Personality disorders

Lecture 1

-PD’s are highly prevalent in clinical practice (40-60%) and interfere with treatment of clinical
disorders and
can be treated through evidence-based therapies.

Personality
refers to the enduring
characteristics and behavior that
comprise a person’s unique adjustment
to life, including major traits, interests,
drives, values, self-concept, abilities,
and emotional patterns.

According to the DSM5 , a personality disorders is :

-an enduring pattern of inner experience
and behavior that deviates from the
expectations of an individual’s culture, is
pervasive and inflexible, has an onset in
adolescence and early adulthood, is stable
over time, and leads to clinically significant
distress or impairment in social, occupational
or other areas of functioning.’

*PD are egosyntonic (vs ego dystonic clinical

disorders such as anxiety disorders) and
interfere with adaptive interpersonal
functioning.

*Pervasive , Persistent , Pathological

General criteria from the DSM5

A. An enduring pattern of inner experience and behavior that

deviates markedly from the expectations of the individual's culture.
This pattern is manifested in two (or more) of the following areas:

1. Cognition (i.e., ways of perceiving and interpreting self, other

people and events)
2. Affectivity (i.e., the range, intensity, liability, and appropriateness
of emotional response)
3. Interpersonal functioning
4. Impulse control

B. The enduring pattern is inflexible and pervasive across a broad range of personal and social
situations.
C. The enduring pattern leads to clinically significant distress or impairment in social,
occupational, or
other important areas of functioning (functional impairment and distress).
D. The pattern is stable and of long duration, and its onset can be traced back at least to
adolescence or
early adulthood.
E. The enduring pattern is not better accounted for as a manifestation or consequence of another
mental disorder.
F. The enduring pattern is not due to the direct physiological effects of a substance (e.g., a drug
abuse, a
medication) or a general medical condition (e.g., head trauma).

PD clusters

Cluster A -odd , Cluster B-dramatic , Cluster C -anxious , fearful ,

eccentric,weird emotional , unpredictable worried

Paranoid personality disorder Borderline personality Avoidant personality disorder

disorder

Schizoid personality disorder Antisocial personality Dependent personality

disorder disorder

Schizotypal personality Narcissistic personality Obsessive compulsive

didorder disorders personality disorder

Histrionic personality
disorder

Prevalence

PD in general population: 10.5 – 12%

Cluster A: 4%
Cluster B: 3.5-4%
Cluster C: 3-9%

*check each diagnosis criteria from the printed slides

The alternative model for PD

• The Work Group for Personality and Personality Disorders reviewed the literature
and explored the possibility of developing a dimensional approach to classification
of personality disorders.
• The APA Board of Trustees then voted to sustain the DSM-IV diagnostic system for
personality disorders, virtually unchanged, in the main section of DSM-5 and to
include the proposed new model as an “alternative DSM-5 model for personality
disorders” in Section III of DSM-5, the section referred to as “Emerging measures
and models”

Suggestions of the alternative model

• Retain 6 of 10 PD with most empirical evidence

• Remove Paranoid PD, Schizoid PD, Histrionic PD, Dependent PD
• Revise the general definition/criteria for PD to impairments at
level of self and interpersonal functioning
• Scholars/therapists agree that the general core of PD = ‘failure to develop
coherent sense of self and chronic interpersonal dysfunction’
• Assess levels (i.e. severity such as ‘mild’ or extreme’) of self and
interpersonal functioning
• Disturbances in levels of self and interpersonal functioning
• Assess underlying pathological personality traits
• BIG-FIVE traits: negative affectivity, detachment, antagonism, disinhibition,
psychoticism.
• Add option to diagnose PD ‘ trait specified’

*when it comes to general criteria there is the inclusion of one or more pathological personality
traits so big five traits
*check the exact criteria for each cluster from the printed slides

Problems with the current assessment of PD types

• Limited empirical evidence for validity for some

existing PD types
• Lack of specificity in general definition PDs
• Inadequate representation of PD severity
• Heterogeneity within types
• Arbitrary thresholds for diagnosis
• Excessive comorbidity among PDs
• Instability of current categorical personality disorder
criteria sets

• The majority of people has two or more PD diagnoses

• The PDNOS category is used very often in clinical practice
• High comorbidity of other clinical disorders (mood, anxiety, addiction etc).

-Inherent to the definition is pervasiveness and stability over time: PDs start early and are
chronic

Prevalence

● Point prevalence is a measure of the proportion of people in a

population who have a condition at a particular time/date
● Lifetime prevalence (LTP) is the proportion of individuals in a
population that at some point in their life (up to the time of
assessment) have experienced a condition
• We would expect the lifetime and point
prevalence to be relatively similar for PDs (i.e.
start early, chronic)
• However, lifetime prevalence of PDs is on
average 3x higher than point prevalence

Conclusion

People seem to possess relatively

stable (maladaptive) personality traits (e.g.
neuroticism – CRIT B hybrid model!) that underlie
symptoms of problematic self-to-self-relating and
interpersonal functioning (CRIT A! Hybrid model)

Book chapters

Chapter 1

*In clinical syndromes (depression , anxiety), the experiences and behaviors are usually
perceived as ego-dystonic, i.e. all aspects
(thoughts, feelings, behaviors) related to the person that are experienced
as not belonging to the person-they also come about spontaneously and disrupt a person/s life
*Personality disorders are usually considered as ego-syntonic:
they experience it as something belonging to them and being part of them

-the emphasis for the

definition of a personality disorder (PD) includes references to functional
impairment and subjective distress
-some have both like borderline / some not really subjective like schizoid and some not
functional impairment like narcissistic

*schizoid PD does not include the psychotic-like

positive symptoms of schizophrenia

*Taken together, the criteria for schizotypal personality disorder impress as

a rather heterogeneous set of mildly psychotic phenomena, rather than
a personality disorder.

*The other category concerns the Unspecified Personality Disorder,

which differs from the Other Specified Personality Disorder in the sense
that it can be used in (a) situations in which the clinician chooses not to
specify the reason that the criteria are not met for a specific disorder, or (b)
when there is insufficient information to make a more specific diagnosis.

ICD-11

-in comparison to DSM5 this one assess the severity and instead of 10 there are 6 categorizes
1. Negative affectivity in Personality Disorder or Personality Difficulty
2. Detachment in Personality Disorder or Personality Difficulty
3. Dissociality in Personality Disorder or Personality Difficulty
4. Disinhibition
5. Anankastic Personality Disorder or Personality Difficulty-a narrow focus on one’s rigid
standard of perfection and of right and wrong, and on controlling
one’s own and others’ behavior and controlling situations to ensure
conformity to these standards

6. Borderline pattern
*However, these prototypes can be as well found within the
alternative model of DSM-5

*Type S, consisting of PD patients who recognize their abnormal

personality functioning and wish to change it, was more often encountered in Cluster C patients

Chapter 2

2 main approaches :
-the standardized medical approach
-alternative model

Construct validity of personality disorders

(a) the conceptualization of the constructs themselves,

(b) the formulation of the essential
(DSM or ICD) diagnostic criteria sets, and
(c) instruments to assess these
constructs

*Taxometrics can be used to investigate whether latent

structures are categorical (taxonic) or dimensional
 ● Millon (1986) has argued for
the three-step criterion of functional inflexibility, self-defeating circles, and
tenuous stability under stress

Diagnosis DSM5

1.establish whether the patient meets the general criteria

for a personality disorder.
2.The clinician has to evaluate
each of these criteria for their presence or absence, count the presence of
these diagnostic criteria, and compare the total number of them to the pre�set cut-off for each
personality disorder

*Polythetic criteria of equal weight: issues of heterogeneity and diagnostic efficiency.

-As
described in Chapter 1 these in turn consists of two elements each: self functioning consists of
identity and self-direction, while interpersonal functioning
consists of empathy and intimacy

Personality disorder assessment instruments

● Structured interviews for diagnosis and trait assessment

● Self-report instruments for diagnosis and trait assessment
● MMPI-2-RF-The Minnesota Multiphasic Personality Inventory
● The SWAP-200-To “standardize” the clinicians view an alternative model, proposing
a dimensional profile to describe the personality disorder categories

DSM5 section on personality disorder

-For a personality disorder to be diagnosed in an individual younger than 18 years, the features
must have been present for at least 1 year/except for antisocial that can not be diagnosed in
minors

Paranoid
-There is some evidence for an increased prevalence of paranoid personality disorder in relatives
of probands with schizophrenia and for a more specific familial relationship with delusional
disorder, persecutory type.

Schizoid
-Schizoid personality disorder is diagnosed slightly more often in males and may cause
more impairment in them.

Schizotypal
-Schizotypal personality disorder has a relatively stable course, with only a small proportion of
individuals going on to develop schizophrenia or another psychotic disorder.

Antisocial
-The highest prevalence of antisocial personality
disorder (greater than 70%) is among most severe samples of males with alcohol use disorder
and from substance abuse clinics, prisons, or other forensic settings
-prevalence is also higher in groups that were affected socioeconomically and also migration
-The diagnosis of antisocial personality disorder is not given to individuals younger than
18 years and is given only if there is a history of some symptoms of conduct disorder before age
15 years. For individuals older than 18 years, a diagnosis of conduct disorder is
given only if the criteria for antisocial personality disorder are not met.

Borderline
-During their 30s and 40s, the majority of individuals with
This disorder attains greater stability in their relationships and vocational functioning.
-borderline personality disorder is about five times more
common among first-degree biological relatives of those with the disorder than in the general
population
-Borderline personality disorder is diagnosed predominantly (about 75%) in females

Histrionic
-Data from the 2001–2002 National Epidemiologic Survey on Alcohol and Related Conditions
suggest a prevalence of histrionic personality of 1.84%.

Narcissistic
-Prevalence estimates for narcissistic personality disorder, based on DSM-IV definitions,
range from 0% to 6.2% in community samples.

Avoidant
-Avoidant personality disorder also tends to be diagnosed with borderline personality disorder
and with
the Cluster A personality disorders (i.e., paranoid, schizoid, or schizotypal personality
disorders).
-There is some
evidence that in adults, avoidant personality disorder tends to become less evident or to
remit with age

Dependent
-Data from the 2001–2002 National Epidemiologic Survey on Alcohol and Related Conditions
yielded an estimated prevalence of dependent personality disorder of 0.49%, and dependent
personality was estimated, based on a probability subsample from Part II of the
National Comorbidity Survey Replication, to be 0.6%.

