Working with personality disorders and severe personality disorders at Trauma Recovery Institute using a unique combination of transference focused psychotherapy and our dynamic psychosocialsomatic psychotherapy

//Working with personality disorders and severe personality disorders at Trauma Recovery Institute using a unique combination of transference focused psychotherapy and our dynamic psychosocialsomatic psychotherapy

Working with personality disorders and severe personality disorders at Trauma Recovery Institute using a unique combination of transference focused psychotherapy and our dynamic psychosocialsomatic psychotherapy

Personality disorder, as a term, may sound negative and judgmental and it is important to have a clear understanding with our patients of the meaning of the term. We explain that there is a group of disorders in the DSM-V, six of them to be specific, that are thought to be long-term and enduring, in contrast to episodic, personality styles that at their core are defined by difficulties in the person’s subjective, internal sense of identity, and chronic difficulties in his or her interpersonal relationships. It is noteworthy that the DSM-V description of personality disorders includes this emphasis on sense of self and relations with others more than the previous editions of the DSM did. These different styles have many overlapping features and most people have a mixture of those styles, but most importantly, that when people personify and live out any of those styles with a certain consistency, inflexibility, and in such a way that causes a certain level of distress in one’s emotional and interpersonal life, they meet criteria for a personality disorder.

Personality, the concept of personality refers to the dynamic integration of a person's subjective experience and behaviour including 1) conscious concrete and habitual behaviour, 2) conscious experiences of self and the surrounding world, 3) conscious explicit psychic thinking, cognitive processes and habitual desires and fears, 4) unconscious behavioural patterns , experiences, views and intentional states. Personality is a dynamic integration in so far as it implies an organised integrated association of multiple traits and experiences that influence each other. In this regard personality represents a much more complex and sophisticated entity than simply the sum of all its component features. In view of that, any current system of understanding and clinically addressing a personality disorder will necessarily be a simplification. Further progress in effectively treating personality disorders requires attention to both the intrapsychic and neurobiological aspects of the condition. Otto Kernberg

Narcissistic Personality Disorder (NPD)

Otto Kernberg’s description of the pathological narcissistic individual centers around a set of paradoxes: self-inflation existing alongside a limitless need for praise, a charming and engaging surface covering a ruthless interior, and a persona of self-sufficiency defending against underlying feelings of intense envy . For Kernberg, the diagnosis of the narcissistic character also depends on the quality of the person’s object relations and the pattern of his or her intrapsychic defenses. Narcissistic individuals experience their relationships with others as exploitative and parasitic. They divide the world between those who contain something that they can extract and those who do not. They distinguish between extraordinary people on the one hand - in association with whom narcissistic individuals experience a sense of greatness themselves - and mediocre or worthless people on the other. Narcissistic individuals idealize the former and are contemptuous of the latter. Yet those they idealize they also fear, as they project onto them their own exploitative wishes and experience them as potentially attacking and coercive. They thus are unable to rely on any object and fear dependence on another person, rendering all their object relations empty and dissatisfying.

Like the borderline character, Kernberg’s narcissistic individual uses primitive defenses of devaluation, projective identification, omnipotence, and primitive idealization in his or her efforts to preserve self-esteem and self-coherence and to combat the intense feelings of envy and rage that threaten to undermine them. The narcissistic individual is distinguished from the borderline individual by his or her sense of object constancy, better impulse control, and better social and professional functioning, although these too may be fragile and hollow beneath a surface of apparent solidity. Although splitting as a defense is found in narcissistic pathology, its use is less prominent than in borderline pathology.

The grandiose self further differentiates the pathological narcissist from the borderline personality. In Kernberg’s theory, the grandiose self represents a pathological fusion of the ideal self, the ideal object, and the real self. It is a defensive structure designed to maintain self-admiration and avoid dependence on any real object by effectively eliminating a need for it from intrapsychic life. Although often toxic in its effects on interpersonal relationships, the grandiose self serves to maintain the narcissist’s otherwise tenuously coherent sense of self.

Criteria for NPD

1) Grandiose sense of self importance
2) Fantasies of success and power
3) Believes self to be special and unique
4) Requires excessive admiration, adoration (Tribute)
5) Sense of Entitlement
6) Interpersonally exploitative
7) Lacks empathy
8) Envious of others at the cost of intimacy with anybody
9) Shows arrogant, haughty behaviors/attitudes



Transference Focused Psychotherapy for Narcissistic Patients

Clinical experience involving the treatment of patients with severe narcissistic pathology suggests that this patient population is among the more treatment refractory within the personality disorder spectrum. Recent studies have suggested that patients with Narcissistic Personality Disorder (NPD) now encompass about 6.2% in community samples (Dhawan et al. 2010) and up to 35.7% of clinical populations (Zimmerman et al. 2005). There are also some indications that NPD is more prevalent among young adults in the U.S. (Stinson et al. 2008), and that narcissistic personality traits in the nonclinical young adult population are on the rise (Twenge & Campbell 2009). In addition numerous studies have shown a high degree of co-occurrence of NPD with other Axis II disorders, especially cluster B (borderline, anti-social, histrionic personality disorders), and Axis I disorders, particularly affective disorders (unipolar and bipolar depression), substance use disorders, anxiety disorders, and eating disorders (Fossati et al. 2000, Simonson & Simonson 2012, Zimmerman et al. 2005). Complicating the diagnostic picture is the fact that pathological narcissism spans a spectrum of pathology from neurotic to borderline levels of organization. Indeed, there has been increasing attention to conceptualizing narcissistic disorders as dimensional disorders with varying degrees of pathology of self and object relations, reflected in the current drafts of the DSM-5 (; Bender et al. 2011). The high level of comorbidity along with increasing attention to the dimensional as well as categorical aspects of personality disorders suggest that narcissistic pathology may be a major factor across the personality disorder spectrum (Ronningstam, 2010, 2011).

