A psychometric and interview perspective on change in music therapy with Anna diagnosed with PTSD – a mixed method case study

Since the 2001 publication of APA’s Practice Guideline for the Treatment of Patients With Borderline Personality Disorder (1), more studies have been published on borderline personality disorder (BPD) than on any other personality disorder (2, 3). New analyses of the validity of the DSMIV-TR criteria–defined construct of BPD have been published, new data on the prevalence of BPD are available, risk factors for and biological characteristics of BPD are being elucidated, and new studies on the treatment of BPD have been carried out. This guideline watch highlights the most important of these developments.

Borderline Personality Disorder, PTSD, and Suicide

Understanding Emotion Regulation in Borderline Personality Disorder: Contributions of Neuroimaging

Music therapy for patients suffering from borderline personality disorder (BPD) has been a standard treatment option for many years in in-patient psychiatric work. The BPD symptoms, such as identity disturbance, emotional regulation and unstable relationships, lead to challenging and stormy therapy sessions for all therapists of all disciplines. In music therapy, difficulties in treatment include, for example, the patient’s refusal to play, extreme loud music or withdrawal from the process. This article presents the method and results of a systematic qualitative research of 20 BPD female patients undergoing individual psychoanalytical music therapy in an acute psychiatric context. The aim of the research was to identify typical interaction patterns, arising from the relationship between patient and therapist and also from the significance of music. The method “forming types by understanding” is based on the well-known sociological research method of “ideal types”. ed results are generated by contrasting cases, and the research process is validated through communicative validation. In total, it was possible to identify 10 typical interaction patterns within music therapy, reflecting typical BPD themes such as regulation of proximity and distance, splitting phenomena, trauma genesis, aggression and mentalization. The 10 typical interaction patterns of BPD patients have provided a way of accessing individual music therapy cases and making them much easier to understand. The interaction patterns help to maintain and reconstruct the therapist’s capacity to play, improvise and to mentalize.

BackgroundSymptoms of borderline personality disorder (BPD) and post-traumatic stress disorder (PTSD) commonly co-occur. Recent evidence supports the concomitant treatment of BPD and PTSD.MethodsThis study uses a longitudinal cross-lagged panel model to examine BPD and PTSD symptom response in a sample of 110 women undergoing residential treatment for BPD. The naturalistic treatment primarily followed a dialectical-behavior therapy protocol, with individualized integration of other major evidence-based treatments (EBTs) for BPD, including mentalization-based treatment, good psychiatric management, and transference-focused psychotherapy.ResultsA residentially-based integration of treatment approaches resulted in significant reductions in BPD (d = 0.71) and PTSD (d = 0.75) symptoms. Moreover, changes in BPD symptoms prospectively predicted changes in PTSD symptoms (constrained path b = 1.73), but the reverse was not true (constrained path b = 0.05).ConclusionsA naturalistic integration of EBTs for BPD may benefit both BPD and PTSD symptoms even in the absence of PTSD-oriented intervention. Additionally, the attenuation of BPD symptoms may have positive impact on PTSD symptoms.

IntroductionThe human reaction to traumatic events is often marked by a dialectic alteration of two emotional states –a state characterized by intrusion, anxiety and hyperarousal, and a state of denial marked by dissociation and numbing. These two seemingly opposite states represent attempts to modulate stress, as gradual reduction of their intensity represents an adaptation to stress. Maladaptive reactions to trauma, however, reflect disrupted regulation capacities, manifested as persistent over-modulation or under-modulation of stress.ObjectivesTo demonstrate that these manifestations of disrupted regulation, as observed among individuals with posttraumatic stress disorder (PTSD) and borderline personality disorder (BPD) are also reflected in patterns of pain modulation.MethodsThree studies using self-report questionnaires and psychophysical tests, assessing sensitivity to pain, as reflected by pain thresholds, and reactivity to suprathreshold noxious stimuli, as implicated in their ratingResultsStudy 1 Included 32 PTSD outpatients, 29 anxiety disorder outpatients, and 20 healthy controls. PTSD patients reported higher rates of chronic pain (83.3%) than anxiety patients (42.0%) and controls (5.0%). PTSD severity correlated with chronic pain severity (r = 0.61, p < 0.01). PTSD patients displayed a unique paradoxical pain profile, according to which their pain thresholds were significantly higher than those of the anxiety patients and controls (p < 0.01), but they perceived suprathreshold stimuli as being much more intense (p < 0.01).Study 2 included 32 PTSD outpatients and 43 healthy controls. Findings replicated the paradoxical pain profile among PTSD patients. Pain thresholds were positively associated with dissociation level (b = 0.49; p < 0.05) and negatively associated with anxiety level (b = -0.63, p < 0.01). Pain ratings were positively associated with anxiety (b = 0.52, p < 0.05) and negatively related to dissociation levels (b = -.51, p < 0.05).Study 3 included 46 women diagnosed with BPD and 47 healthy controls. Women with BPD reported higher levels of childhood trauma (p < 0.05) than the controls. They also demonstrated higher pain thresholds (p < 0.05). Among subjects with high levels of body dissociation, implicated by reduced body awareness, those with BPD demonstrated hyposensitivity to pain, manifested in higher pain thresholds, lower suprathreshold pain ratings, and pain evoked by higher temperature, than the controls. Among those with low levels of body dissociation, BPD subjects demonstrated increased reactivity to pain as manifested in higher pain ratings and pain evoked by lower temperature.ConclusionsThese findings demonstrate the association between over-modulation and under-modulation of stress and over-modulation and under-modulation of pain, respectively, among PTSD and BPD patients. These findings point to parallel processes of disrupted regulation among traumatized individuals.Disclosure of InterestNone Declared