Obsessive
-Many of the features of obsessive-compulsive personality disorder overlap with
“type A” personality characteristics (e.g., preoccupation with work, competitiveness, time
urgency), and these features may be present in people at risk for myocardial infarction.
There may be an association between obsessive-compulsive personality disorder and depressive
and bipolar disorders and eating disorders.
-In systematic studies, obsessive-compulsive personality disorder appears to be diagnosed
about twice as often among males.

DSM5 hybrid model

Pathological Personality Traits

1. Negative Affectivity,
2. Detachment,
3. Antagonism,
4. Disinhibition, and
5. Psychoticism
-Within the five broad trait
domains are 25 specific trait facets

-Importantly, individuals high in trait anxiousness would not necessarily be anxious at

all times and in all situations. Individuals’ trait levels also can and do change throughout
life. Some changes are very general and reflect maturation (e.g., teenagers generally are
higher one trait impulsivity than are older adults), whereas other changes reflect individuals' life
experiences.
-broad trait dimensions
are called domains, and specific trait dimensions are called facets

Lecture 2

-Knowledge about epidemiology, course

and risk factors is necessary for
detection, prevention and effective
treatment of PD’s.

Impairments in functioning

• PD’s are associated with impairment in relationships,

occupational, leisure functioning, quality of life.
• Schizotypal, BPD, avoidant have most reduced
impairment in quality of life.
• Obsessive compulsive and histrionic PD are less
associated with impairments in functioning.
• Linear negative relationship between number of criteria
of PD and quality of life, independent of any specific PD.
• Individuals with PD use more psychiatric and health
care services, especially dependent PD.
• PDs are associated with physical health complaints:
cardiovascular arthritis, sleep, obesity, pain.

Stability

• 10 year follow up 93% of BPD have clinical remission for

at least 2 years
• 86% clinical remission for at least 4 years.
• 39, 3% showed clinical remission after only 2 years.
However:
• 4,4 % of BPD patients died from suicide
• Recurrence of BPD symptoms in about 1/3 of the
patients who lost BPD diagnosis during 10 year
follow up.
• Only 50% recovered from diagnosis + good social
and vocational functioning

-not as stable as thought before but more stable than depression

-also the underlying traits are much more stable over time
-• However, a considerable number of people
still have 1 or more symptoms and ordinal
ranks (ordering of people according to
number of symptoms/criteria they meet) are
considerably stable.
-symtopms like identity issues tend to be more table than suicidal intentions

BPD

-severe in patients in their 20s and then plateaus in the 30s

-not clear if the improvements are due to treatment or maturity
-for most BPD good outcomes come from the lack of a relationship

Antisocial PD

-delinquency in young predicts antisocial later

-strongest predictors of criminal behavior :
• low parental education,
• poor parental supervision,
• poor child-rearing skills,
• large family size

-antisocial men younger than 40 have more predisposition to premature death (violence ,
cardiovascular disease)
-like BPD they sometimes mature out of the disorder due to the decrease of impulsivity
-due to their high stress level
-structured , strict context tend to be beneficial to their recovery
• Early substance abuse and more severely
antisocial behavior are associated with worse
late life symptoms (Reid & Gacono, 2000).

Cluster C

-anxiety becomes more pronounced with age unlike cluster b

-individual with avoidant pd were more severely distressed over 12 years
-OCD more prevalent in older age groups

Cross cultural aspects

• No evidence for increasement of PDs in Western cultures due

to achievement and individualistic culture.
-increase in antisocial pd found in some ghettos in europe and the us may be accounted for by a
large increase in substance abuse and dependence resulting in criminal behavior because of
drugs not necessarily a true increase in antisocial
-PD rates were higher however in african americans than caucasians or asians
-BPD more often in hispanics
-schizo in african america while ocd less common in hispanics and asian americans
-in europe the prevalence of antisocial pd was lower than in than in the us

Comorbidity

-high among personality disorders within clusters and also other disorders

Within clusters
• Grant et al., 2005: Avoidant is highly co-occurrence with dependent
and lesser to OC-PD
• Fossati et al., 2001: Schizotypal is related to paranoid and
schizoid PD

Between clusters
• Togerson et al., 2001 >25% of individuals with one PD had at
least 1 one other PD
• McGlashan et al., 2000: average 1.4 PD
• Coid et al., 2006: 54% one PD, 22% 2 PDs, 11% three PD’s
14% 8 PDs
• Comorbidity of PD between cluster-B and A and C is common
• Dependent and Histrionic are associated with BPD (Bornstein,
2012).

- Somatization disorder is related to antisocial, borderline,

histrionic, avoidant, dependent and narcissistic PD
(related to difficulties regulating emotions).

Addiction and disorder

• Rates of PD are high among individuals with

substance abuse and gambling disorders (40-
50%).
• Substance abuse and dependence is high in
BPD and antisocial PD

Anxiety disorders

• 35-52% of individuals with anxiety disorder has a PD

• Especially a cluster-C PD (39%), compared to Cluster A
(13%) Cluster-B (19%).

Mood disorders

• 40-50% of individuals with mood disorders have at least 1 PD

• In bipolar disorder Cluster C is slightly more prevalent than Cluster B
PD
• Cluster-C PD are especially related to mood and anxiety disorders (particularly dependent PD
and avoidant PD). But clearly not limited to
• Paranoid and schizoid PD most strongly related to dysthymia, mania,
panic disorder with agoraphobia, social phobia, and generalized anxiety
disorder
• Histrionic and antisocial most strongly associated with mania, panic
disorder with agoraphobia, social phobia, and generalized anxiety
disorder

Theoretical model to explain co occurrence

-Vulnerability model: PD predisposes to development of syndrome disorders: cluster�C

predisposes to development of anxiety and mood disorders.
-Continuity model: PD are viewed as subclinical manifestations of a slowly
developing syndromal clinical disorder: for instance schizotypal may predispose
individuals to schizophrenia
-Complication model: PD develop as a result of an enduring syndrome disorder:
Anxiety disorder in childhood enhances risk for an avoidant PD later in life.
Depression in childhood may enhance the risk for PD
-Coeffect model, or shared risk model: PD and clinical disorders are two separate
structures, but co-occur a a result of a third common factor or causal process, for
instance abuse disorder and BPD due to hereditary disinhibition problems or
physical and sexual abuse, abusive parenting.
-Attenuation model:both disorders are alternative expressions of the same genetic
or constitutional liability. BPD and mood disorders may occupy different points
along a common affective or depressive spectrum.

Risk factors for pd

-genes : • Personality traits (BIG-5): 40-50% of variance of personality

traits is related to genetic factors. But it is unclear which
specific genes or interaction between specific genes are
involved.
• Factors underlying the biology of PDs: (1) anxious/emotional
dysregulation, (2) antisocial, (3) social withdrawal, and (4)
anankastic/ compulsive.
• Heritability of about 41% Antisocial, BPD 37%, Histrionic
31% and Narcissistic 35%
• Antisocial PD: 56% of the risk for antisocial behavior is related to
genes, which might be higher for psychopathy.
• Externalizing disorders (conduct disorder, antisocial PD, alcohol and
drugs dependence): highly vulnerability general genetic vulnerability,
behavioral under control, which genes exactly remains unclear.
• Dopamine genes (MAO-A polymorphism) is related to antisocial
behavior especially in the presence of childhood maltreatment (gene
x environment interaction).
• A common genetic factors for Avoidant (83%) dependent (48%),
OCPD (15%), genetic effects for obsessive-compulsive PD are
relatively specific.
• Dopamine receptors (DRD4 and DRD3) are related to avoidant and
OC PD traits in depressed PD individuals.
• D3 dopamine receptor Gly/Gly genotype related to OC-PD,
increased risk 2.4

Cloninger’s (1987) Biosocial theory of PD

-Cloninger proposed that personality can be considered

as a multidimensional construct that includes lower and
higher levels of personal functioning through the features
of temperament and character.

• Genetic temperament factors: individual differences in behavioural

learning mechanisms, explaining responses to novelty, danger, or
punishment and cues for reward, avoiding aversive stimuli, and reactions
to rewards.
• Harm avoidance: tendency to behavioural inhibition of responses to
aversive stimuli. Related to the serotonergic system.
• Novelty seeking: behavioural activation to novel stimuli leading to pursuit of
reward and escape of punishment. Related to dopaminergic activity
• Reward dependence: positive response to conditioned signals of reward
that maintains behaviour. Mediated by noradrenergic activity
• Persistence: related to perseverance despite frustration and fatigue
• Cluster-A: low Reward dependence
• Cluster-B: high Novelty seeking
• Cluster-C: high Harm avoidance

Character factors: character is less heritable than temperament and matures

with age.
• Self-directedness: self-acceptance, self determination and control of
adaptive behaviour to situations
• Cooperativeness: acceptance of others
• Self-transcendence: degree to which some-one feels part of nature, the
universe at large, associated with spirituality
• Temperament and character domains, although distinct, interact with each
other in shaping behaviour.
• The character dimensions of self-directedness and cooperativeness have
been found to be strongly linked to the presence of PD.

Neurobiology of BPD

• Hypo functioning of serotonergic system, especially 5HT�system is associated to BPD and

characteristics
associated with BPD, including impulsivity, self�mutilation, and affective instability
• Childhood abuse is related to hyperresponsiveness of
ACTH (adrenocorticotropic hormone) release.
• There therefore is some support for using serotonin
reuptake inhibitors (SSRIs) in BPD patients.
• BPD : disturbances in neurotransmictters systems of: opioids
(feelings of pleasure and soothing), oxytocin (related to ability to
thrust others) and vasopressin (aggression regulation).

Stress response system in BPD

• Under stress, our body produces cortisol

• Chronic exposure to cortisol has negative effects
• HPA axis functioning
is dysregulated in patients with BPD
• BPD: problems with suppression of cortisol secretion
• probably influenced by PTSD, trauma history or
depression.
• Causing abnormalities to stress response (emotional
sensitivity and reactivity) in combination with other
mechanisms

Neurobiology in ASPD

• Serotonergic abnormalities were found in some

studies in individuals with psychopathy.
• Reduced frontal lobe functioning associated with
aggression and antisocial behaviour and impaired
executive functioning.
• Structural and functional abnormalities in
paralimbic system: orbitofrontal cortex,
dorsolateral prefrontal cortex, anterior cingulate
cortex, superior temporal gyrus, hippocampus,
insula, and amygdala in antisocial PD.