The current DSM V proposal puts new emphasis on structures and mechanisms related to impairments of self and interpersonal relations in all personality disorders including NPD. Narcissistic disorders are thought to involve 1) Impairments in identity, characterized by a specific pattern or style of unrealistic self experiences, including particularly exaggerated self appraisals; grandiosity expressed either covertly or overtly (exaggerated sense of superiority or inferiority or shifts between the two); and, in some patients, an overreliance on others for shaping the patient’s sense of identity and self definition; 2) Impairments in interpersonal functioning, particularly the use of others for self esteem regulation; superficial, shallow relationships, lacking in empathy, and designed to fulfill the patient’s need for admiration, attention, and validation; and antagonism as opposed to agreeableness in relationships (shown to be associated with narcissistic personality disorder in DSM-5 field trials). Such difficulties in the regulation of aggression along with other impairments in self and interpersonal functioning for individuals with NPD stem from a particular configuration of self and object representations, the pathological grandiose self, which involves a condensation of ideal self, ideal other, and real self representations. Such a self structure excludes the possibility of engaging in relations in depth – there is a “dismantling” of relations with others because of chronic devaluing of others. Negative affects, particularly devalued aspects of self are split off, denied and projected onto others leading to antagonism towards others and an inner sense of emptiness.

As Kernberg (1975) stated, “Pathological vicissitudes of aggression may determine the failure of such … an integration of object representations, with the subsequent development of pathological object relations and a pathological, grandiose self.” (p. 246) Transference Focused Psychotheapy (TFP) is a psychodynamic approach to psychotherapy developed to treat patients with a range of personality disorders at different levels of severity, including individuals with NPD. Borderline and narcissistic personalities share core structural features, specifically, identity pathology, supported by the operation of “primitive” defensive strategies for the unconscious management of intolerable self-states and affects. The central focus of TFP is the identification and naming of maladaptive, distorted self representations, along with their complementary distorted object representations, in the service of interpreting and ultimately resolving the splitting and other primitive defensive operations which prevent a more realistic, integrated, differentiated assessment of self and others. Through the tracking of these self-object dyads in the patient’s internal world, and identifying the defensive processes which support them, through working with negative affects (antagonism) and the object relational dyads that fuel them, TFP constitutes an effective treatment for a spectrum of narcissistic disorders from low to high functioning, i.e., grandiose, vulnerable, malignant. In addition, since TFP emphasizes the identification with both self and object poles of the object relational dyads that comprise the internal world (e.g. grandiose self, devalued other; vulnerable self, idealized other), it is also effective in addressing the different phenotypic presentations, forms of expression, and/or fluctuating mental states from grandiose to vulnerable, from arrogant/entitled to depressed/depleted that may characterize narcissistic personality disturbances (Cain et al. 2011, PDM Task Force 2006).

Based on our clinical experience with and research data on patients with narcissistic personality disorders, we have developed modifications of Transference-Focused Psychotherapy (TFP) to treat patients with different levels of severity of narcissistic pathology (Diamond et al, 2011; Diamond et al. in press). These modifications focus around the centrality of the grandiose self, its central defensive role in psychological structure of the patient with NPD, and how best to address this rigid defensive system. Modifications to standard TFP technique at all stages of TFP include the following: 1) Modifications to the assessment and treatment contracting phase of TFP including a more prolonged and flexible phase of contract setting; 2) A more prolonged phase of inquiry-based interpretive efforts, i.e., those aspects of the interpretive process that focus on requesting clarification from the patient about his or her mental life rather than the more traditional delivery of interpretations by the therapist; and 3) the enumeration of several technical strategies that support the patient’s ability to tolerate the necessarily painful and threatening feelings (e.g., anxiety, rage, a sense of disorientation and/or annihilation) that accompany the more challenging aspects of interpretive work in a psychoanalytic psychotherapy with narcissistic patients. Our clinical formulations have been informed by our research on patients with co-morbid borderline and narcissistic disorders (NPD/BPD) from three international samples of BPD patients in Transference-Focused Psychotherapy. In brief our findings suggest that the NPD/BPD patients may be distinguished from BPD patients without NPD on a variety of clinical dimensions including: 1) a particular pattern of co-morbidity with other AXIS II disorders (histrionic, anti-social, schizoptypal and paranoid) and 2) distinctive internal working models of attachment (Diamond et al. in press). In brief, individuals with NPD/BPD are characterized by attachment representions including dismissing devaluation of attachment relationships, preoccupation with unresolved anger about early attachment experiences, often oscillating between these two contradictory states of mind with respect to attachment—which helps us to understand the fluctuations in narcissistic resistances and transferences that make these patients so challenging to treat. Our research and clinical findings have been presented in a number of publications and presentations that are available on our website. In addition, our faculty have been involved in training and teaching TFP for NPD internationally.



