Practitioner review: Borderline personality disorder in adolescence: Recent conceptualization, intervention, and implications for clinical practice

The past decade has seen an unprecedented increase in research activity on personality disorders in adolescents. The increase in research activity, in addition to major nosological systems legitimizing the diagnosis of borderline personality disorder (BPD) in adolescents, highlights the need to communicate new research on adolescent personality problems to practitioners. In this review, we provide up-to-date information on the phenomenology, prevalence, associated clinical problems, etiology, and intervention for BPD in adolescents. Our aim is to provide a clinically useful practitioner review and to dispel long-held myths about the validity, diagnostic utility, and treatability of personality disorders in adolescents

There is room for even more doublethink: the perilous status of psychoanalytic research

The opposition between psychoanalysis and systematic interdisciplinary research is to be regretted. The target article attempts to bridge the intellectual divide and for this aim as well as the intellectual adroitness shown it is to be celebrated. Much harder to understand is the high level of affect generated by the debate. Accusations of “doublethink” are helpful. The present paper, like the target paper it follows, attempts to develop an understanding of the position of those who are categorically opposed to interdisciplinary systematic research linked to psychoanalysis. Appreciating the perspective of those deeply opposed to such work could help to create a shared agenda from which our troubled discipline could benefit. This is predicated on the possibility of an open collegial dialogue which this journal was founded to create

Clinical Associations of Deliberate Self-Injury and Its Impact on the Outcome of Community-Based and Long-Term Inpatient Treatment for Personality Disorder

Background: Deliberate self-injury (DSI) is significantly associated with personality disorder (PD). There are gaps in our knowledge of DSI as an indicator of severity of psychopathology, as moderator of outcome and with regard to its response to different treatment programs and settings. Methods: We compare 2 samples of PD with (n = 59) and without (n = 64) DSI in terms of clinical presentation, response to psychosocial treatment and relative outcome when treated with specialist long-term residential and community-based programs. We test the assumption that DSI is an appropriate indicator for long-term inpatient care by contrasting the outcomes (symptom severity and DSI recidivism) of the 2 DSI sub-groups treated in the 2 different approaches. Results: PD with DSI had greater severity of presentation on a number of variables (early maternal separation, sexual abuse, axis-I comorbidities, suicidality and inpatient episodes) than PD without DSI. With regard to treatment response, we found a significant 3-way interaction between DSI, treatment model and outcome at 24-month follow-up. PD with DSI treated in a community-based program have significantly greater chances of improving on symptom severity and recidivism of self-injurious behaviour compared to PD with DSI treated in a long-term residential program. Conclusions: Although limitations in the study design invite caution in interpreting the results, the poor outcome of the inpatient DSI group suggests that explicit protocols for the management of DSI in inpatient settings may be beneficial and that the clinical indications for long-term inpatient treatment for severe and non-severe PD may require updating. Copyright (C) 2010 S. Karger AG, Base

Another step closer to measuring the ghosts in the nursery: preliminary validation of the Trauma Reflective Functioning Scale

The aim of this study was to examine preliminary evidence of the validity of the Trauma Reflective Functioning Scale and to investigate reflective functioning (RF) and attachment in pregnant women with histories of trauma, with a particular focus on the capacity to mentalize regarding trauma and its implications for adaptation to pregnancy and couple functioning. The Adult Attachment Interview was used to assess attachment, unresolved trauma and mentalization (measured as RF) regarding relationships with attachment figures (RF-G) and trauma (RF-T) in 100 pregnant women with histories of abuse and neglect. The majority (63%) of women had insecure attachment states of mind and approximately half were unresolved regarding trauma. Furthermore, the majority of women manifested deficits specific to RF-T. Their RF-T was significantly lower than their RF-G; the findings indicate that women with histories of childhood abuse and neglect do not manifest a generic inhibition of reflectiveness, but a collapse of mentalization specific to trauma. Low RF-T, indicative of difficulty in considering traumatic experiences in mental state terms, was associated with difficulty in investment in the pregnancy and lack of positive feelings about the baby and motherhood. In addition, low RF-T was also associated with difficulties in intimate relationships. Results of a regression analysis with RF indicated that RF-T was the best predictor of investment in pregnancy and couple functioning. In sum, the study provides preliminary evidence that RF-T can be reliably measured and is a valid construct that has potential usefulness for research and clinical practice. It highlights the importance of mentalization specifically about trauma and suggests that it is not the experience of trauma per se, but the absence of mentalization regarding trauma that is associated with difficulties in close relationships and in making the transition to parenthood

The risk-taking and self-harm inventory for adolescents: Development and psychometric evaluation

In this study, we report on the development and psychometric evaluation of the Risk-Taking (RT) and Self-Harm (SH) Inventory for Adolescents (RTSHIA), a self-report measure designed to assess adolescent RT and SH in community and clinical settings. 651 young people from secondary schools in England ranging in age from 11.6 years to 18.7 years and 71 young people referred to mental health services for SH behavior in London between the ages of 11.9 years and 17.5 years completed the RTSHIA along with standardized measures of adolescent psychopathology. Two factors emerged from the principal axis factoring, and RT and SH were further validated by a confirmatory factor analysis as related, but different, constructs, rather than elements of a single continuum. Inter-item and test–retest reliabilities were high for both components (Cronbach's α = .85, rtt = .90; Cronbach's α .93, rtt = .87), and considerable evidence emerged in support of the measure's convergent, concurrent, and divergent validity. The findings are discussed with regard to potential usefulness of the RTSHIA for research and clinical purposes with adolescents