Neurobiology schizotypal

• Abnormalities in cingulate system (part of cortex: involved in

affect, memory executive functioning) has been implicated
as a dysfunctional region in schizophrenia. Schizotypal PD
patients demonstrate a pattern lying in between
schizophrenic patients and normal subjects
• Schizotypal and schizophrenia have common neuro
developmental aberrations, with schizotypal having milder
aberrations.

Environmental factors

-child abuse : • Maltreatment: physical, emotional, sexual abuse and neglect are related to
PD’s, but also PTSD, substance abuse, depression and poor academic
performance.
• Patients with BPD reported higher rates of child maltreatment, including
sexual abuse, than either patients with other PD or patients with syndrome
disorders.

• Dependent PD is less associated with childhood abuse and parental neglect

• Antisocial behaviour problems emerge when genetically vulnerable children
encounter family environments in which they are maltreated

Adult attachment and personality traits

• Secure Attachment is moderately negatively correlated with
neuroticism and moderately positively correlated with
extraversion and agreeableness, modestly positively correlated
with conscientiousness, and not correlated with openness.
• Attachment anxiety is moderate to highly related to neuroticism
(depression vulnerability, and anxiety) not to openness
• Attachment avoidance is modestly negatively related to
extraversion and agreeableness, but not with openness.

Perinatal environmental
risks

• Low birth weight

• Obstetric complications
• Influenza exposure during pregnancy
• Prenatal malnutrition
• Dermatoglyphic abnormalities and other signs of
intrauterine developmental instability
Are related to different positive/negative symptoms of
schizophrenia and schizotypy in general, and STPD

Book chapter 3

*psychopathy is believed to occur in approximately 1%

of the general population, and in 15–25% of the male and female prison
population

*Cluster
B personality disorders were more prevalent in hospital-treated patients
than in the community, whereas Cluster C personality disorders were more
common in the community sample.
*psychopaths
more than individuals with antisocial PD remain at high risk for violent
offences much later in life

Book chapter 4

Consistent evidence that four

factors underlie the biology of personality disorders:
(1) anxious/emotional
Dysregulation,
(2) antisocial,
(3) social withdrawal, and
(4) anankastic/
compulsive

Lynch et all article

The introduction section outlined the rationale and objectives of the systematic review,
emphasising the importance of understanding psychopathology among young people. It
highlighted the prevalence and impact of mental health issues in youth and underscored the need
for early intervention and prevention strategies to mitigate the long-term consequences of
psychopathology.

The section provided an overview of the methodological approach adopted in the review,
including the use of systematic search strategies and quality assessment tools. It also referenced
key frameworks and guidelines, such as the PRISMA-P statement, that guided the design and
execution of the review.

Moreover, the introduction section set the stage for the subsequent sections by outlining the
search criteria, databases utilized, and the focus on examining risk factors and models of
psychopathology among young individuals. It underscored the potential implications of the
review findings for informing interventions and strategies aimed at addressing mental health
challenges in youth.

Overall, the introduction section served as a foundational framework for the systematic review,
contextualizing the significance of the research topic and outlining the objectives and scope of
the review.

Results Summary:

Selection of Studies:
 ● Initially, 160 studies were identified, with 119 excluded after full-text review.
● Inter-rater reliability was high for both title/abstract screening (92% agreement) and
full-text screening (82% agreement).

Characteristics of Included Studies:

● 41 studies were included, with 26 cross-sectional and 15 longitudinal studies.

● Majority of studies were from the USA, with some from Australia, Europe, the UK, and
South Korea.

Risk and Protective Factors:

● 31 studies analyzed biological factors, 15 analyzed socio-environmental factors, and 19

analyzed psychological factors.
● Over 130 unique risk and protective factors were examined, with some factors supported
by evidence from multiple studies.

Overall Quality:

● The mean quality rating of included studies was 90%, with cross-sectional studies scoring
higher (93%) than longitudinal studies (84%).
● Lower quality ratings were often due to issues like unaddressed confounding factors.

Models of Psychopathology:

● 50 structural models from 41 studies were examined, with a 3-group model being
common.
● The models focused on internalizing and externalizing dimensions, highlighting
consistencies and limitations in previous research.

Methodological Considerations:

● Variability in measures, statistical approaches, and outcomes across studies was noted.
● The inconsistency in indicators and measures may have contributed to mixed findings.
● Future research should address methodological complexities and uncertainties for a
clearer understanding of psychopathology among young individuals.

Lecture 3

-cluster C is the most prevalent in community samples despite the fact that there is not enough
research on it
• The construct of dependent PD might be comprised of two factors
• Dependency and incompetence: seeing oneself as incompetent,
lacking self-confidence, and needs reassurance and support in
practical areas from a stronger other.
• Attachment abandonment: excessive interpersonal dependency
(neediness), feeling lonely, empty, and experience a strong longing
for a loving person.
• DSM-5 assesses: “functional dependency”: individual sees
him/herself as incompetent, lacks self-confidence and wants
continuous reassurance and support in practical areas from someone
stronger than him/herself.
• Emotional dependency: the emotional need that somebody else is
securely attached to the person. Without emotional connection,
people high in emotional dependency feel lonely and empty,
experience abandonment fears.

• Dependent and avoidant PD share a

common
latent factor, OC PD appears to represent a
different domain.
• Dependent PD shows overlap with panic disorder
/ agoraphobia
• Avoidant PD shows overlap with social phobia.
• Anxiety disorders share significant genetic
variance with the personality trait of neuroticism
which is highly related to cluster-C PDs.

Biopsychological model

*A core psychological/cognitive component – a self�concept of ‘being ineffectual and weak

and needing
others to be happy’ (dependent PD) ‘being inferior and
avoid others who are critical’ (avoidant PD) ‘being
responsible, accountable, fastidious (OCPD)– develops
through a combination of A genetic predisposition for anxiety-harm avoidance and
dependency-related factors + Early (traumatic) learning (neglect,
negative rearing and attachment experiences and (gender-related)
socialization (socialization encourages passivity, acquiescence and
accommodation for girls more compared to boys).

• Cognitive theory overlaps with attachment theory, both

under stripe the formation of cognitive schemas in early
life.
• When schema's are activated they usually lead to the use
of maladaptive coping strategies.

Treatment
Dutch Guideline recommends for avoidant PD:
• Cognitive Behavioral Therapy (CBT)
• Brief Psychodynamic Psychotherapy (STDP)
• Schematherapy (ST)
• Affect-phobia Therapy (AFT)
No recommendations for dependent and OC-PD, due
to lack of evidence.

Assessment of PDs in clinical practice

Phase 1: inventory
• (Hetero)anamnesis, in which patient tells about his symptoms and
extent to which the patient experiences problems in functioning.
Comprehensive assessment
• Inventory of various problem areas of the personality disorder
• Inventory of associated problems (psychiatric, social, somatic)
• Risk assessment
• Medication history
• Life context (family, neighborhood, social context)
• Strengths, and support network

Phase 2: classification
USE structured clinical interviews to avoid biases!
For assessment of clinical disorder: MINI-DSM-5 of SCID-5-S/CV
For assessment of PD: SCID-5-P or STIP 5.1

Phase 3: diagnostic formulation

The diagnostic formulation describes the patient's problems in their unique individual
context.
Relevant factors include: history, living situation, finances, education and/or
employment, quality of social network and social relationships, care for children and
loved ones, physical health, somatic comorbidity and medication use.

• Structured interviews for specific personality

traits:
• Diagnostic Interview for BPD-Revised
(assess BPD criteria in depth)
• Borderline personality disorder severity
index, currently also developed for cluster�C PD
• Structured interview for the Five-Factor
Model (assesses personality traits)

HI-TOP model

Book chapter 5
*there is now rather
consistent evidence that avoidant and dependent PDs belong to the same
cluster, and the results with respect to obsessive-compulsive PD are currently inconclusive

*In cognitive views (Beck et al., 2004), personality disorders are conceptualized as the overt
expression of underlying dysfunctional beliefs and
schemas, which make such individuals vulnerable to negative life experiences

-Beliefs-It is assumed that specific sets of beliefs and schemas are associated
with each personality disorder

Attentional bias- According to schema theory it

is assumed that schemata are biassed towards threats and that threat-related
material is always favoured in cognitive thinking

Informational bias- evidence was found that avoidant and

dependent PDs versus borderline PD patients were characterized by disorder-specific
interpretation biases, but this was not the case for obsessive�compulsive PD

*as many as
80% of individuals with dependent PD were victims of violent acts
*obsessive-compulsive PD was the
most prevalent personality disorder in men convicted for severe intimate
partner violence

Dependent personality disorder

-Studies have shown that dependent persons are characterized by high trait
anxiety
-This personality style of dependency
has been found to be associated with strict, controlling, and inconsistent
parental rearing
-the criteria for dependent PD form two distinct components:
dependency/incompetence and attachment/abandonment
-There is a high risk of suicide attempt for persons with dependent PD

Avoidant personality disorder

- a central characteristic of avoidant PD is social
avoidance, together with hypersensitivity to negative evaluation, fears of
rejection, and feelings of inferiority
-studies suggest that avoidant personality may be
broadened to include avoidance of situations other than social situations,
including emotional distress in general and novel situations.
-avoidant PD features were associated with a measure of “sensory processing sensitivity”
-The relationship between social phobia and avoidant PD may be explained by the
attenuation hypothesis (see Chapter 4): both disorders are alternative
expressions of the same genetic or constitutional liability in terms of underlying personality
traits, possible candidates being high introversion (low
extraversion) and high neuroticism (low emotional stability)

Obsessive compulsive personality disorder

-Obsessive-compulsive PD involves a chronic maladaptive pattern of excessive perfectionism,
preoccupation with orderliness and detail, and need for
control over one’s environment
-The presence of obsessive-compulsive PD
in OCD patients is associated with an earlier age of onset of OCD symptoms, and greater
frequency of symmetry and hoarding obsessions
-multivariate analysis showed that obsessive-compulsive PD
was significantly related to the paraphilic child molestation act and
explained 14% of the variance in molestation

Article Groot et al

The research study is designed to investigate and compare the efficacy of Group Schema
Therapy (GST) and Individual Schema Therapy (IST) in treating individuals diagnosed with
Cluster-C Personality Disorders. The primary objectives of the study are to assess the impact of
these therapeutic interventions on symptom reduction, quality of life improvements, and overall
well-being of the participants.
One of the key aspects of the study is the exploration of predictors and moderators that may
influence the allocation of treatments to individuals with Cluster-C Personality Disorders. By
identifying factors that can affect treatment outcomes, the study aims to tailor interventions more
effectively to meet the specific needs of each patient.