An Opioid Deficit in Borderline Personality Disorder: Self-Cutting, Substance Abuse, and Social Dysfunction

PurposeSchema therapy was first applied to individuals with borderline personality disorder (BPD) over 20 years ago, and more recent work has suggested efficacy across a range of disorders. The present review aimed to systematically synthesize evidence for the efficacy and effectiveness of schema therapy in reducing early maladaptive schema (EMS) and improving symptoms as applied to a range of mental health disorders in adults including BPD, other personality disorders, eating disorders, anxiety disorders, and post‐traumatic stress disorder.MethodsStudies were identified through electronic searches (EMBASE, PsycINFO, MEDLINE from 1990 to January 2016).ResultsThe search produced 835 titles, of which 12 studies were found to meet inclusion criteria. A significant number of studies of schema therapy treatment were excluded as they failed to include a measure of schema change. The Clinical Trial Assessment Measure was used to rate the methodological quality of studies. Schema change and disorder‐specific symptom change was found in 11 of the 12 studies.ConclusionsSchema therapy has demonstrated initial significant results in terms of reducing EMS and improving symptoms for personality disorders, but formal mediation analytical studies are lacking and rigorous evidence for other mental health disorders is currently sparse.Practitioner pointsFirst review to investigate whether schema therapy leads to reduced maladaptive schemas and symptoms across mental health disorders.Limited evidence for schema change with schema therapy in borderline personality disorder (BPD), with only three studies conducting correlational analyses.Evidence for schema and symptom change in other mental health disorders is sparse, and so use of schema therapy for disorders other than BPD should be based on service user/patient preference and clinical expertise and/or that the theoretical underpinnings of schema therapy justify the use of it therapeutically.Further work is needed to develop the evidence base for schema therapy for other disorders.

This chapter contains sections titled: Introduction Borderline Personality Disorder Histrionic Personality Disorder Summary References This chapter also contains the following commentaries: From Shifting Diagnoses to Empirically-based Diagnostic Constructs Authored by W. John Livesley What is a Personality Disorder, a Set of Traits or Symptoms? Authored by Allan Tasman Mentalization and Borderline Personality Disorder Authored by Anthony W. Bateman Complex and Diverse, Yet Similar? Authored by Sigmund Karterud, Theresa Wilberg and Øyvind Urnes The Need for New Paradigms in the Research Approaches to Borderline Personality Disorder Authored by Larry J. Siever Borderline Personality Disorder: From Clinical Heterogeneity to Diagnostic Coherence Authored by Cesare Maffei Borderline Personality Disorder: Problems of Definition and Complex Aetiology Authored by Jiri Modestin Some Problems in the Current Conceptualization of Borderline and Histrionic Personality Disorders Authored by Enrique Baca Baldomero Borderline (and Histrionic) Personality Disorders: Boundaries, Epidemiology, Genetics and Treatment Authored by Svenn Torgersen Categorical Conundrums Authored by John F. Clarkin Are Cyclothymic Temperament and Borderline and Histrionic Personality Related Concepts? Authored by Giulio Perugi Borderline and Histrionic Personality Disorders: Implications for Health Services Authored by Brian Martindale Psychotherapy for Borderline Personality Disorder: Some Tentative Interpretations of the Available Empirical Findings Authored by Roel Verheul How to Cope with the Burden of Trying to Help a Borderline Patient? Authored by Vera Lemgruber Borderline Personality Disorder: A Complex Disorder, but not just Complex Post-traumatic Stress Disorder Authored by Christian Schmahl Borderline Personality Disorder between Axis I and Axis II Diagnosis Authored by Tarek A. Okasha Histrionic and Borderline Personality Disorders: A View from Latin America Authored by Néstor M. S. Koldobsky