A developmental, mentalization-based approach to the understanding and treatment of borderline personality disorder

The precise nature and etiopathogenesis of borderline personality disorder (BPD) Continues to elude researchers and clinicians. Yet, increasing evidence from various strands of research converges to suggest that affect dysregulation, impulsivity, and unstable relationships constitute the core feature,,, of BPD. Over the last two decades, the mentalization-based approach to BPD has attempted to provide a theoretically consistent way of conceptualizing the interrelationship between these core features of BPD. with the aim of providing clinicians with a conceptually sound and empirically supported approach to BPD and its treatment. This paper presents an extended version of this approach to BPD based oil recently accumulated data. In Particular, We Suggest that the core features of BPD reflect impairments in different facets of mentalization, each related to impairments in relatively distinct neural circuits underlying these facets. Hence, we provide a comprehensive account of BPD by showing how its core features are related to each other in theoretically meaningful ways. More specifically, we argue that BPD is primarily associated with a low threshold for the activation of the attachment system and deactivation of controlled mentalization. linked to impairments in the ability to differentiate mental states of self and other, which lead to hypersensitivity and increased susceptibility to contagion by other people's mental states, and poor integration of cognitive and affective aspects of mentalization. The combination of these impairments may explain BPD patients' propensity for vicious interpersonal cycles, and their high levels of affect dysregulation and impulsivity. Finally, the implications of this expanded mentalization-based approach to BPD for mentalization-based treatment and treatment of BPD more generally are discussed

Measuring mental health and wellbeing outcomes for children and adolescents to inform practice and policy:a review of child self-report measures

There is a growing appetite for mental health and wellbeing outcome measures that can inform clinical practice at individual and service levels, including use for local and national benchmarking. Despite a varied literature on child mental health and wellbeing outcome measures that focus on psychometric properties alone, no reviews exist that appraise the availability of psychometric evidence and suitability for use in routine practice in child and adolescent mental health services (CAMHS) including key implementation issues. This paper aimed to present the findings of the first review that evaluates existing broadband measures of mental health and wellbeing outcomes in terms of these criteria. The following steps were implemented in order to select measures suitable for use in routine practice: literature database searches, consultation with stakeholders, application of inclusion and exclusion criteria, secondary searches and filtering. Subsequently, detailed reviews of the retained measures’ psychometric properties and implementation features were carried out. 11 measures were identified as having potential for use in routine practice and meeting most of the key criteria: 1) Achenbach System of Empirically Based Assessment, 2) Beck Youth Inventories, 3) Behavior Assessment System for Children, 4) Behavioral and Emotional Rating Scale, 5) Child Health Questionnaire, 6) Child Symptom Inventories, 7) Health of the National Outcome Scale for Children and Adolescents, 8) Kidscreen, 9) Pediatric Symptom Checklist, 10) Strengths and Difficulties Questionnaire, 11) Youth Outcome Questionnaire. However, all existing measures identified had limitations as well as strengths. Furthermore, none had sufficient psychometric evidence available to demonstrate that they could reliably measure both severity and change over time in key groups. The review suggests a way of rigorously evaluating the growing number of broadband self-report mental health outcome measures against standards of feasibility and psychometric credibility in relation to use for practice and policy

Attachment, mentalization, and the self

Mentalizing is often simplistically understood as synonymous with the capacity of empathy toward other people. In fact, mentalizing comprises a spectrum of capacities that critically involve the ability to see one’s own behavior as coherently organized by mental states, and to differentiate oneself psychologically from others. It is these capacities that tend to be noticeably absent in individuals with a personality disorder (PD), particularly at moments of interpersonal stress. In this chapter, we will attempt to demonstrate that such impairments in mentalizing are at the heart of our explanatory framework for conceptualizing PDs. The foundations of our thinking lie in attachment theory, but, according to our most recent formulation, the heart of the relationship between mentalizing and personality pathology lies in the capacity of engaging productively in communication, and more specifically, in the quality of epistemic trust the individual possesses in relationships and, formatively, in the relationship between the child and his/her primary caregivers. Epistemic trust is defined in terms of an individual’s experience of communication from others, specifically, the ability to receive and treat new knowledge from others as personally relevant and therefore capable of modifying durable representational structures pertaining to self, others, and interpersonal relationships. Underpinning this capability is the consideration of the informant as a “trustworthy” source likely to communicate information that is generalizable and relevant to the self

Mentalization-Based Treatment

The concept of mentalizing has captured the interest and imagination of an astonishing range of people—from psychoanalysts to neuroscientists, from child development researchers to geneticists, from existential philosophers to phenomenologists—all of whom seem to have found it useful. According to the Thompson Reuter maintained Web of Science, the use of the term in titles and abstracts of scientific papers increased from 10 to 2,750 between 1991 and 2011. Clinicians in particular have enthusiastically embraced the idea, and have put it to innovative use in their practices. Mentalization-based treatment (MBT)—making mentalizing a core focus of therapy—was initially developed for the treatment of borderline personality disorder (BPD) in routine clinical services delivered in group and individual modalities. Therapy with mentalizing as a central component is currently being developed for treatment of numerous groups, including people with antisocial personality disorder, substance abuse, eating disorders, and at-risk mothers with infants and children (A. Bateman & Fonagy, 2011). It is also being used with families and adolescents, in schools, and in managing social groups (Asen & Fonagy, 2011; Fonagy et al., 2009; Twemlow, Fonagy, & Sacco, 2005a, 2005b). In this article, we focus on MBT in the treatment of BPD