Is BORDERLINE PATHOLOGY a FOCUS FOR SPECIFIC TREATMENT APPROACHES

1
Is BORDERLINE PATHOLOGY a FOCUS FOR SPECIFIC
TREATMENT APPROACHES?

• John F. Clarkin, Ph.D.
• Weill Medical College of Cornell University

2
Personality Disorder Institute

• Psychoanalysts/Expert Clinicians
• O. KERNBERG M. STONE
• E. CALIGOR F. YEOMANS
• Psychotherapy Researchers
• J. CLARKIN M. LENZENWEGER
• K. LEVY
• Neurocognitive Scientists
• M. POSNER D. SILBERSWEIG

3
My Own Experience and Bias

• Researcher bipolar disorder and borderline
  personality disorder
• Clinician
• Therapists approaches to specific patient
  pathologies
• Psychotherapy research has focused too much on
  therapy orientations, with little attention to
  the specifics of the pathology
• The therapist is as important as the treatment
  orientation

4
Agenda

• Disorder specific psychotherapy One treatment
  approach does not fit all
• Nature of borderline pathology
• Observable interpersonal behavior
• Internal representations of self and others
• Cognitive and emotional functions
• Common features of empirically supported,
  modified treatment approaches to borderline
  pathology
• The TFP approach to borderline pathology
• Summary and conclusions

5
Treatment Modifications for BPD

• Both cognitive-behavioral and psychodynamic
  therapists see the need to modify treatment for
  borderline pathology
• DBT is a specific cognitive-behavioral treatment
  for borderline pathology effective as compared
  to TAU (Linehan, et al, 1991)
• Mentalization Based Treatment (MBT) and
  Transference Focused Psychotherapy (TFP) are
  modifications of dynamic treatments for BPD both
  are effective (Bateman Fonagy, 1999 Clarkin et
  al, 2007)

6
WHAT IS THE NATURE OF BORDERLINE PATHOLOGY?

• Self-destructive behaviors
• Negative affect combined with low constraint
• Relations with others that are constricted or
  conflicted (hyperactivating or deactivating)
• Internal representations (working models) of self
  and others that are extreme, distorted, marred by
  past experiences

7
Growing Consensus About Personality Disorders

• Conception of self and others
• Interpersonal behavior
• Livesley, 2000 Pincus, 2005

8
Key Constructs in Models of Personality Disorder
(Lenzenweger Clarkin, 2005)

• Disturbed internal working models (Bowlby, 1979)
• Maladaptive schemas (Beck et al., 2004)
• Limited and incoherent conception of self and
  others (Identity diffusion) (Kernberg Caligor,
  2005)
• Disturbed Attachment (Meyer Pilkonis, 2005)
  leading to disturbed cognitive-affective
  motivational patterns (representational systems
  of self and others, goals and strategies to
  pursue them)
• Conceptions of self in interaction copied from
  past (Benjamin, 2005)

9
Elements of Interpersonal Functioning
10
1. Observable Interpersonal Behavior

• Work and marital status
• Ratings of quality of love relations and work
  performance

11
Rating of Love Relations

• 1. Absence of sexual/romantic relations
• 2. Brief relations, conflict, devoid of sexual
  contact
• 3. Brief sexual contacts without romance
• 4. Sexual contacts sensual without romance
• 5. Sexual contact with one partner without
  romantic feelings
• 6. Romantic involvement with one partner, no
  sexual involvement
• 7. Satisfying sexual romantic involvement with
  one partner

12
Rating of Work

• 1. No voluntary or paid work
• 2. Some volunteer work
• 3. Part-time volunteer or paid work
• 4. Part time work, not commensurate with
  education
• 5. Full time work not commensurate with
  education, no absences
• 6. Effective full time work, not commensurate
  with education
• 7. Full time work, commensurate with education,
  works up to potential

13
Percentage of Patients Involvement in
Relationships and Work
14
2. Internal Representations Self-Report
Attachment Patterns (ECR) (Hazan Shaver, 1987)

• Secure It is relatively easy to get close to
  others I am comfortable depending on them and
  having them depend on me. I dont worry about
  being abandoned or someone getting too close.
• Avoidant I am uncomfortable being close to
  others it is difficult to trust others and to
  depend upon them
• Anxious I find others reluctant to get as close
  as I would like I worry that my partner doesnt
  really love me or wont want to stay with me.