In addition to the primary outcomes, the research project includes sub-studies that focus on
different aspects of the therapeutic interventions. These sub-studies will examine treatment
integrity to ensure that the therapies are delivered as intended, conduct qualitative analyses to
gain insights into patient experiences and perspectives, and evaluate the cost-effectiveness of the
different treatment approaches.

Ethical approval has been obtained for the study, indicating that the research adheres to ethical
standards and guidelines in conducting human research. The funding for the study is provided by
ZonMw, a reputable organization dedicated to promoting health research and innovation in the
Netherlands.

The study design emphasizes the inclusion of a diverse and representative sample of participants
to enhance the generalizability of the findings to real-world clinical settings. Rigorous measures,
such as validated questionnaires and semi-structured interviews, will be utilized to collect data,
with trained research assistants ensuring the reliability and validity of the information gathered.

Long-term follow-up assessments are planned to track the sustainability of treatment effects
beyond the active therapy period. This longitudinal approach will provide valuable insights into
the long-term benefits and outcomes of the different therapeutic interventions for individuals
with Cluster-C Personality Disorders.

Overall, this comprehensive research project aims to contribute significant advancements in the
understanding and treatment of Cluster-C Personality Disorders by investigating the
effectiveness of GST and IST, exploring treatment mechanisms, and optimizing treatment
allocation strategies to improve patient outcomes and quality of life.

Lecture 4

Antisocial personality disorder and psychopathy

-4 main clusters
-1st cluster more about social interaction /overlap with narcissism
-2nd cluster how they process emotions
-3rd cluster and 4th more about behavior and everyday activity
-there is a lot of overlap with antisocial

From the video

-he expressed a need for stimulation/needed adrenaline to feel something
-very arrogant and narcissistic

The psychopathic brain process

- Cold cognition
- Low–fear-in a stressful situation the heart rate was lower compared to other people
- Lack of empathy, less mirror emotions
- Inability to learn from experiences of other people
-only the frontal lobe is activated/no amygdala activation so do not feel the emotions associated
with a memory
Psychopathy and the DSM
- Contemporary societal viewpoints influence what we perceive as deviant
- There is cultural and gender bias in the DSM
- The DSM is merely based on consensus/agreement not on empirical evidence
ASPD DSM3
-Spitzer and Robbins worked together to include ASPD and write it as it is today/Hervey
Cleckley and the psychopathy researchers were not invited to work together
-later Spitzer admitted that they did not think about societal context and environment when
creating the criteria for ASPD thus putting people in poverty at more risk to be diagnosed with
ASPD

Consequences of ASPD in DSM

-stigma and ASPD and psychopathy are very intertwined
• ASPD is higher prevalent in disadvantaged neighborhoods (this is not the case for
psychopathy)
• Social problems may be labeled as medical/psychiatric disorder which may reduce
our perspectives on solutions.

Societal context
• living in disadvantaged in neighborhoods leads
to more mistrust and aggression
-poverty impedes cognitive functioning
• Social societal circumstances may lead to the
emergence of specific subcultures with deviant
potential to lead to aggression and antisocial
Behavior
-genes make up 50% but it is also a combo between shared and non shared environmental factors

Pathways to antisocial behavior

• Survival strategy: Collective altruïsm
• Conditions for collective altruism
• Trust
• Reciprocity

Trust and antisocial behavior

• Trauma and affective neglect are highly prevalent in
youth of ASPD patients
• Current social environment in which ASPD patients
live is often competitive and hostile
• ASPD patients are hypervigilant on threat/hostility
Reciprocity and antisocial behavior
• Emotional neglect is common in ASPD childhood and
leads to poorer mentalizing ability.
• A subgroup of ASPD patients cannot properly assess
emotions in others such as fear and sadness.
• Impulsivity has a negative impact on assessing
emotional needs of other people
• Just like mental retardation, addiction, stress and
poverty.

Treatment of ASPD and psychopathy

-DBT/MBT/CBT/SFT
Treatment options of underlying pathways
-pathway 1 trust :• Trauma treatment, EMDR, Schema Focused Therapy, CBT
• Goal: Decrease of arousal and realistic threat assessment
-pathway 2 reduced skills to reciprocate:• Social Cognition Training (VR), MBT, ILC
• Goal: Learning to empathize with the emotions
and the needs of others.
-Pathway 3 Psychopathy (they can mentalize but they do not care):• CBT, External structuring
treatment, protective factors,
treatment of sub-problems such as addiction, trauma and
aggression, cognitive remediation training
• Goal: to oversee the long-term consequences of behavior
and to estimate the risks realistically.

● A lot of therapists avoid treating ASPD patients

● Also a lot of ASPD patients have a bad time in therapy and do not feel like they get the
help they need/ there is also a lot of stigma behind therapy
● Suitable therapists for treating ASPD should be firm and kind, have an open attitude,
flexibility
Book chapter 8

-Reactive acts occur in response to actual or perceived threat

from others, whereas proactive behaviors are initiated by the individual
him- or herself

Dodge’s model of social information processing

-reactive aggression is mediated by a readiness to perceive hostile intent in
the actions of others
Four different phases: aggressive children
(a) selectively attend to hostile
cues,
(b) display hostile attributional biases,
(c) readily access aggressive
responses and fail to access many competent responses, and
(d) are
inclined to give positive evaluations of aggressive responses

-Low physiological arousal (e.g. low resting heart rate) in children has been
found to be associated with violent offending in adulthood

Stimulation-seeking theory
-According to this theory, low arousal represents an unpleasant
physiological state, and antisocial individuals will seek stimulation in
order to increase their arousal level

*According to DSM-5, for a person to be

diagnosed as antisocial PD he/she should have at least three symptoms of
conduct disorder (such as destruction of property, aggression to animals
or people, or theft). Further, there should be at least three behavioral
problems occurring after the age of 15

*Currently, psychopathy is conceived of as consisting of two distinct, but

interrelated facets

1.primary psychopathy or
core psychopathy, consists of emotional-interpersonal traits emphasizing
narcissism and social dominance
2.secondary psychopathy, refers primarily to social deviance
(impulsiveness, aggressiveness, low tolerance to frustration, anxiety, irresponsibility, antisocial
behaviours, etc.)

- Indeed, more recent studies of the PCL-R

found support for a two-factor four-facet model including interpersonal (e.g.
glibness, pathological lying), affective (callousness, shallow affect), lifestyle
(e.g. impulsivity, parasitic lifestyle), and antisocial factors (e.g. juvenile
delinquency, criminal versatility)

*For girls more

than for boys, antisocial behaviours are more likely to be a consequence of
the quality of interpersonal relationships with others, particularly opposite�sex peers and
partners. Girls’ antisocial behaviour is more likely to be
motivated by interpersonal conflict than boys’ conduct problems

*High levels of aggression and attention problems/restlessness (ADHD) at

age five increased the risk of antisocial behaviour at age 14 by a factor of
two

Article Aerts summary

The study aimed to gain insights into therapeutic aspects and processes in the therapeutic alliance
(TA) when treating patients diagnosed with Antisocial Personality Disorder (ASPD). It sought to
identify essential factors crucial for establishing a strong TA with individuals with ASPD,
focusing on treatment goals, tasks, and the therapeutic bond as directed by Bordin (1979). The
research employed a qualitative research design to gather knowledge from therapists with
extensive experience working with patients diagnosed with ASPD.

Thematic analysis was used to identify themes, with interviews conducted between September
2019 and January 2021 at participants' workplaces. Due to the COVID-19 pandemic, some
interviews were conducted via video calling. The study revealed six themes related to the TA in
treating patients with ASPD, emphasizing the specific features and dynamics encountered, the
attitude and skills required for a strong TA, and the factors contributing to a valuable treatment
process and goals.

Therapists highlighted the importance of a connective attitude characterized by authenticity,

non-judgmental openness, genuine involvement, and firmness in developing personal bonds with
patients with ASPD. Specific skills were deemed essential for overcoming challenges in
engaging with this target group. The study recommended further research to explore the
perspectives of patients with ASPD to gain a broader understanding of the therapeutic
relationship.

The findings suggested that therapy modalities could be adapted and refined based on the
insights derived from the study to enhance effectiveness in treating patients with ASPD. The
study provided valuable insights into the complexities of establishing a therapeutic alliance with
individuals diagnosed with ASPD, emphasizing the need for therapists to be firm, yet flexible
and adaptable to the patient's needs.

Article De Witt summary

The Hierarchical Taxonomy of Psychopathology (HITOP) model is a sophisticated framework
that addresses the complexity of comorbidity among mental disorders by categorizing traits
along dimensional spectra and acknowledging the heterogeneity within diagnoses. This model
offers a nuanced understanding of the diverse manifestations of mental health conditions,
including antisocial behavior.

Brazil et al. advocate for a more in-depth exploration of the underlying bio-cognitive
mechanisms that contribute to antisocial behavior. By identifying specific subgroups within the
antisocial population based on these mechanisms, tailored therapeutic interventions can be
developed to target individual needs effectively. This approach emphasizes the importance of
personalized treatment strategies in addressing antisocial behavior.

Trust and reciprocity are fundamental components of prosocial behavior, and their absence or
impairment can lead to the development of antisocial tendencies. Understanding the role of these
factors in shaping behavior can provide valuable insights into the origins of antisocial behavior
and inform intervention strategies aimed at promoting positive social interactions.

Personality traits play a crucial role in differentiating between externalizing and internalizing
psychopathology. Researchers have highlighted the significance of personality traits in
contributing to the heterogeneity observed within the antisocial population. By examining how
these traits influence antisocial behavior, clinicians and researchers can gain a deeper
understanding of the underlying mechanisms driving such behaviors.

The presence of hypomentalizing modes in individuals with antisocial behavior may be linked to
experiences of insecure attachment during childhood and underlying neurobiological
predispositions. Addressing these underlying factors through targeted therapeutic interventions
can help individuals develop healthier cognitive and emotional processing patterns, potentially
reducing the risk of engaging in antisocial behaviors.

Treatment strategies that target the core dynamics of antisocial behavior have shown promise in
reducing recidivism rates among individuals with psychopathic traits. By focusing on addressing
the root causes of antisocial behavior, such interventions aim to promote long-term behavioral
change and improve outcomes for individuals with antisocial tendencies.