Further Reading on Narcissistic Pathology :

Narcissistic Pathology 


About Borderline Personality Disorder

Personality disorder, as a term, may sound negative and judgmental and it is important to have a clear understanding with our patients of the meaning of the term. We explain that there is a group of disorders in the DSM-IV, ten of them to be specific (a number that will be reduced to six in the DSM-V), that are thought to be long-term and enduring, in contrast to episodic, personality styles that at their core are defined by difficulties in the person’s subjective, internal sense of identity, and chronic difficulties in his or her interpersonal relationships. It is noteworthy that the DSM-V description of personality disorders includes this emphasis on sense of self and relations with others more than the previous editions of the DSM did.
We explain that the ten different styles have many overlapping features and that most people have a mixture of those styles, but most importantly, that when people personify and live out any of those styles with a certain consistency, inflexibility, and in such a way that causes a certain level of distress in one’s emotional and interpersonal life, they meet criteria for a personality disorder. For patients with BPD, in reviewing the DSM-IV symptoms that the particular patient in question meets, we note that there are different sub-types of BPD patients, each with different sets of primary or most-problematic features. Some may be more impulsive and overtly inappropriately angry, whereas others may be more “under the radar,” characterized more prominently by the sense of emptiness, fears of abandonment, suicidal feelings, and more subtle shifts in their experience of others, from idealizing others to more quietly feeling devaluing or contemptuous of them. So with each patient we explain our understanding of his or her BPD symptoms. We also find it helpful to give an overview of BPD as a disorder comprising difficulties in four areas: 1) emotions tend to be intense and rapidly shifting; 2) relationships tend to be conflicted and stormy; 3) there may be impulsive, self-destructive or self-defeating behaviors; and 4) there is a lack of a clear and coherent sense of identity (this last problem may underlie all the preceding ones).

Our view is that the problems in the patient’s identity, that interact with a propensity to intense emotional responses and lead to the associated difficulties in the patient’s interpersonal life and the other symptoms of BPD, are best explained by a “divided” or “split” sense of self and others. We refer to this as the “split psychological structure” in which different, contradictory ways of thinking about the self and others manifest themselves at different times, or in different ways, but rarely if ever, at the same time. For example, a patient may present as morally rigid, highly concerned about proper and respectful behavior, but at other times engage in questionable moral practices and behave in provocative and inappropriate ways. Or a patient may present as very quiet and meek, describing a history of poor treatment by others but may, at times, demonstrate hostile and contemptuous behavior toward others. Yet another patient may present as self-sufficient, arrogant, a “know-it-all”, rejecting all that the therapist has to offer, whereas the therapist knows from the history and referral source that the patient has recently suffered fleeting depressive and suicidal feelings pursuant to one in a string of occupational failures. None of these “self representations” are specifically listed as BPD criteria in the DSM. Nevertheless, they each can be viewed as part of a dyad – a specific internal mental representation of self in relation to another. A borderline patient’s particular set of mental dyads involves contradictory representations of self, each of which experienced as true and authentic parts at the time it is being experienced. This alternation across time between different experiences of self can lead to confusion, anxiety, depression, and a sense of emptiness that comes from not having a stable sense of the core self.

How does this “split” sense of identity emerge, and why? We understand personality a person’s habitual way of experiencing self and others and of interacting with the world around him. We see these habitual patterns of experiencing the self and others as built up from people’s prior experiences, particularly those emotionally-charged interactions between the infant/child and significant caregivers, which are repeated over time. These experiences of self-in-relation-to-others from early in life are part of the normal developmental process and result in a set of expectancies as to how the self will be treated or experienced by another, and vice-versa, in subsequent relationships. In early infant development, specific experiences lead to dyads that are associated with specific emotions – pleasure/satisfaction and pain/frustration. In early life, these dyads are not accurate or literal representations of what is actually happenig; rather, they tend to represent polarized, extreme images and affects which are affected by the individual’s particular temperament – intense or quiescent, which links this way of thinking about BPD to current neurobiological studies.

In the case of healthy psychological development, these early, extreme and disconnected representations gradually become integrated into more complex, subtle and realistic internal images of self and others. We come to realize that we, and others, have both good qualities and bad, that we can experience disappointments in ourselves or others while still appreciating the good qualities. We learn that experiencing negative emotions does not destroy the capacity for positive emotions and that our emotional state can be complex, with a variety of emotions of multiple valence (rather than only all positive or all negative) in relation to others. In the case of healthy identity, various representations or ways of experiencing the self can co-exist without a sense of tension, dissonance, or threat. One can see oneself in any given interaction as smart, yet with something still to learn; one can see oneself as driven, a bit aggressive, yet at the same time patient and forgiving; one can see oneself as one who is dependent upon others, but is capable of operating in various spheres, effectively, on one’s own.
Indeed, healthy identity is defined as integrated and coherent, stable across time, and as based on a realistic self assessment in which positive affects predominate over negative affects, and with resulting ego strength that is sufficient to navigate life’s challenges and disappointments. In the case of the personality disorders, and BPD in particular, however, there is a failure of integration of these self representations. Internalized dyads associated with sharply different affects (positive and negative) remain split off and continue to exist independently from one another so that the world is experienced in highly concrete/all-or-nothing terms, and with confusion and lack of continuity. Consequently, in response to triggers (life events), an individual experiences himself, and others, in terms of extreme and simplistic representations that are not coherently connected with the representations of self and other that might be triggered by a minor event (e.g., the individual may feel very happy and valued when a friend smiles at him, and may feel sad and worthless if the friend is late for meeting; the corresponding images of the friend would be a loving person in the first instance and a rejecting person in the second.)

Let us now extend this idea of the split sense of self, this sense of a dyad that is split, with part of the self being experienced at one time and another part at a second point in time, to the realm of interpersonal relationships. For the BPD patient, at each point in time he is experiencing only one self-representation, connected to one dyad; for example, the rigidly moralistic self at one moment, or the victimized self at another moment, or the nurtured self at a third moment. We find that each of these partial self-representations corresponds, at that moment, to a view of the other, who is experienced in the moment as the embodiment of the other side of the dyad. When a BPD patient is experiencing himself as moralistic, he tends to experience others as loose, slackers, unrighteous. Similarly, the patient experiencing herself as a meek, innocent victim tends to experience others as hostile, hurtful, and persecutory. The BPD individual who is experiences herself as nurtured and cared tends to experience the other as the perfect provider and caretaker. As life develops the situation is complicated by the fact that the patient may have populated his or her life with characters who actually, or at times, embody some of those tendencies. It is therefore very important, in the course of therapy, to sort out the degree to which the patient’s description of others is colored by the representations in his or her mind in contrast to the degree to which the patient is accurately describing others. This is one reason we find it very useful in therapy to focus on the transference – the patient’s perception of the relation with the therapist – so that we can compare the patient’s experience of what is happening with what appears to be happening on an objective level. As we get to know patients, what we tend to find is that patients need to experience others, including often their therapist, as embodying the opposite of side of the dyad. In sum, the patient’s experience of others is as divided, split, and unrealistic as is his or her sense of self.

