are

potentially self-damaging; #5: recurrent suicidal behavior, gestures or

threats, or self-mutilating behavior

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Etiology of BPD

Type 3: Aggressive (Kernberg) **A primary moderately heritable aggressive

temperament, or a secondary reaction to early trauma and/or abuse

Prototypic Criteria: #8: inappropriate, intense anger or difficulty

controlling anger; #6: affective instability due to marked

reactivity of mood (irritability)

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Etiology of BPD

Type 4: Dependent (Masterson and Rinsley; Gunderson)

**intolerance of aloneness, and impaired autonomy, possibly secondary to parental separation-resistance

Prototypic Criteria: #1: frantic efforts to avoid real or imagined

abandonment; #6: affective instability due to marked reactivity

of mood (anxiety)

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Etiology of BPD

Type 5: Empty (Mahler; Adler and Buie) **failure to develop an evocative memory

secondary to lack of empathy and inconsistency in early parenting

Prototypic Criteria: #7: chronic feelings of emptiness; #3: identity disturbance: markedly and

persistently unstable self-image or sense of self

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APA Practice Guidelines Work Group on Borderline Personality Disorders

John Oldham, M.D. (Chair)Glen Gabbard, M.D.Marcia Goin, M.D., Ph.D.John Gunderson, M.D.Paul Soloff, M.D.David Spiegel, M.D.Michael Stone, M.D.Katherine Phillips, M.D.

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Part A: Treatment Recommendations for Patients with Borderline Personality Disorder

II. Formulation and Implementation of a Treatment Plan

E. Specific Treatment Strategies for the Clinical Features of Borderline Personality Disorder

1. Psychotherapy2. Pharmacotherapy and other somatic

treatments

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Type 1 (Affective)

Type 2 (Impulsive)

Type 3 (Aggressive)

Type 4 (Dependent)

Type 5 (Empty)

PsychotherapyPsychotherapy

PharmacotherapyPharmacotherapy

BBPPDD TTyyppee

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Common Features of Recommended Psychotherapy for BPD

1. Non-brief 2. Strong therapeutic alliance 3. Establishment of clear roles and

responsibilities of patient and therapist 4. Active therapist 5. Hierarchy of priorities 6. Empathic validation + need for patient to

control behavior 7. Flexibility 8. Limit-setting 9. Concomitant individual and group approaches

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Table 2. The Hierarchy of Priorities in Therapeutic SessionsTable 2. The Hierarchy of Priorities in Therapeutic Sessions

Dialectical Behavior TherapyDialectical Behavior Therapy(Linehan 1993)(Linehan 1993)

Psychoanalytic/Psychodynamic TherapiesPsychoanalytic/Psychodynamic Therapies(Kernberg et al. 1989; Clarkin et al. 1999)(Kernberg et al. 1989; Clarkin et al. 1999)

suicidal behaviorssuicidal behaviors suicide or homicide threatssuicide or homicide threats

therapy-interfering behaviorstherapy-interfering behaviors overt threats to treatmentovert threats to treatment continuitycontinuity

quality-of-life interfering behaviorsquality-of-life interfering behaviors dishonesty or deliberatedishonesty or deliberate withholdingwithholding

contract breachescontract breaches

in-session acting outin-session acting out

between-session acting outbetween-session acting out

nonaffective or trivial themesnonaffective or trivial themes

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Part A: Treatment Recommendations for Patients with Borderline Personality Disorder

IV. Risk Management Issues in Treating Borderline PatientsA. General Considerations

1. Good collaboration and communication 2. Assessment of risk, careful

documentation3. Attention to problems in the transference

or countertransference4. Consultations5. Psychoeducation

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Part A: Treatment Recommendations for Patients with Borderline Personality Disorder

IV. Risk Management Issues in Treating Borderline PatientsB. Suicide

1. Monitor for suicide risk2. Take suicide threats seriously3. Address chronic suicidality without acute risk,

in therapy4. Actively treat comorbid Axis I conditions5. Consultation6. Involvement of family7. Non-reliance on “suicide contract”

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Part A: Treatment Recommendations for Patients with Borderline Personality Disorder

IV. Risk Management Issues in Treating Borderline PatientsC. Anger, Impulsivity, and Violence

1. Monitor for impulsive or violent behavior2. Address abandonment/rejection issues,

anger, impulsivity, in therapy3. Careful coverage arrangement and

documentation when away4. Take action if necessary to protect self or

others

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Part A: Treatment Recommendations for Patients with Borderline Personality Disorder

IV. Risk Management Issues in Treating Borderline PatientsD. Boundary Violations

1. Monitor counter transference2. Be alert to deviations from standard

practice3. Avoid boundary violations4. Consultation

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The Effectiveness of Psychodynamic Therapy and Cognitive Behavior Therapy in the Treatment of Personality Disorders: A Meta-Analysis

Both psychodynamic therapy and cognitive behavior therapy are effective treatments of personality disorders

For psychodynamic therapy, the effect sizes indicate long-term rather than short-term change in personality disorders (mean follow-up period = 1.5 years [78 weeks] vs CBT mean follow-up = 13 weeks)

Leichsenring F, Leibing E, Am J Psychiatry 2003; 160:1223-1232

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Summary Present diagnostic classification systems are

inadequate for severe personality disorders Alternative models assess interaction of

temperament and developmental experience Research evidence for borderline personality

emphasizes psychotherapeutic interventions Development and maintenance of an effective

therapeutic alliance is critical for success no matter what form of psychotherapy is utilized