While the proposed conceptual framework offers a promising direction for enhancing diagnostics
and tailoring therapeutic interventions for individuals with antisocial behavior, ongoing empirical
research is needed to validate its efficacy in clinical practice. By refining diagnostic approaches
and treatment programs based on empirical evidence, clinicians can better meet the complex and
varied needs of individuals with antisocial behavioral problems.

Article van den Bosch

Antisocial Personality Disorder (ASPD) is a mental health condition characterized by a pattern
of disregard for and violation of the rights of others. It is often associated with substance use
disorders, functional impairments, criminal behavior, and an increased risk of mortality. Despite
the significant impact of ASPD, research on effective psychosocial treatments for this disorder is
limited, presenting challenges for clinicians in providing optimal care.

To address this gap, a study was conducted to develop a practice-based framework aimed at
identifying the necessary criteria and resources required to deliver effective treatment to
individuals with ASPD. The framework emphasizes the importance of evidence-based
treatments, such as Mentalization-Based Therapy (MBT) and Cognitive Behavioral Therapy
(CBT), in improving outcomes for ASPD patients. These therapies focus on addressing
maladaptive behaviors, enhancing emotional regulation, and promoting positive social
interactions.

The study also involved a Delphi study, which gathered insights from experts in the field to
determine the competencies and conditions essential for a treatment team to work effectively
with individuals diagnosed with ASPD. Key competencies identified included the ability to treat
patients as equals, apply motivational techniques, empathize with challenging patients, and
maintain hope for change. Professionals were advised to avoid labeling patients as either
"offenders" or "victims," provide protocol-based treatment, possess knowledge of co-occurring
disorders, and be open to supervision and self-reflection.

Furthermore, the study highlighted the importance of creating a non-judgmental treatment

climate, implementing evidence-based therapies, and fostering a collaborative approach among
treatment teams to enhance the care provided to individuals with ASPD. It emphasized the need
for ongoing research and replication studies to validate the effectiveness of treatments in
real-world settings serving ASPD patients. By integrating these findings into clinical practice,
clinicians can better tailor their interventions to meet the complex needs of individuals with
ASPD and improve treatment outcomes.

Lecture 5 Borderline PD

Short history
• Early in 20th century: dominance of psychoanalytic
thinking, personality structure
• Stern (1938): described patients on the border line
between neurosis and psychosis
• Kernberg: borderline personality organization
• Grinker and Gunderson: developed criteria and
characteristics for BPD
• BPD first classified in DSM-III (1980)
• Borderline PD is named ‘Emotionally unstable’ PD in ICD�10

-15-20% in psychiatric outpatients

-15-40 for psychiatric inpatients
-Men-women 50-50, but not in psychiatric samples (3/4 women) in stead of
forensic care

Epidemiology
• BPD in adolescence is predictor of poor psychosocial
functioning later in life and more syndromal disorders
(mood disorders and addiction).
• Small associations to living status: currently in
(un)fortunate social situation
• Highly related to poor societal functioning & QoL
• Highly related to attendance psychiatric facilities

Criteria domains

Core features of BPD

-emotional dysregulation
-high levels of impulsivity
-disturbed interpersonal functioning

Alternative model BPD

• Moderate or greater impairment in personality functioning, manifested by characteristic
difficulties in two or more of the following four areas:
-identity
-self direction
-empathy
-intimacy
• Four or more of the following seven pathological personality traits ,at least one of which must
be (5) Impulsivity, (6) Risk taking, or (7) Hostility:
-emotional lability
-anxiousness
-separation insecurity
-depresivity
-impulsivity
-risk taking
-hostility

BPD and stigma

Interventions:
• A one-day professional workshop on BPD —Systems Training for
Emotional Predictability and Problem Solving (STEPPS)
• Significantly improved clinicians’ attitudes toward patients with
BPD and their desire to work with them.
• A three-hour workshop on BPD and Dialectical Behavior Therapy
• Significantly reduced stigma and increased empathy.

Comorbidity
• Mood disorders (major
depression, bipolar, anxiety,
PTSD)
• Eating disorders
• Substance abuse
• Other PDs
*Comorbidity is elevated especially
in clinical BPD patients as compared
to nonclinical (high-functioning) BPD
patients.
Suicide and BPD
• 1 in 3 BPD patients attempt suicide
• 8-10% mortality, often before age of 40
• Studies investigating risk factors present mixed
results (affective instability; depressed mood;
intensity of negative affect; poor psychosocial
adjustment)
• 50 times higher risk than persons from the general
population

Functions of self harm and suicide attempts

• 1) self-injure (temporarily) alleviate
overwhelming negative emotion.
• 2) self-injure as a form of self-directed anger or
self-punishment
• 3) multiple other functions, such as a desire to
influence others or to produce a physical sign of
emotional distress, avoiding tasks.
• 4) to die

Course and prognosis of BPD

• 10 year follow up 93% have clinical remission for at least 2
years,
• 86% clinical remission for at least 4 years.
• 39, 3% showed clinical remission after only 2 years.
• 2/3 shows clinical remission after 6 years
• Only 50% recovered from diagnosis + good social and
vocational functioning

Factors associated with recovery

Better
• High intelligence
• Giftedness
• Physical attractiveness
Worse
• Low education
• Low socio-economic status
• Ongoing abuse

Gene environment interaction

Relatives of BPD patients have 4-20 times
-more often BPD.
-MonoZygotic Twins: 35% concordance rates,
-7% in Dizygotic Twins
-Approximately:
45% heritable through multiple genes / 55% of
BPD traits explained by unique environmental
experiences.
-Especially genes related to different levels
of serotonin (related to negative affectivity and impulsivity)
and dopamine (related to psychosis, substance abuse and
anger) involved.
*BPD itself is not heritable but the traits that make you susceptible are
• Early traumatic experiences are much more
common in BPD than in any other disorder
• 1/3 of BPD patients also had comorbid
PTSD
-strong relationship between trauma and bpd

• Of those who experienced childhood maltreatment (CM),

54% developed any PD versus 11% that developed PD
following no-CM

*trauma and insecurities lead to an insecure attachment style

• Insecure and disorganized attachment might underlie one of
the core symptoms of BPD: difficulties in interpersonal
relationships (concept of self and others).
• Maternal overinvolvement, maternal hostility and maternal
inconsistency predicts BPD
• Low parental affection and aversive parenting predicts BPD

Environment
• variables that predict BPD features in adolescents:
(1) less emotional warmth
(2) more overprotection
(3) more general psychopathology in mothers

Neurochemistry
• Genes involved in serotonin synthesis and
metabolism are 5HTT, MAO-A, and TPH. Studies
show that people with BPD have more/less of these
genes and/or a different built-up of these genes.
• Genes involved in dopamin synthesis and metabolism
are DAT1, DRD2, and DRD4

• HPA axis functioning

is dysregulated in patients with BPD
• BPD: problems with suppression of cortisol secretion
• probably influenced by PTSD, trauma history or
depression.
• Causing abnormalities to stress response (emotional
sensitivity and reactivity)
*In BPD context: the frontolimbic system is involved in
impulsivity, aggression, self-harming behavior and
fears of abandonment.
• BPD patients perform worse than healthy
controls on executive functioning and
memory tasks.
• Example: The Go / No-go task as a test of
behavioural inhibition…..

Emotion regulation
- BPD patients do seem to be hypersensitive to negative stimuli
(earlier detection and more intense reactions)
• BPD patients are worse at self-soothing in response to
emotions and do not have a large repertoire of emotion
regulation strategies

Adult attachment and BPD

• Only 6-8% of BPD adult patients is securely
attached
• 50-88% shows preoccupied attachment

Treatment of BPD
• Dialectical Behavior Therapy (DBT)
• Mentalization-Based Treatment (MBT)
• Schema Therapy (ST)
• Transference-Focused Psychotherapy
(TFP)

Chapter 6
-Prevalence estimates for the general adult population are between
1% and 2.7%), but the disorder is clinically
quite common, with prevalence estimates of 15–20% for psychiatric out�patients (Gunderson,
and from 15% up to 40% for psychiatric
inpatients

-In epidemiological
studies, borderline PD in adolescence was found to be a predictor for
psychosocial dysfunctioning later in life
-High intelligence, giftedness, and, in
females, physical attractiveness appeared to increase the odds of positive
outcome, while low education, low socio-economic status, and ongoing
abuse were associated with worse outcome

-some criteria
can be thought of as primarily cognitive versus primarily interpersonal in
nature (e.g. unstable self-image), or as impulsivity-related versus interpersonal (e.g. oscillating
between extremes in relationships)
-Self-injurious thoughts and behaviors are maladaptive strategies used to regulate emotional
states when individuals
lack to utilize adaptive regulation strategies

-A substantial number of borderline PD patients have experienced one or

more traumas: about one third of them have comorbid PTSD.

Three variables were the strongest predictors

of borderline PD features in adolescents, namely
(1) less emotional warmth,
(2) more overprotection, and
(3) more general psychopathology in mothers

Linehan’s model

-According to Linehan
(1993a) emotionally vulnerable individuals growing up in an emotionally
“invalidating environment” are at particular risk of developing borderline
PD (see Musser et al., 2018). Individuals high on emotional vulnerability
have low thresholds for their emotional reactions, tend to experience
intense emotional reactions, and have difficulty in downregulating their
emotional arousal
-Also, there is considerable evidence
that borderline PD patients engage in maladaptive emotion regulation such
as thought suppression, rumination, experiential avoidance, and impulsive
and self-injurious behaviours

Young schema theory

-The theory describes how various dysfunctional family

characteristics, such as deprivation, rejection, or subjugation, lead to frustration of specific core
emotional needs of the young child. These frustrations,
in turn, give rise to the formation of maladaptive schemata. Subsequent
Borderline personality disorder information processing is heavily guided by such schemata, and
underlies
the borderline PD pathology
-Young
distinguishes ten distinctive schema modes, including four child modes,
three dysfunctional coping modes, two dysfunctional parent modes, and
the healthy adult mode

Aud Article

● Meta-analysis aimed to investigate the effectiveness of specialized psychotherapies for

adults with Borderline Personality Disorder (BPD).
● Pooled specialized psychotherapies to create a solid evidence base and compared
effectiveness with community treatment by experts.
● Search strategy included various databases and contact with authors for additional data.
● Assessment of bias and statistical heterogeneity conducted.
● Results showed moderate evidence of specialized psychotherapies reducing overall BPD
severity and dropout rates.
● Head-to-head comparisons of specialized psychotherapies also conducted.
● Funding provided by Netwerk Kwaliteitsontwikkeling GGz.