15
(No Transcript)
16
Internal Representations BPD Attachment Patterns
(Levy et al, 2006)
17
3. Cognitive/emotional Functions

• Effortful control
• Neurocognitive functioning in processing negative
  affect

18
Neurocognitive FunctioningFunctioning

• Lab tests of effortful executive functioning BPD
  and controls differed significantly on WCST
  perseverative responses, of perseverative
  errors, and errors (Lenzenweger, Clarkin,
  Fertuck, Kernberg, 2004)
• fMRI tests of inhibition under the influence of
  negative affect emotional linguistic go/no go
  task (Silbersweig, Clarkin, Goldstein, Kernberg,
  et al, 2007)

19
Emotional Stroop Task
20
Behavioral Results

• Patients rated negative words more negative
• Longer reaction times for patients during no-go
  blocks
• Greater errors of omission for patients during
  no-go and negative no-go
• Greater errors of commission for patients under
  negative no-go condition

21
Neuroimaging Results

• Behavioral inhibition and negative emotion
  Patients manifested decreased ventromedial
  prefrontal (medial orbitofrontal, subgenal
  anterior cingulate) activity
• Behavioral inhibition and negative emotion
• Patients manifested decreasing vetromedial
  prefrontal increasing extended
  amygdalar-ventral striatal activities
• These activites signficantly correlated with
  trait measures (MPQ) of decreased constraint and
  increased negative emotion

22
Discussion

• OFC lesions/dysfunction associated clinically
  with socio-emotional dyscontrol
• In BPD, a bias toward intense negative feelings
  may dominate the process coupled with failure of
  top-down control
• Negative affective memories/states may propel
  behavior, unchecked by evolving socioemotional
  contexts

23
Implications
Persecuting Object
Victimized Self
Affect State
Hypervigilant Anxiety

• The affect state of anxiety and hypervigilance
  associated with HPA hyperreactivity is linked to
  a specific internal object relationship involving
  a persecuting object and a victimized self.
• (Gabbard,2005)

24
Aspects of Borderline Pathology That Call for
Treatment Modifications

• Chronic suicidal and parasuicidal behavior
  (Linehan)
• Treatment interfering behaviors (Linehan)
• Deficits in comprehending self and others in
  terms of emotions, cognitions, motivations
  (mentalization) (Bateman Fonagy)
• Borderline personality organization requires
  specific modifications in the therapeutic
  relationship (Kernberg)

25
COMMON FEATURES OF EFFECTIVE TREATMENTS FOR BPD
PATIENTS

• Well structured treatments
• Effort to enhance compliance
• Clear treatment focus
• Theoretically highly coherent to both therapist
  and patient
• Relatively long-term
• Encourage a powerful attachment relationship
  between therapist and patient therapist
  relatively active
• Well integrated with other services for the
  patient
• (Bateman Fonagy, 1999)

26
Three Treatments Modified for BPD
27
TFP AN OBJECT RELATIONS APPROACH TO BPD PATHOLOGY

• Structured
• Enhance compliance
• Focus
• Coherent to patient and therapist
• Encourage relationship

28
(No Transcript)
29
TFP Structured

• Treatment begins with negotiation of a contract
  between therapist and patient
• Contract specifies general responsibilities of
  patient and therapist
• Contract specifies responsibilities around acting
  out (e.g., cutting, suicidal thoughts behavior)
• The framework (contract) is referred back to
  whenever there is a breach of the contract

30
TFP Enhancement of Compliance

• Statement of mutual responsibilities if treatment
  is to occur (Contract)
• If patient fails to come to session, telephone
• If patient breaches the contract, re-negotiate
  the contract
• Any indication of self-destructive behavior or
  destruction of the treatment, high priority of
  the session

31
TFP Clear Focus

• Current behavior outside therapy job,
  relationships
• Current behavior of patient toward therapist
  hyperactivating and deactivating
• Current internal experience in relationship
  between patient and therapist

32
Object Relations Model of BPO
Self
Other
Affects
The Object Relations Dyad
33
Transference

• The activation of internal object relations in
  the relationship with the therapist.
• These internalized relations with significant
  others are not literal representations of past
  relations, but are modified by fantasies and
  defenses.
• In borderline patients, internal object relations
• have been segregated and split off from each
  other
• include fantasized persecutory and idealized
  relations.
• Working with object relations that are activated
  in the immediate moment creates a therapy that is
  experience-near

34
Patients Internal World
.
-S1
-a1
-O1

• S Self-Representation
• O Object - Representation
• a Affect
• Examples
• S1 Meek, abused figure
• O1 Harsh authority figure
  
• a 1 Fear
• S2 Childish-dependent figure
• O2 Ideal, giving figure
• a2 Love
• S3 Powerful, controlling figure
  
• O3 Weak, Slave-like figure
• a3 Wrath

S2
O2
a2
-O3
-a3
-S3
Etc.
35
Why focus onTRANSFERENCE?