The other BPD criteria tend to follow from this description of splits in the representation of self and other. When a person lives life with a need to avoid certain experiences of the self, positive or negative – loving or hating, because that self representation is too threatening (or perhaps too exciting), it results in a feeling of instability, of incompleteness, as the experience of the self shifts across situations and different interpersonal situations. Indeed, patients with BPD describe a subjective sense of instability, emptiness, and inner confusion. Other people then, come to play an important, albeit unrealistic role in the BPD patient’s life. They are not simply friends with whom to experience and share life, but crucial assistants in the patient’s self regulation (although usually unaware that they have been placed in this role). For example, if a patient needs to experience himself as smart or popular, and chooses associates that help mirror that feeling, then he needs to carefully control interactions: he can’t have others look smarter or more attractive than he is, because then his sense of inadequacy would come into awareness. Similarly, a patient can’t have the other leave him because then he’s on his own, to face his worst sense of self. In another example, if a patient can’t tolerate her own tendencies to be judgmental, contemptuous, and hostile, it stands to reason that she will often see in others those same tendencies, and will experience others as judging her, as being unreasonably cruel or angry with her, and at times may accuse them as such.

Although these processes do not operate consciously in the individuals with personality disorders, one can easily imagine the strains that this way of experiencing the self and the world places on one’s interpersonal relationships, and one can also see how some of the other BPD criteria would logically follow, namely the intense and unstable interpersonal relationships, the propensity towards intense, inappropriate anger, the fears of abandonment, and, one can imagine, the impulsivity, the transient suicidal feelings and parasuicidal behaviors that result when others fail to assume the roles the borderline patient has unconsciously assigned them, or when others actually reject or leave the patient, with a mix of confused, exasperated, angry, and/or frustrated feelings.

Borderline Personality Disorder (BPD) is a serious and prevalent psychiatric condition characterised by affective instability, marked impulsivity, and significant deficits in the capacity to work and maintain meaningful relationships. Patients with BPD struggle with a profound fear of abandonment, identity disturbances, and paranoid ideations. They are at risk for suicide, repetitive self-destructive behaviours, and comorbid mood, anxiety, and substance use disorders. Stern (1938) coined the term "borderline personality" to describe low-functioning, difficult-to-treat psychiatric patients whose symptoms lay between neurosis and psychosis. Thus, 'borderline' constituted a "broad category of patients whose psychology did not portray the chaos, disorganization, or defect in reality testing associated with psychotic patients, but also lacked the integration, stability of relationships, and regulation of affect associated with neurotic patients" (Kernberg and Michels 2009). Borderline personality disorder remains one of the most severe mental health problems in all of psychiatry.

Our understanding of borderline personality disorder began to take shape with the seminal work of Otto Kernberg (1967), who offered a perspective of 'borderline' as a syndrome and not as a default categorization of individuals that did not meet the neurotic or psychotic diagnosis. Following this breakthrough, Grinker and colleagues published the first empirical study of the Borderline Syndrome (Grinker et al. 1968). Subsequently, Gunderson and Singer (1975) provided the first clinical conceptualization of the disorder and attempted to define diagnostic criteria for BPD. By 1980, the construct of BPD was considered developed and validated to the extent that the disorder was included in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III; American Psychiatric Association 1980). Since then, the disorder has captured the attention of scores of researchers and clinicians and has become the most studied personality disorder.

Clinical Presentation and Diagnosis

BPD is a complex clinical syndrome that has three core features: emotional instability, impulsive behaviours, and interpersonal turmoil. These basic features, as well as cognitive symptoms, are captured by the DSM-IV-TR diagnostic criteria for BPD (American Psychiatric Association 2000). The DSM-IV-TR considers 9 diagnostic criteria in total, but only 5 are required to make a diagnosis of BPD. Below, we briefly describe each of the 9 criteria.

1) Avoidance of Abandonment

People with BPD have a strong fear of abandonment, and are thus very sensitive to any cue (real or perceived) that they are being rejected or abandoned. This can include strong reactions to seemingly minor rejections by others (e.g., becoming enraged when someone cancels plans). People with BPD will often engage in behaviours designed to reduce concerns that they are being abandoned (e.g., frequently calling someone they are in a relationship with to "make sure" that there are no signs of impending abandonment). Unfortunately, this type of behaviour may actually create the feared outcome, leading to failed relationships and even greater fears of being abandoned.

2) Unstable and Intense Interpersonal Relationships

Individuals with BPD attach rapidly and profoundly to others, even early on in relationships. Their perception of intimacy is greater than that of the other persons, and in many cases, it is inappropriate. Moreover, their perception of others often alternates between over-idealization and devaluation, which is also known as splitting. Splitting refers to difficulty holding opposing thoughts, feelings, or beliefs about one self or others. In other words, positive and negative attributes of a person are not joined together into a cohesive set of beliefs. For example, a person with BPD may view her boyfriend as "good" one minute, but shift to seeing him as all "bad" or even evil the next. Because of splitting, it is difficult for individuals with BPD to recognize that "good" people sometimes do things imperfectly or make mistakes.