Key Points:

● The meta-analysis focused on examining the effectiveness of specialized

psychotherapies, such as Dialectical Behavior Therapy (DBT) and Schema-Focused
Therapy (ST), for adults diagnosed with Borderline Personality Disorder (BPD).
● The study aimed to establish a robust evidence base by pooling data from various sources
and comparing the efficacy of specialized psychotherapies against community treatment
by experts.
● A comprehensive search strategy was employed, involving multiple databases and direct
communication with authors to gather additional relevant information.
● Methodological aspects, including bias assessment and evaluation of statistical
heterogeneity, were carefully considered during the analysis process.
● The findings of the meta-analysis indicated a moderate level of evidence supporting the
effectiveness of specialized psychotherapies in reducing overall BPD severity and
decreasing dropout rates among patients.
● In addition to overall outcomes, the study also conducted head-to-head comparisons of
different specialized psychotherapies to assess their relative efficacy in treating BPD.
● The research received funding from Netwerk Kwaliteitsontwikkeling GGz, emphasizing
the importance of quality improvement in mental health care services.
Lecture 6 Schema therapy
-first old guy developed Transformed Focus Psychotherapy , an option for treating personality
disorders
-the 2 guys worked on MBT
-right side guy is the schema therapy founder
-the woman is DBT/struggled with borderline personality disorder as well

-those are the four most popular PDs treatment options

- a new 5th one is STEPPS
• CBT treatment program for BPD
• Aims at emotion regulation and behavior
management skills
• 20 studies, 3 randomized controlled trials
• 1 study in adolescents
• No studies in older adults
• STEPPS has both been studied as add-on
therapy to patients' ongoing treatment,
and, with the addition of individual
STEPPS sessions, as standalone
treatment

Jeffrey Young and schema therapy

• Integrative psychotherapy model that blends:
- Cognitive-behavioral therapy
- Experiential psychotherapy
- Psychodynamic therapy
- Attachment theory
• Expands on traditional CBT: greater emphasis on
exploring childhood and adolescent origins of
psychological problems, experiential techniques,
therapeutic relationship and maladaptive coping
Styles
*schema therapy had the best results for borderline PD

Early Maladaptive Schemas

• Self-defeating emotional and cognitive patterns
that begin early in our development and repeat
throughout life
• EMS are the building blocks of personality
disorder
• Maladaptive behavior develops as a response
to a schema
• Schemas are influenced by biological,
psychological, social and cultural factors

1. Secure attachment to others

2. Autonomy, competence and sense of identity
3. Freedom to express valid needs and emotions
4. Spontaneity and play
5. Realistic limits and self-control
*not just from unmet needs but also genetic factors like temperament
Results from emotional temperament

Schema operations:perpetuations
3 primary mechanisms:
1. Cognitive distortion: misinterpret situations so
that schema is reinforced, accentuating
information that confirms and minimizing
information that contradicts
Affectively: blocking emotions
2. Self-defeating life patterns:
Unconsciously selecting and remaining in
situations and relationships that trigger and
perpetuate the schema, while avoiding
relationships that are likely to heal the schema
3. Maladaptive coping styles:
• Surrender: yield to schema, accept the schema is
true, act in a way to confirm the schema
• Avoidance: try to arrange their lives so that the
schema is never activated, avoid thinking about the
schema
• Overcompensation: try to fight the schema by
thinking, feeling, behaving and relating as though
the opposite of the schema is true
Example of maladaptive coping styles for schema
emotional deprivation
• Surrender: select emotional depriving partners
and does not ask them to meet needs
(‘resignation’)
• Avoidance: avoids intimate relationships all
together
• Overcompensation: acts emotionally demanding
with partners and close friends (‘inversion’)

Schema operations:healing
• Diminishing the intensity of the memories
connected to the schema, the schema’s
emotional value, the strength of the bodily
sensations and the maladaptive cognitions
• Also involves behavior change
• Schema never disappears: becomes activated
less often, affect less intense and is active more
briefly

Modes
-Moment to moment emotional states and coping responses
(adaptive and maladaptive) that we experience
Often triggered by life situations that we are oversensitive to
• Child modes: vulnerable child, angry child,
impulsive child, happy child
• Dysfunctional coping modes:
– surrender: compliant surrenderer
– avoidance: detached protector
– overcompensation: overcompensator
• Dysfunctional parent modes:
– punitive parent
– demanding parent
• Healthy adult mode

Schema assessment
- Identify schemas
- Understand the origins in childhood and
adolescence
- Educate about schema model
- Learn to recognise schema coping styles
- Learn to observe schema modes
By life history interviews, questionnaires, self�monitoring assignments and imagery exercises

Change phase
• Cognitive techniques: build a case against the
schema, review evidence
• Experiential techniques: fight the schema at an
emotional level, by imagery, role-play
• Behavioral pattern breaking: new, more
adaptive behavior
• Therapist-patient relationship: empathic
confrontation and limited reparenting

Schema therapy later in life

• Connects to psychotherapy expectations of older adults:
• Structured
• Skill-enhancing
• Problem-focused
• “Now or never” after reviewing one’s life
• Integrates CBT and experiential techniques, relying less on executive
functioning
• Enormous under-treatment of personality disorders in older adults
Book chapter 10
-Schema therapy is a cognitive therapy dealing with Early Maladaptive Schemas in patients with
personality disorders
-Schemas are self-defeating emotional and cognitive patterns established from
childhood and repeated throughout life. Young et al (2003) developed an
integrative model for schema therapy where the Early Maladaptive Schemas
were used as the basic unit of analysis, and therapy focusing on schema
modes was developed as a potentially effective approach for treating shifting
emotional states in patients with complex personality disorders such as
borderline PD

- CBT was found to be significantly superior to brief

dynamic therapy on most measures: only 9% of the CBT patients were still
classed as having avoidant personality disorder, whereas 36% of the brief
dynamic therapy patients still fulfilled the criteria.

5 therapy options for Borderline PD

1.cognitive-behavioural
therapy (Beck et al., 2004),
2. dialectical behavior therapy (Linehan, 1993a),
3.schema-focused therapy (Young et al., 2003),
4. transference-focused therapy
(Clarkin et al., 1999), and
5.mentalization-based therapy

*DBT was specifically developed for chronically suicidal and severely dysfunctional borderline
individuals
- In the DBT treatment model, the fundamental
“dialectic” of DBT is between acceptance and change
-DBT differs from CBT in that it is directed
to teaching new skills rather than emphasizing cognitive restructuring
Schema therapy

Young et al. also propose four types of early life

experience that foster the acquisition of schemata:
1.toxic frustration of needs
(leading for example to the schema of deprivation)
2.traumatization (leading
to mistrust and abuse schemata)
3.overindulgence (leading to entitlement and
dependence schemata)
4.selective internalization (leading for example to
a subjugation schema)

Coping behaviors can be classified into 3 types :

1.overconfidence
2.avoidance
3.surrender

5 specific schema modes

-abandoned/abused child
-angry and impulsive mode
-detached protector mode
-coping mode
-punitive parent mode
-underdeveloped healthy adult mode

Summary

-In recent years a number of controlled studies have revealed that both
cognitive-behavioural and structured manualized psychodynamic therapies
are effective treatments, but most of these studies have been conducted
with patients with borderline PD. As to avoidant PD, there is consistent
evidence that behavioural and cognitive-behavioural approaches are beneficial and might be
more effective than psychodynamic therapy. Results
with respect to treatment of antisocial PD are still inconclusive and it is
doubtful that current interventions have much to offer to true psychopaths.
Unfortunately, there are no evidence-based treatments for patients with
Cluster A personality disorders, but (elements) of treatments which have
been found effective in patients with psychotic disorders may also prove
beneficial to patients with Cluster A disorders.
Article Young

● Patients Seeking Treatment: Patients seeking cognitive-behavioral treatment often present

with chronic characterological problems that impact various aspects of their lives, such as
relationships and work satisfaction.
● Challenges in Traditional Therapy: Traditional cognitive-behavioral therapy may not
effectively address the complex needs of patients with characterological issues, leading to
treatment failures.
● Development of Schema Therapy: Dr. Young developed schema therapy as a systematic
approach to help patients with chronic characterological problems who did not benefit
from traditional cognitive-behavioral therapy.
● Understanding Schemas: Schemas are patterns imposed on reality or experience to help
individuals explain and navigate their perceptions and responses. They are abstract
representations of significant elements in events or experiences.
● Domains of Schemas: Patients may exhibit schemas related to disconnection and
rejection, impaired autonomy and performance, impaired limits, and other core emotional
needs that were not met during childhood.
● Case Example: A patient named Natalie with an Emotional Deprivation schema struggles
with chronic depression due to unmet emotional needs in childhood and patterns of
attracting emotionally depriving partners.
● Therapeutic Approaches: Schema therapy involves cognitive, experiential, and behavioral
strategies, as well as healing components within the therapist-patient relationship.
Therapists aim to create a safe environment to engage in emotionally focused dialogues
and address deep-rooted schemas.
● Impact of Schemas: Schemas established in childhood often manifest in adulthood,
influencing how individuals perceive and interact with the world, leading to difficulties in
various life areas.

This detailed summary provides insights into the development of schema therapy, the impact of
schemas on patients' lives, and the therapeutic approaches used to address deep-rooted beliefs
and behaviors.

Lecture 7

Narcissistic and histrionic PD

-they function quite well when they are treated the way they want to /they usually come to
treatment for addiction or when in crises but not because of their personal disorder

Differential diagnoses with other PDs

BPD

The relative stability of self-image as well as the relative lack of self-destructiveness,

impulsivity, and abandonment concerns also help distinguish NPD from BPD.

Histrionic

Excessive pride in achievements, a relative lack of emotional display, and disdain for

others’ sensitivities help distinguish narcissistic PD from histrionic PD

Antisocial

Individuals with antisocial and NPD share a tendency to be tough-minded, glib, superficial,

exploitative, and unemphatic, interpersonal disesteem”: an exploitative, selfish

interpersonal orientation

Alternative model

1.identity -looks at others for appreciation and self esteem

2.self direction-always look at ways to gain attention from others

3.empathy-difficulty recognizing the feeling of others

4.intimacy -can not really form long lasting relationships

Personality traits : grandiosity and attention seeking (both facets of antagonism)

*when their self esteem is threatened they tend to show quite a lot of anger NPD is positively
correlated with extraversion and negatively with agreeableness

OVERT: Grandiose sense of self-importance and uniqueness, a

striking sense of privilege or entitlement, and an

expectation of special treatment. They harbor fantasies of

unlimited success, power, brilliance, beauty, or ideal love. /they like to tell others that they are
great and show off

COVERT: Underlying the demanding and entitled presentation is the

preoccupation with a fragile sense of self and self-esteem;/struggle to regulate their sense of self
and if not grandiose tend to feel worthless and incompetent , difficulties in having a stable sense
of self

*decreases a bit over time

• Gains in functioning are associated with three specific kinds of corrective experiences:

• achievements

• new durable relationships

• disillusionments

Aetiology

• Emotionally unattuned, unresponsive, and cold attachment is

assumed pathogenic for some, perhaps temperamentally more

vulnerable, in the development of NPD.