Autistic traits (AT) seem to be particularly frequent among patients with borderline personality disorder (BPD). Moreover, the autism spectrum is considered a vulnerability factor for the development of post-traumatic stress disorder (PTSD) symptoms, increasing the vulnerability of BPD subjects toward the development of a stress-related disorder. The study aimed to investigate the association between AT and trauma-related symptoms in a clinical sample of patients with BPD. A total of 48 patients with a clinical diagnosis of BPD and 52 healthy control (HC) subjects were recruited and assessed with the Adult Autism Subthreshold Spectrum Self-Report (AdAS Spectrum) questionnaire and the Trauma and Loss Spectrum-Self-Report questionnaire (TALS-SR). The BPD group was divided into two subgroups: BPD with a symptomatological diagnosis of PTSD (pBPD = 25) and BPD not diagnosed with PTSD (No-pBPD = 23). The clinical sample scored significantly higher in almost all AdAS domains. Moreover, pBPD groups reported higher AdAS and TALS-SR scores in the total and in various domains than the No-pBPD group, which scored higher in several domains than HC. AdAS Restricted interests and rumination domain scores were positive predictors of BPD presence independently from PTSD, while Inflexibility and adherence to routine domain was a negative predictor. Finally, AdAS Hyper/hyporeactivity to sensory stimuli domain was a positive predictor only for inclusion in the pBPD group. Our study confirmed the existence of a statistically significant relationship between the autism spectrum and BPD, while BPD subjects diagnosed with PTSD seem to show a higher autism spectrum burden.

Persistent somatic symptom severity in patients with borderline personality disorder: Trauma-related symptoms as mechanism for improvement during inpatient dialectical behavior therapy.

The authors examined whether patients with comorbid borderline personality disorder and posttraumatic stress disorder (PTSD) have a more severe clinical profile than patients with either disorder without the other. Outpatients with borderline personality disorder without PTSD (N=101), PTSD without borderline personality disorder (N=121), comorbid borderline personality disorder and PTSD (N=48), and major depression without PTSD or borderline personality disorder (N=469) were assessed with structured interviews for psychiatric disorders and for degree of impairment. Outpatients with diagnoses of comorbid borderline personality disorder and PTSD were not significantly different from outpatients with borderline personality disorder without PTSD, PTSD without borderline personality disorder, or major depression without PTSD or borderline personality disorder in severity of PTSD-related symptoms, borderline-related traits, or impairment. The additional diagnosis of PTSD or borderline personality disorder does little to augment the pathology or dysfunction of patients who have either disorder without the other.

The Complexity of Complex PTSD

BackgroundMeta-analyses of studies on psychological treatment of refugees describe highly varying outcomes, and research on multi-facetted and personalized treatment of refugees with post-traumatic stress disorder (PTSD) is needed. Music therapy has been found to affect arousal regulation and emotional processing, and a pilot study on the music therapy method Trauma-focused Music and Imagery (TMI) with traumatized refugees resulted in significant changes of trauma symptoms, well-being and sleep quality. The aim of the trial is to test the efficacy of TMI compared to verbal psychotherapy.MethodsA randomized controlled study with a non-inferiority design is carried out in three locations of a regional outpatient psychiatric clinic for refugees. Seventy Arabic-, English- or Danish-speaking adult refugees (aged 18–67 years) diagnosed with PTSD are randomized to 16 sessions of either music therapy or verbal therapy (standard treatment). All participants are offered medical treatment, psychoeducation by nurses, physiotherapy or body therapy and social counseling as needed. Outcome measures are performed at baseline, post therapy and at 6 months’ follow-up. A blind assessor measures outcomes post treatment and at follow-up. Questionnaires measuring trauma symptoms (HTQ), quality of life (WHO-5), dissociative symptoms (SDQ-20, DSS-20) and adult attachment (RAAS) are applied, as well as physiological measures (salivary oxytocin, beta-endorphin and substance P) and participant evaluation of each session.DiscussionThe effect of music therapy can be explained by theories on affect regulation and social engagement, and the impact of music on brain regions affected by PTSD. The study will shed light on the role of therapy for the attainment of a safe attachment style, which recently has been shown to be impaired in traumatized refugees. The inclusion of music and imagery in the treatment of traumatized refugees hopefully will inform the choice of treatment method and expand the possibilities for improving refugee health and integration.Trial registrationClinicalTrials.gov ID number NCT03574228, registered retrospectively on 28 June 2016.

Dissociative symptoms and suicidality are transdiagnostic features of posttraumatic stress disorder (PTSD) and borderline personality disorder (BPD). The primary objective of this study was to examine associations between dissociation (i.e., depersonalization and derealization) and suicidality (i.e., self-harm and suicide attempts) among individuals with PTSD and BPD. We analyzed data from the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC-III; N = 36,309). The Alcohol Use Disorder and Associated Disabilities Interview Schedule for DSM-5 was used to assess lifetime PTSD and BPD. Estimated rates of self-harm among individuals who endorsed dissociation were 15.5%-26.2% for those with PTSD and 13.7%-23.5% for those with BPD, and estimates of suicide attempts among individuals who endorsed dissociation were 34.5%-38.1% for those with PTSD and 28.3%-33.1% for those with BPD. Multiple logistic regressions were conducted to examine the associations between dissociation (derealization, depersonalization, and both) and both self-harm and suicide attempts among respondents with PTSD and BPD. The results indicated that dissociation was associated with self-harm and suicide attempts, especially among individuals with BPD, aORs = 1.39-2.66; however, this association may be driven in part by a third variable, such as other symptoms of PTSD or BPD (e.g., mood disturbance, PTSD or BPD symptom severity). These results may inform risk assessments and targeted interventions for vulnerable individuals with PTSD, BPD, or both aimed at mitigating the risk of self-harm and suicide.