3) Identity Disturbances

Unexpected and sudden changes in goals, interests, preferences, and values are portrayed by persons afflicted with BPD. These unanticipated changes can range from relatively minor things, such as changes in appearance, to aspects central to the life of the individual, such as career paths and goals. These sudden changes usually accompany interpersonal turmoil. Realistic or unrealistic perception of abandonment, feelings of loneliness, emptiness, and hopelessness are usually the specific triggers of these changes. Identity disturbances in individuals with BPD usually reflect efforts to preserve a sense of self-worth in the presence of interpersonal turmoil.

4) Impulsivity

Impulsivity is a tendency to act quickly without thinking about the consequences of one's actions. Impulsive behaviour usually occurs in reaction to some event that has caused the person to have some kind of emotional response. Unprotected promiscuous sex, substance abuse, reckless driving, and binge eating are some examples of the impulsive behaviours seen in people with BPD. The impulsivity of individuals with BPD may be the consequence of their perception that they are not valued by others. As such, impulsive self-damaging behaviours are used to shield themselves from possible abandonment by a significant other. Alternatively, impulsivity in people with BPD may be caused by an inability to control motor responses (Nigg et al. 2005). These behaviours can increase the risk of suicide, and thus are of great concern.

5) Recurrent Suicidal Behaviour, Gestures, or Threats, or Self-Mutilating Behaviours

Emotional instability, behavioural impulsivity, and fears of abandonment put individuals with BPD at a high risk for self-harming behaviours. It is believed that suicidal behaviours, gestures, or threats are meant to retain the attention and affection of significant others. Although these threats are usually regarded as manipulative tactics on the part of the individual with BPD, they are very difficult to ignore. Therefore, such behaviour is reinforced by the success of bringing the other person closer and eliminating the sense of abandonment. On the other hand, if the threat is ignored, an actual attempt at ending their lives might be carried out with a great probability of being successful.

Self-mutilating behaviour involves the direct and deliberate destruction or alteration of the body. This is also referred to as self harm or self injury. Examples of self harming behaviours include cutting, burning, needle sticking, and severe scratching. Self-mutilating behaviours are seen as coping mechanisms used to regulate negative emotions such as pain, loneliness, and extreme anger (Klonsky and Olino 2008). These behaviours are generally not conducted with the intent to commit suicide.

6) Affective Instability

A key feature of BPD is affective instability (also called emotional lability or affective dysregulation). People with BPD experience a lot of dramatic shifts in their emotional states. They may feel okay one moment but then feel angry, sad, lonely, afraid, jealous, or shameful moments later. These emotional shifts are intense and frequent. Changes in mood can last for hours and in rare cases for days. People with BPD experience changes in their affect more readily when confronted with interpersonal stress. This being said, it is rare that others can persuade these individuals out of their mood states. Instead, people with BPD may react with intense anger to the efforts of those attempting to provide some emotional relief.

7) Chronic Feelings of Emptiness

Persistent feelings of emptiness are often expressed by individuals with BPD. They are usually unable to express their aspirations and desires. To an outside observer, a person affected with BPD may appear as shallow and unmotivated. The feeling of emptiness and the inability to express what they desire in life brings upon feelings of anxiety and self-defeating behaviours. Individuals with BPD often believe that their feelings of emptiness will push significant others away, thus, increasing their fear of abandonment. This can elicit behaviours that are meant to attract others, while in reality these behaviours usually trigger interpersonal conflict.

8) Inappropriate, Intense, Uncontrollable Anger

Intense, inappropriate anger is one of the more troubling symptoms of BPD. Anger in BPD is deemed inappropriate because its level is usually more intense than is warranted by the situation or event that triggered it. For example, a person with BPD may react to an event that may seem small or unimportant to someone else (e.g., a misunderstanding) with very strong feelings and manifestations of anger (e.g., yelling or becoming physically violent). The stability of social relationships is constantly threatened due to the explosive nature of the anger.

9) Paranoid and Dissociative Symptoms

Paranoid thoughts and dissociative symptoms are common in BPD. They are typically transient and appear at times of extreme stress. Perceived abandonment from a significant other frequently serves as the cause of these symptoms. Paranoid thoughts of someone with BPD may involve unrealistic ideas about others trying to harm him/her, or that everyone around is purposefully abandoning him/her as part of a conspiracy plan. Dissociative symptoms reflect depersonalization experiences whereby the person feels as an observer in his or her own life, and able to observe his or her life from outside their own body. Generally, by taking away the trigger of the stress it is possible to end the paranoid or dissociative experiences. Consequently, the paranoid and dissociative episodes characteristic of BPD patients differ significantly from those experienced by patients with psychotic disorders whose symptoms are more stable.

Are you or someone you know living with borderline personality disorder? It’s possible if at least five of the following symptoms are present:

1) Extreme reactions to the idea of abandonment, such as panic, depression, rage, or frantic actions
2) A pattern of intense and stormy relationships with family members, friends, and loved ones
3) A distorted and unstable self-image or sense of self
4) Impulsive and often dangerous behaviors, such as spending sprees, unsafe sex, substance abuse (drugs and/or alcohol), reckless driving, and binge eating
5) Recurring suicidal behaviors or threats or harming oneself, such as cutting, hitting, or head banging.
6) Intense and highly changeable moods, with each episode lasting from a few hours to a few days
7) Chronic feelings of emptiness and/or boredom
8) Inappropriate, intense anger or problems controlling anger
9) Having stress-related paranoid thoughts or strong feelings of being cut off from oneself, observing oneself from outside the body, or losing touch with reality.

People with BPD may experience these feelings in response to certain triggers. For example, they may see anger in someone else’s face, even though that person is not feeling that way, and have a stronger reaction to words with negative meanings than people who do not have BPD. Identifying and learning to respond to these triggers is a major step toward recovering from the illness.

Risky Behaviors: People with BPD often have trouble regulating their emotions. They may engage in risky behaviors, such substance abuse or eating disorders, as a short-term distraction from their intense emotions.