• Compared to BPD, much less physical or sexual abuse

experiences among NPD patients.

• Important risk factors for the development of NPD.

• Cold overcontrolling parents may stimulate vulnerable

narcissism

• Permissiveness may be a risk factor for grandiose narcissism

• There is (limited) evidence that there is genetic liability explaining

about 40% of the variance for NPD.

Risk factors : suicide acts as a way to protect their sense of self/more succesful their suicide
attempts compared to BPD

Psychodynamic theory Kohut

• Central to Kohut’s thinking is the concept of self objects.

• Self-objects are representations in one’s mind of

close, sustaining relationships that fuel a sense of

personal strength and confidence.

• When these intrapsychic self object fail to develop

adequately, a feeble self- structure with

compromised affect regulatory capacity will emerge.

• Archaic grandiosity remains if the mother’s

confirming responses are deficient and if the

empathic attunement between mother and child is

severely lacking.

-put NPD in the neurotic spectrum of psychopathology

Kernberg

• Kernberg (1984, 1996) places the NPD at the borderline level of

organization.

• The structural damage of NPD patients is rooted in growing up in an

emotionally depriving environment, e.g. a chronically cold,

unempathetic mother.

• Feeling unloved and “bad”, the child projected his rage onto his

parents, who then were perceived as even more sadistic and

depriving.

• The child’s defense was to take refuge in some aspect of himself that

his parents valued. Thus, the “grandiose self” developed.

• Therapist needs to interpret the defensive function of the grandiosity

to the patient, i.e. it protects them from feeling unlovable and inferior.
• The interpretations aim to connect the extreme positive (grandiose)

and negative (inferior, unlovable) self-representations.

Social learning model

• Millon (1981), posited that parental overvaluation rather than devaluation is at the root of NPD.

• Children are led to believe they are special and perfect

through a constant showering of attention and

admiration.

• When disappointment occurs, the overinflated sense of

self-worth fuels rage.

• This overinflated self-image is intermittently reinforced,

thus making it highly resistant to extinction.

Theoretical models of NPD

• The covert narcissist / avoidant subtype does not overtly exhibit

haughtiness and arrogance, but secretly holds a similar sense of entitlement

and grandiose expectations.

• The covert NPD is an avoidant subtype is conflicted between asserting their

demands, and being ashamed about them and stifling them.

• However, the motivation is quite different: NPD patients do not wish

to expose themselves to the disappointment and shame of unmet

expectations, while the avoidant PD patients fear social rejection

because of being inadequate.

Histrionic PD

• Comorbidity with BPD, narcissistic, and dependent

personality disorders is very high

• Biological and genetic studies have not found relevant

factors associated with histrionic PD

• Histrionic PD on its own hardly leads to significant

impairment.

Alternative model personality traits

1.negative affectivity

2.detachment

3.antagonism

4.disinhibition

5.psychoticism

Dependent and histrionic

• In dependent PD, the individual is excessively dependent on others for

praise and guidance, but is without the flamboyant, exaggerated,

emotional features of individuals with histrionic PD.

• In Histrionic excessive emotionality and attention seeking, in order to be

center of attention, because when they are not in the center they feel

empty and lonely.

• Dependent PD: “functional dependency”: incompetence, lack of self�confidence and

continuous reassurance and support in practical areas

from someone stronger than him/herself.

Histrionic and comorbidity

• Histrionic PD is associated with

• eating disorders and fibromyalgia.

• substance abuse.

• somatic symptom disorder, conversion disorder

• major depressive disorder

• Histrionic traits during adolescence are associated with eating

disorder symptomatology in adulthood

• Women with vaginismus showed significantly higher histrionic

symptoms and traits compared with subjects with other sexual

complaints.

Cluster B and stalking

Meloy’s theory on stalking

• Stalking behavior is a reflection of attachment

pathology.

• Perceived rejection or abandonment activates

the stalker’s maladaptive attachment system.

• The intrusive behavior and violent efforts to

regain the partner can best be seen as a protest

towards being abandoned.

• The stalker, motivated by the disintegration

anxiety of a vulnerable self-system, is unable to

let go of the person who holds the key to his

fragile psychic equilibrium.

Chapter 7 * In contrast to suicide attempters with other Cluster B personality disorders, suicide
attempters diagnosed with narcissistic personality disorder are less impulsive but have suicide
attempts characterized by higher lethality
-they can experience empathy and mentalize with others but they refuse to do it

*the prevalence in the community is around 1% so not as common as other PDs

-has overlap with cluster b specifically antisocial and borderline

Kernberg-because of neglectful parents, the child starts acting bad in hopes of being noticed, the
child thus takes refugee in a part of himself that his parents value which gives birth to the
grandiose sense of self / the therapists has to connect this sense of self to the interpretation of the
way in which it helps the patient

*paradox of narcissism-narcissist are high in explicit but low in implicit self esteem, so they
want to seem confident but in reality are insecure

Young-schema therapy creator -lonely child, the self-aggrandizer, and the detached protector
modes pre-eminent in narcissistic PD/As a young child, the narcissistic PD patient feels unloved
and unlovable, and develops the emotional deprivation schema/ when the schema is triggered
they try to switch to the coping such as detached protector or self-aggrandizer

-schema-focused therapy aims to teach the patient to love and be loved to repair the emotional

deprivation scheme of the lonely child, and to develop more adaptive options of coping with
emotional pain by strengthening the healthy adult mode at the expense of the self-aggrandizer
and the detached protector modes.

Developmental perspective

-40%heritability and the rest is environmental influence/ factors that put you at risk include
cold,harsh parents for vulnerable narcissism and too permissive for grandiose narcissism

-vulnerable or cover narcissist does not overtly exhibit the haughtiness and arrogance
characteristics of narcissistic PD, but secretly holds a similar sense of entitlement and grandiose
expectations

Histrionic personality disorder - does not carry the negative ethical implications of the other
personality disorders from ClusterB

*In a review of 16 studies (Samuel & Widiger, 2008) histrionic personality was correlated
positively with all six Extraversion Facets: Warmth, Gregarious, Assertiveness, Activity,
Excitement Seeking, and Positive Emotions

-histrionic has been shown to be associated with eating disorders

Lecture 8 Schizotypal, schizoid and paranoid

-prevalence in common population 4%

• Schizoid PD is the least studied among PDs

• Paranoid PD is also marginally studied, and does rarely occur as a stand alone in clinical
practice

Paranoid theories

-psychodynamic theory : defense mechanism to help them cope with the feelings of shame and
guilt they felt because of their critical environment

-Distrust and lack of confidence in others are cognitive defenses against the subjects’ feelings of
low self-esteem and the perception that they will be rejected and fail

-cbt:CBT emphasizes the core assumption of PPD sufferers that others are malevolent,
deceptive, and ready to attack if they get the chance- so individuals with pb are vigilant so they
can prevent attach or see attach coming and protect themselves

*In combination, these view theorize that paranoid tendencies

are linked to attempts to maintain self-esteem by attributing

negative events to the actions of other people

Biases

-attributional bias-• They have a personalizing bias rather than a general external attribution for
negative events, i.e. they blame other people rather than the situation/they seem to put the blame
on the outside rather than themselves

-reasoning bias-they require less information before they make a decision and in general tend to
jump to conclusions before having more evidence

Schizoid PD

The core feature are:

-social detachment

-lack of feelings/anhedonia

- withdrawal
*elderly report more prevalence of spd than young people but that might just be due to the fact
that older people present characteristics due to age and not necessarily pd

-nutritional deficiencies in the early gestation phases were associated with more cases of schizoid
especially in men

Pharmacological treatment

• Studies evaluating the use of olanzapine, risperidone, haloperidol,

fluoxetine, and thiothixene did yield beneficial results for STPD;

however, treatment with such agents should be considered on a

case-by-case basis.

Pharmacotherapy in Cluster A is given for:

- Affective dysregulation (angry, anxious, depressed, labile mood)

- Cognitive-perceptual symptoms (auditory, visual hallucinations)

- Impulsive aggression (self-cutting, suicidality)

Etiology

-genes predispose some people to higher levels of schizotypy but the interaction between genes
and environment and perinatal conditions is what leads to the development of the disorder

-twin and family studies show high heritability 60%

Individuals with schizotypal PD (moderate) and schizophrenia (severe)

share deficits in cognitive domains

1. Attention deficits: In both the ability to sustain and inhibit attention.

2.Memory deficits: In working memory and episodic memory

3.Impaired executive functioning

Chapter 9

-unlike schizophrenia, schizotypal is stable over time and does not only manifest during stressful
periods
-negative schizotypy reflects a pattern of social withdrawal and anhedonia, the diminished
capacity to experience pleasant emotions that may later manifest itself as negative symptoms of
schizophrenia. /predicts emotional disturbances

-Similarly, positive schizotypy reflects idiosyncratic cognitive styles that may later deteriorate
into the positive symptoms of schizophrenia, including delusions and hallucinations/predicts
psychotic like symptoms

* It has been found in twin-studies that shared genetic risk factors for schizotypal as well as
paranoid PD are highly stable in adults over a ten-year period while environmental risk factors
are less stable.

Cognitive impairments in the following areas :

-attention deficits

-memory deficits

-impaired executive functioning

*several studies have shown that artists score higher than the general population on sportive
schizotypy

Schizoid personality disorder

-least studied in the literature

Consists of 3 factors

-social detachment

-withdrawal

-lack of attachment

*has been associated with autism spectrum disorder /has a high prevalence in violent crimes ,
specifically prevalent in prison populations despite the small general population prevalence

Paranoid personality disorder

-the paranoid ideas are seen as a coping/defensive mechanism

-many of those patients avoid self blaming or responsibility by putting it on others

Article Koch
 Personality disorders, including cluster A disorders such as paranoid, schizoid, and schizotypal
personality disorders, are characterized by enduring patterns of behavior, cognition, and inner
experience that deviate from cultural expectations and cause distress or impairment in social,
occupational, or other important areas of functioning. Pharmacotherapy is often considered as an
adjunctive treatment for severe cases of personality disorders, aiming to provide stabilization to
facilitate engagement in psychosocial interventions.

