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. KERNBERGM. STONE E. CALIGOR F. YEOMANS  Psychotherapy Researchers J. CLARKIN M. LENZENWEGER K. LEVY  Neurocognitive Scientists M. POSNERD. 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 Interpersonal Behavior Internal representations Cognitive and emotional functions

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 don’t 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 doesn’t really love me or won’t want to stay with me.

16. Internal Representations: BPD Attachment Patterns (Levy et al, 2006) Secure5 % Preoccupied48.3% Dismissing46.7 %

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 POSITIVE VERBAL STIMULI GoNo-go NEUTRAL VERBAL STIMULI GoNo-go NEGATIVE VERBAL STIMULI GoNo-go

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 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) Persecuting Object Victimized Self Affect State: Hypervigilant Anxiety

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 1. Well structured treatments 2. Effort to enhance compliance 3. Clear treatment focus 4. Theoretically highly coherent to both therapist and patient 5. Relatively long-term 6. Encourage a powerful attachment relationship between therapist and patient; therapist relatively active 7. Well integrated with other services for the patient (Bateman & Fonagy, 1999)

26. Three Treatments Modified for BPD DBTMBTTFP StructuredContract Enhance Compliance Validating environment Efforts to understand patients perceptions Explore objections to contract; pursue no shows Clear FocusSkillsMentalizationIntegration of self-other representations Coherent to patient and therapist Explain rationale of treatment Contract states responsibilities Encourage relationship ValidationFocus on understanding disruptions Sessions 2 per week

27. TFP: AN OBJECT RELATIONS APPROACH TO BPD PATHOLOGY  Structured  Enhance compliance  Focus  Coherent to patient and therapist  Encourage relationship

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. Patient’s Internal World 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. -S3 -O3 -S1 -O1 +S2 +O2 -a3 -a1 +a2 Etc.

35. Why focus on TRANSFERENCE?  Experience of Self  …and of therapist S1 S2 S3 O1 O2 S1 S2 S3 O3 a1 a2 a3

36. Victim Persecutor Victim (Oscillation is usually in behavior, not in consciousness) OBJECT RELATIONSHIP INTERACTIONS: OSCILLATION Fear, Suspicion, Hate Self-Rep Object Rep

37. Victim Cared-for Child Persecutor Perfect Provider Opposites OBJECT RELATIONSHIP INTERACTIONS: DEFENSE Fear, Suspicion, Hate Longing, Love

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