Cutting: The physical pain of cutting and other forms of self harm may momentarily distract a person with BPD from their intense psychological pain and bring a sense of relief.


Suicidal Thoughts: The intense ups and downs of BPD, loss of sense of self, and belief that no one else values them can cause people with BPD to think about or attempt suicide.



In the general population, the prevalence of BPD varies from 0.4% to 1.8%, with a pooled rate of 1.1% (Korzekwa et al. 2008). The lifetime prevalence of BPD among primary care patients has been estimated at 6.4% (Gross et al. 2002). In clinical samples, BPD is usually the most common personality disorder. In outpatient samples, the rates of BPD have varied from 8% to 27%. More recently, reported rates of 9.3% to 18% have been reported, with a pooled rate of 11.9% (Korzekwa et al. 2008). Studies of psychiatric inpatient populations have reported rates of BPD at about 40% (Marinangeli et al. 2000).

Sex Distribution

Women are more often diagnosed with BPD compared to men, accounting for about 75% of the cases of BPD (Nehls 1998). A variety of explanations have been proposed to account for this disparity. For example, it has been suggested that the prevalence difference is due to differences in the presentation of symptoms among men and women. Johnson and colleagues (2003) found that women diagnosed with BPD tend to exhibit the more dramatic aspects of BPD symptoms such as intense and unstable emotionality and self-harm behaviours, while men present more subtle antisocial and impulsive behaviours. The prevalence difference may also reflect biases held by mental health providers when diagnosing BPD. Skodol and Bender (2003) argue that the general belief that BPD is more prevalent in women than in men creates a bias toward identifying the disorder in women while exploring other disorders for men. Recent studies from Norway, the United States, and Great Britain have challenged the notion of a sex disparity, finding little or no difference in the prevalence of BPD among men and women (Coid et al. 2006; Lenzenweger at al. 2007; Torgersen et al. 2001).

Comorbidity BPD is highly comorbid with other personality disorders, as well as with a number of Axis I disorders, most notably depression, anxiety, eating disorders, posttraumatic stress disorder, and substance abuse (Zanarini et al. 1999). Zanarini and colleagues (Zanarini et al. 1999) found that BPD could be depicted by a pattern of what she called complex comorbidity, characterized by multiple comorbid diagnoses that included both internalizing and externalizing disorders. Consistent with this finding, Grilo and colleagues (Grilo et al. 1997) found that 86% of those meeting criteria for major depression and substance abuse were comorbid for BPD. This is particularly problematic in relation to the finding that treatment outcome studies of Axis I disorders that included comorbid BPD patients have found that BPD has detrimental effects on the treatment of the Axis I disorders (Clarkin 2006).


As with many other psychiatric disorders, BPD is widely regarded as the product of complex interactions among multiple factors, including genetic, neurochemical, neuroanatomical, and psychological factors. It is important to emphasize that there is considerable diversity in the literature with regard to etiological understandings of BPD, and that many conclusions remain speculative.

Genetic Factors

Evidence suggests that BPD runs in families. Through the study of biological relatives of people with BPD, it has been proposed that BPD is 4 to 20 times more prevalent among relatives of those with BPD compared to relatives of individuals not diagnosed with BPD (Links et al. 1988; White at al. 2003). Torgersen and colleagues (2000) provided support for the genetic vulnerability of BPD by studying monozygotic and dizygotic twins. In their study, the concordance rate of BPD among monozygotic twins was 35% compared to a 7% concordance rate among dizygotic twins. The high concordance rate of BPD found in monozygotic twins is strongly suggestive of genetics playing a role in the aetiology of BPD.

Neurochemical Factors

There is some support for neurochemical vulnerability in people with BPD. Specifically, two neurotransmitters have caught the attention of researchers: serotonin and norepinephrine. Serotonin has been found to be associated with aggression and impulsivity, whereby as levels of serotonin decrease, aggression and impulsive behaviours increase. Thus, it has been suggested that the characteristic aggressive and impulsive behaviours of BPD are the result of decreased or low levels of serotonin in the brain (Rinne et al. 2000). In much the same way, norepinephrine has been found to be related to aggressive behaviours in BPD. Coccaro et al. (2003) found that males with lower levels of norepinephrine were more likely to be diagnosed with BPD and more likely to have a lifetime history of aggression.

Neuroanatomical Factors

Researchers have also found anatomical and physiological brain differences between those with and without BPD. Hyperactivity of the amygdala, a brain structure in charge of autonomic responses associated with fear, arousal, and emotional responses, has been found in people with BPD (Wingenfeld et al. 2010). Additionally, decreased functioning of the prefrontal and preorbital cortex in patients with BPD has been related to a decreased capacity of affect control (Kernberg and Michels 2009). These findings might explain the sensitivity to environmental stressors and the deep impact that these stressors have in the interpersonal relationships and the affect of individuals with BPD.

Psychological Factors

Consistently, individuals diagnosed with BPD report trauma and adversity as characteristic of their early lives. These individuals tend to differ from those without mental health concerns and from people diagnosed with other personality or mood disorders on reports of physical abuse, sexual abuse, and neglect during childhood (Ogata et al. 1990; Perry and Herman 1993; Weaver and Clum 1993; Zanarini et al. 2000). Similarly, people with BPD report more maternal and paternal abandonment, more parental conflict, and higher rates of being raised by relatives or in foster homes (Bandelow et al. 2005).

The emotional and interpersonal instability characteristic of BPD may be the result of a failure to create secure attachments early in life. Bowlby (1973) suggested that there is continuity between the quality of our early relationships with caregivers and our adult interpersonal relationships. Therefore, the early unstable and ambivalent relationships consistently found in people with BPD are more likely to lead to insecure relationships in adulthood (Levy 2005).