In the context of cluster A personality disorders, pharmacotherapy is typically used off-label, as

there are no FDA-approved medications specifically indicated for these conditions. Studies have
explored the use of various medications, including antipsychotics like flupentixol, bromperidol,
and promazine, as well as antidepressants such as thiothixene, olanzapine, risperidone,
haloperidol, and fluoxetine, in managing symptoms associated with these disorders. These
medications have shown some efficacy in addressing affective dysregulation,
cognitive-perceptual symptoms, and impulsive aggression commonly seen in cluster A
personality disorders.

However, the existing literature on pharmacotherapy for cluster A personality disorders is limited
by factors such as small sample sizes, high rates of comorbid conditions like borderline
personality disorder, and methodological limitations in study designs. The effectiveness and
safety of pharmacological interventions for personality disorders remain areas that require
further investigation and research to establish evidence-based treatment approaches.

In conclusion, while pharmacotherapy can play a role in the comprehensive management of

cluster A personality disorders, it is essential for healthcare providers to carefully consider the
risks and benefits of medication use in each individual case. Collaborative and multidisciplinary
approaches that integrate pharmacotherapy with psychosocial interventions are likely to be most
beneficial in addressing the complex and multifaceted nature of personality disorders.

Lecture 9

Mentalization based treatment

-mentalizing=implicitly and explicitly interpreting the actions of oneself

and others as meaningful on the basis of intentional mental states

*Rooted in Attachment theory and Psychodynamic concepts

Mentalizing

• Multidimensional construct with the following polarities:

–Automatic versus controlled

– Internally versus externally focused

–Self- versus other-oriented

– Cognitive versus affective

Good mentalizing

Bad mentalizing

Developmental roots of mentalizing

-partly developmental achievement

-the achievement depends upon the quality of the attachment relationship

-disturbances in the early childhood and attachment traumas can

have a profound detrimental impact on this developmental process

-mentalizing start even before birth as parents start thinking about their future child

• Through their mirroring of (their reading of) the child’s mind,

parents give the message that the child has a mind and an ‘I’

• Through their mirroring, parents substitute the ‘effect’ by

something else (a ‘word’): representation

• In this way mirroring contributes to an inner representational

world in which affective somatic states (‘distress’) can become

represented, differentiated, understood

-mentalizing develops in childhood until the age of 4 and then it gets better as you mature

*congruent -what is being mirrored should match what the child is feeling

*marked -it should be clear that you are mirroring the child's feelings so exaggeration
Problems arise when:

-there is no mentalizing so for orphans

-if the mirroring is bad so incongruent or unmarked

-if trauma is taking place

Epistemic trust

• A human specific, cue –driven social cognitive adaptation of

mutual design to ensure efficient transfer of relevant cultural

knowledge

• Humans are predisposed to teach and learn new and relevant

cultural information each other:

– Cultural knowledge

– Generic knowledge

• Transfer by way of Marked and Ostensive communication:

–Signal information is relevant to the listener

– Information is generalizable to other situations

Ostensive Cues

• Eye contact

• Turn taking contingent reactivity

• Motherese

• Name calling

• Signals to get across relevant

information

• Feeling of being recognized as a

individual

• Attention: ‘this information is

especially relevant to me’

*deconstruction of epistemic trust by neglect or trauma /lack of epistemic trust leads to trust
issues and vigilance /difficulty to change and epistemic hunger

-if the metalizing does not develop correctly the person continues to act in a primitive way

oUnmarked mirroring is associated with psychic equivalence

mode: inner and outer reality are the same, what I feel and

think, is true

oEven more primitive is the teleological mode: only concrete

actions are real

oIncongruent mirroring is associated with pretend mode: inner

and outer reality are decoupled: dissociation, emptiness,

meaninglessness

• A ‘part of the self’ is being left unmentalized, the ‘alien self’

oAlien self is painful, threatens the stability of the sense of self

(a ‘discontinuous’ part of the self), therefore it should be

evacuated (projective identification)

Biobehavioral switch model

BPD from this perspective

• BPD patients can mentalize, but lose their ability to mentalize easily

o Insecure attachment: sensitive for experiences of loss

o Hyper-activation of the attachment system (‘triggered too readily’)

o Long recovery time to regain mentalizing abilities

• This forces them to rely upon pre-mentalizing modes

o Psychic equivalence: rigid, black and white thinking, hostile,

paranoia, mood swings, overwhelming impulses and aggressiveness

o Pretend: dissociation, meaninglessness, emptiness, detachment from

others

o Teleological: needy for concrete actions from others

• BPD symptoms can be understood as consequences of a loss of

mentalizing

Characteristics of MBT:

• High level of structure

• Dosage/intensity adapted to the patients capacity to tolerate

• (Striving for) a consistent, coherent and reliable application

• Active, outreaching approach

• Focus on affective, mental states

• Focus on mentalizing process

• Focus on relationship (including patient-therapist)

Clarification and elaboration

-step by step reconstruction of the events

-trace actions to feelings

-investigate non mentalizing signs

Three treatment phases:

– Initial phase:

• Assessment, psycho-education, treatment plan,

crisis planning

• Focus on commitment and destructive behavior

– Main phase:

• ‘Hard work’

• Focus shifts towards mentalizing of relationships

(transference)

– Termination phase:

• Separation

• Reintegration Treatment plan

– Dynamic case formulation

– Treatment goals

• Commitment to the treatment

• Reducing psychiatric symptoms

• Improving interpersonal relationships

• Reducing (self) destructive behavior

• Improving social and occupational functioning

– Crisis plan
• Signals of escalating crisis + actions

• Emergency pathway

Article Bateman

Mentalization, the ability to understand actions based on underlying mental states, plays a crucial
role in interpersonal interactions. Individuals with Borderline Personality Disorder (BPD) and
Antisocial Personality Disorder (ASPD) often struggle with mentalizing, leading to instability
and imbalances in cognitive-affective processes. In BPD, there is a tendency towards excessive
affective mentalizing with low cognitive mentalizing, resulting in heightened sensitivity to others
but a diminished sense of self. Clinical intervention for BPD focuses on managing emotional
dysregulation by enhancing mentalizing and improving cognitive control of emotions.

In ASPD, individuals may exhibit higher cognitive mentalizing of self and others, often
combined with tendencies towards exploitation or control of others due to a lack of affective
empathy. The clinical task in ASPD is to increase affective mentalizing and empathy for others.
Mentalization-Based Treatment (MBT) suggests focusing on identifying nonmentalizing loops
and promoting more mentalizing loops to improve understanding of emotions, recognizing
others' feelings, and empathizing with their experiences for more constructive interpersonal
behavior.

MBT aims to develop full mentalizing capacities by addressing vulnerabilities and imbalances in
mentalizing. Trauma or adverse experiences can further disrupt mentalizing as a protective
mechanism, limiting exposure to dehumanizing experiences. MBT interventions are structured
around collaborative formulation, monitoring mentalizing capacity, and addressing mentalizing
vulnerabilities to enhance stability and improve outcomes for individuals with ASPD and BPD.

Rooted in neuroscience and attachment research, MBT offers a structured approach to identify
triggers of non mentalizing episodes and promote mentalizing stability. By targeting mentalizing
vulnerabilities at the core of ASPD and BPD, MBT has shown positive outcomes in reducing
symptoms and enhancing quality of life for individuals with these personality disorders. The
focus on enhancing mentalizing capacities and addressing imbalances provides a comprehensive
framework for effective clinical intervention and treatment.

Overall, MBT emphasizes the importance of understanding mentalizing as a multidimensional

process that fluctuates based on individual strengths and weaknesses. By integrating cognitive
and affective mentalizing, MBT aims to foster empathy, self-coherence, and improved
interpersonal relationships. The approach involves a combination of psychoeducation,
interpersonal processes, and collaborative goal-setting to support individuals in developing
robust mentalizing skills and achieving better outcomes in managing personality disorders.
Article Gardner

The qualitative study delved into the experiences of service users undergoing or having
completed intensive outpatient Mentalization-Based Treatment (MBT) for Borderline Personality
Disorder (BPD) within the United Kingdom. The analysis of responses to semi-structured
questions was conducted using Interpretative Phenomenological Analysis (IPA) following
guidelines outlined by Smith et al. (2009). IPA was chosen to place individual participants, their
attitudes, and beliefs at the core of the analysis, emphasizing the importance of understanding the
subjective experiences of those receiving MBT.

Transcripts were meticulously analyzed by the first three authors, who then collaboratively
discussed, debated, and agreed upon codes and emergent themes. The authors, with extensive
experience in working with individuals with personality disorders or research expertise in the
field, ensured that potential biases were addressed to maintain the credibility and trustworthiness
of the data.

The study identified three superordinate themes: being borderline, being in the group, and being
on a journey. Participants shared their experiences of grappling with their BPD diagnosis,
engaging in therapy, and navigating the challenges and transformations that occurred during their
therapeutic journey. The study highlighted the significance of therapist qualities such as empathy,
trust, and the ability to mentalize effectively in supporting individuals with BPD through their
treatment.

Group therapy emerged as a central aspect of MBT, providing a platform for participants to
engage with shared experiences, confront challenges, and foster interpersonal connections. While
participants found group therapy both challenging and essential for their progress, they also
emphasized the transformative impact of shared experiences and emotional support within the
group setting.

The study underscored the importance of capturing the nuanced experiences of service users to
enhance the understanding of recovery and change during MBT. Participants discussed
improvements in skills, social interactions, and personal growth, indicating the broader impact of
therapy beyond symptom reduction. The findings suggested that changes experienced during
therapy extended into participants' daily lives, emphasizing the holistic nature of recovery in
individuals with BPD.

Overall, the study contributes valuable insights into the lived experiences of individuals
undergoing MBT for BPD. The clinical implications of the findings underscore the need for
continued research to explore the experiences of both therapists and clients, with the aim of
optimizing MBT programs and improving outcomes for individuals with BPD. Understanding
the multifaceted journey of individuals with BPD in therapy can inform tailored interventions
and enhance the effectiveness of treatment approaches for this complex and challenging disorder.