• Experience of Self

• and of therapist

S1
S1
O1
a1
S2
S2
a2
O2
S3
O3
S3
a3
36
OBJECT RELATIONSHIP INTERACTIONS OSCILLATION
Object Rep
Self-Rep
Fear, Suspicion, Hate
Persecutor
Victim
Fear, Suspicion, Hate
Persecutor
Victim
(Oscillation is usually in behavior, not in
consciousness)
37
OBJECT RELATIONSHIP INTERACTIONS DEFENSE
Fear, Suspicion, Hate
Persecutor
Victim
Opposites
Longing, Love
Perfect Provider
Cared-for Child
38
TFP Coherent to Patient and Therapist

• Treatment contract carefully articulates patient
  and therapist responsibilities
• Clarification leading to confrontation leading to
  interpretation in the here-and-now

39
TFP Encourage Relationship

• Sessions at a frequency of 2 times a week
• Attention is drawn to implicit and explicit
  relationship conceptualizations

40
Randomized Controlled Trial (Clarkin, et al, 2007)

• Male and female BPD, ages 18 to 50
• Inclusion criteria Axis II BPD
• Exclusion criteria Schizophrenia, Bipolar
  Disorder, Eating Disorder and Substance
  Dependence
• Randomized to one of three treatments TFP, DBT,
  SPT
• If indicated, medication by algorithm
• Assessment at four points in time during one year
  of treatment

41
Summary Clinical change

• Three structured treatments (TFP, DBT, SPT) are
  related to significant change in multiple domains
• TFP was predictive of significant improvement in
  6 domains DBT predictive in 4 SPT in 5.
• In direct contrast analyses, only change in
  suicidal behavior trended to favor TFP and DBT
  over SPT
• Clarkin, Levy, Lenzenweger Kernberg, 2007

42
BPD Mechanisms of Change

• DBT borderline patients change by learning
  affect regulation skills in the context of
  validation (Linehan)
• MBT borderline patients change by increasing
  mentalization (Bateman Fonagy)
• TFP borderline patients change by integrating
  representations of self and others and related
  affects (Kernberg)

43
Mechanism of Change in TFP

• In successful treatment, the patient goes from
  intense, split, negative conceptions of self and
  others to affectively and cognitively nuanced and
  complicated conceptions of self and others
• This process of change is experienced in the
  evolving conception of the therapist and self in
  the treatment relationship
• This process of change is captured in the
  Reflective Functioning scale

44
Reflective Function (Fonagy, Target, Steele,
Steele, 1998)

• Reflective Function is defined as the capacity to
  think or mentalize in terms of mental states
  (emotions, intentions, motivations) in
  understanding self and other.
• RF rated on specific items of the Adult
  Attachment Interview (AAI)

45
Change in RF as a Function of Time and Treatment
(Levy et al, 2006)
46
SUMMARY AND CONCLUSIONS

• Cognitive-behavioral and dynamic researchers see
  the need for treatment modification for
  borderline pathology
• Treatments are modified to meet the nature of
  borderline pathology impulsivity, affect
  dysregulation, self-other relationship
  difficulties
• Different treatments are effective but only for
  about 60 of the patients
• Further treatment refinement through
• Identifying subgroups of BPD
• Focus on the mechanisms of change

47
SUMMARY AND CONCLUSIONS (2)

• Psychotherapy must be focused to be effective and
  efficient
• The focus is on the problem areas presented by
  the patient
• Patient problems reside in a context, i.e., the
  context of the individuals personality
• Non-personality disordered patients can work
  collaboratively in problem-solving with the
  therapist
• Patients with personality disorders present
  impediments to cooperative problem solving

48
SUMMARY AND CONCLUSIONS (3)

• Tailoring the treatment is not totally dependent
  on the diagnosis but also on non-diagnostic
  issues (Beutler Clarkin)
• The more severe the pathology, the more need to
  tailor the treatment