Integrating parallel streams of thought from the fields of psychoanalysis, developmental psychology, and cognitive neuroscience, comprehensive theories of BPD have been developed by leading authorities in the field including Kernberg (1984), Fonagy (1991), and Linehan (1993). Although differing in certain aspects, these theories all attend to the issue of mentalisation. The concept of mentalisation describes the way humans make sense of their social world by imagining the mental states (e.g., beliefs, motives, emotions, desires, and needs) that underpin their own and others' behaviours in interpersonal interactions. Fonagy (1991) has elaborated a theory of how the capacity to mentalise develops in early childhood and, alternatively, how deviations from this normal developmental path result in severe forms of adult psychopathology, most notably BPD.

An Integrative Perspective

Oldham (2009) recently provided an eloquent and succinct summary of contemporary research on BPD, which integrates recent advances in our understanding of BPD. As Oldham explains, contributions of clinical and basic science research have helped us recognize that the "stress-vulnerability" model of disease is a useful guide for considering a biopsychosocial concept of BPD. Researchers have identified core heritable endophenotypes (a special kind of biomarker) of affective dysregulation and impulsive aggression (Siever et al. 2002). Additional findings that brain abnormalities can be identified by brain imaging techniques, and that inherent hyperactivity of the amygdala has been detected lend further support to the idea that borderline pathology is at least partially "hard-wired" (Donegan et al. 2003). The heritable "priming" for emotional overactivity, coupled with an impairment in the usual cortical capacity to downregulate or inhibit this limbic-driven emotionality or impulsivity (New et al. 2007), can interfere with the normal attachment process during development (which can be magnified when there is inadequate parental support). Such a disposition can arrest or distort integration of aspects of self and others, resulting in early onset and persistence of profound interpersonal difficulties that characterise those with BPD.

Natural Course and Prognosis

A common misconception is that BPD is a chronic, unrelenting mental health disorder - a sentence to a life of misery. Fortunately, evidence suggests otherwise. Most people with BPD improve with time (Paris 2007). About 75% will regain adaptive functioning by the age of 40 years, and 90% will recover by the age of 50 (Paris and Zweig-Frank 2001). A long-term study of the phenomenology of BPD (Zanarini et al. 2007) found that half of the 24 BPD symptoms assessed showed patterns of sharp decline over time and were reported at 10-year follow-up by less than 15% of the patients who reported them at baseline. The other 12 symptoms showed patterns of less dramatic decline over the 10-year period. Symptoms reflecting core areas of impulsivity (e.g., self-mutilation and suicide efforts) and active attempts to manage interpersonal difficulties (e.g., problems with being demanding/entitlement and serious treatment regressions) seemed to resolve the most quickly. In contrast, affective symptoms reflecting areas of chronic dysphoria (e.g., anger and loneliness/emptiness) and interpersonal symptoms reflecting abandonment and dependency issues (e.g., intolerance of aloneness and counterdependency problems) seemed to be the most stable. Unfortunately, about 10% of people with BPD eventually succeed in committing suicide (Paris 2003). However, this outcome is difficult to predict, and 90% of those with BPD improve despite having threatened to end their lives on multiple occasions. We do not fully understand the mechanisms of recovery in BPD, but impulsivity generally decreases with age, and people learn over time how to avoid the situations that give them the most trouble (e.g., intense love affairs), finding stable niches that provide the structure they need. The development of effective treatments for BPD has also helped improve the prognosis of those affected with this disorder.


Psychological Approaches

The mainstay of treatment for BPD is psychotherapy. Currently, four comprehensive forms of psychotherapy have been found to be effective in treating those with BPD (Hadjipavlou and Ogrodniczuk 2010). Two of these treatments (mentalisation based therapy, transference focused therapy) are viewed as psychodynamic in nature and two (dialectical behavioural therapy, schema focused therapy) are viewed as more cognitive behavioural in nature.

Mentalisation based therapy (MBT) is a complex psychodynamic treatment that is rooted in attachment theory and draws on concepts from cognitive psychology. Bateman and Fonagy (2006) describe MBT as "a focus for therapy rather than a specific therapy in itself," employing "a reiteration of well-known basic therapy practices such as support, empathy, exploration and challenge" (2006). The focus of MBT is on enhancing mentalisation. As described above, mentalisation is the capacity to understand behaviour, one's own and that of others, in terms of underlying mental states (for example, thoughts and feelings). MBT seeks to enhance this reflective capacity, which is posited to be disrupted in patients with BPD—particularly in the context of relationships that activate their attachment system—and underlies their disturbed interpersonal relatedness. The integration of one's experience of one's own mind with the view presented by the therapist is a key component of MBT.

Transference focused therapy (TFP) is a structured, psychodynamic approach, which emphasizes the integration of affect-laden mental representations of self and others that were originally derived through the internalization of attachment relationships with caregivers (Clarkin et al. 2006). Understanding how these internal representations become activated in the here-and-now relationship with the therapist is a key part of therapy. In this way, negative affect states, particularly aggression, are gradually controlled by understanding them as they unfold in the relationship with the therapist. TFP aims for full recovery, which encompasses reducing suicidality and self-injurious behaviour, improving behavioural control and affect regulation, and enhancing the ability to pursue gratifying relationships and meaningful life goals.

Dialectical behavioural therapy (DBT) conceptualizes the core problem of BPD as a habitual breakdown of patients' cognitive, behavioural and emotional regulation systems when they experience intense emotions (Linehan 1993). It is thought to facilitate change through the learning of emotional regulation skills in the validating treatment environment. DBT is a comprehensive treatment package that involves 4 modes of therapy: individual, in which the therapist oversees treatment integration and manages life-threatening behaviours and crises; group skills training, including mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness; skills generalization through telephone contact outside of normal therapy hours; and a consultation team to support therapists working with difficult clients.

Schema focused therapy (SFT) is an integrative therapy that brings together elements of cognitive therapy, behavioural therapy, object relations, and gestalt therapy. It focuses on patients' maladaptive schemas or pervasive patterns of thinking, feeling, and behaving that are developed during childhood and are associated with problems in one's identity and sense of self, interpersonal functioning, and affect regulation (Kellogg and Young 2006). In this approach, BPD is thought to involve regression into early maladaptive modes of being that are tied to specific schemas and associated intense emotional states. Therapy involves recognition of self-perpetuating processes that maintain maladaptive schemas and render them resistant to change. Identifying and changing maladaptive schemas is the main focus of treatment. Changing schemas involves both cognitive and experiential work. It also includes approaches such as limited adaptive re-parenting (emphasizing acceptance and validation) and empathic confrontation. Maladaptive behaviours outside of therapy are also addressed. Recovery is the goal of treatment, and is achieved when maladaptive schemas no longer dominate patients' lives, allowing them to implement more adaptive coping skills.

There are a number of other promising psychological treatments for BPD. Included among these are systems training for emotional predictability and problem solving (STEPPS) and nidotherapy. STEPPS is an adjunctive treatment program designed to supplement patients' ongoing care, be it psychotherapy or case management (Blum et al. 2008). STEPPS combines elements of CBT and skills training with a "systems" component, which actively involves people with whom the patient interacts regularly and has designated as their system members (family, significant others, and health care professionals). Nidotherapy refers to the systematic manipulation of the physical and social environment to help achieve a better fit for a person with personality disorder such as BPD (Tyrer and Bajaj 2005). There are five essential principles of nidotherapy: collateral collocation, the formulation of realistic environmental targets, the improvement of social function, personal adaptation and control, and wider environmental integration involving arbitrage (i.e., involving others in resolving change).

Pharmacological Approaches

Pharmacological treatments for BPD are limited in their effectiveness. In most cases, the use of drugs to treat BPD only 'manages' the symptoms by decreasing their impairment on the patient. Although some authors have suggested that mood stabilisers and second-generation antipsychotics may be effective for treating specific symptoms of BPD and associated pathology (Lieb et al. 2010), the National Institute for Health and Clinical Excellence (NICE 2009) guideline for BPD does not recommend drug treatment other than for the treatment of comorbid disorders. Specifically, these guidelines state that "drug treatment should not be used specifically for borderline personality disorder or for the individual symptoms or behaviour associated with the disorder (for example, repeated self-harm, marked emotional instability, risk-taking behaviour, and transient psychotic symptoms)."

Ogrodniczuk JS, Sierra Hernandez CA. 2010. Borderline Personality Disorder. In: JH Stone, M Blouin, editors. International Encyclopedia of Rehabilitation. Available online:


Research By Otto Kernberg MD and Frank Yeoman MD Phd Specialising in personally disorders for over 30 years.


Working with Personality Disorders at Trauma Recovery Institute

Trauma Recovery Institute offers unparalleled services and treatment approach through unique individual and group psychotherapy. We specialise in long-term relational trauma recovery, sexual trauma recovery and early childhood trauma recovery. We also offer specialized group psychotherapy for psychotherapists and psychotherapy students, People struggling with addictions and substance abuse, sexual abuse survivors and people looking to function in life at a higher level. Trauma recovery Institute offers a very safe supportive space for deep relational work with highly skilled and experienced psychotherapists accredited with Irish Group Psychotherapy Society (IGPS), which holds the highest accreditation standard in Europe. Trauma Recovery Institute uses a highly structured psychotherapeutic approach called Dynamic Psychosocialsomatic Psychotherapy (DPP) with an added focus on Transference as with transference Focused psychotherapy mentionaed above. This is a highly effect treatment approach with positive treatment outcomes for people suffering with personality disorders.



Dynamic Psychosocialsomatic Psychotherapy (DPP) at Trauma Recovery Institute Dublin

Dynamic Psychosocialsomatic Psychotherapy (DPP) is a highly structured, once to twice weekly-modified psychodynamic treatment based on the psychoanalytic model of object relations. This approach is also informed by the latest in neuroscience, interpersonal neurobiology and attachment theory. As with traditional psychodynamic psychotherapy relationship takes a central role within the treatment and the exploration of internal relational dyads. Our approach differs in that also central to the treatment is the focus on the transference and countertransference, an awareness of shifting bodily states in the present moment and a focus on the client’s external relationships, emotional life and lifestyle.

Dynamic Psychosocialsomatic Psychotherapy (DPP) is an integrative treatment approach for working with complex trauma, borderline personality organization and dissociation. This treatment approach attempts to address the root causes of trauma-based presentations and fragmentation, seeking to help the client heal early experiences of abandonment, neglect, trauma, and attachment loss, that otherwise tend to play out repetitively and cyclically throughout the lifespan in relationship struggles, illness and addictions. Clients enter a highly structured treatment plan, which is created by client and therapist in the contract setting stage. The Treatment plan is contracted for a fixed period of time and at least one individual or group session weekly.

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“Talk therapy alone is not enough to address deep rooted trauma that may be stuck in the body, we need also to engage the body in the therapeutic process and engage ourselves as clients and therapists to a complex interrelational therapeutic dyad, right brain to right brain, limbic system to limbic system in order to address and explore trauma that persists in our bodies as adults and influences our adult relationships, thinking and behaviour.”


By | 2017-12-01T13:40:09+01:00 October 26th, 2015|Blog|Comments Off on Working with personality disorders and severe personality disorders at Trauma Recovery Institute using a unique combination of transference focused psychotherapy and our dynamic psychosocialsomatic psychotherapy