Frank E. Yeomans

Transference-focused psychotherapy.

Transference-Focused Psychotherapy (TFP) is a manualized evidence-based treatment for borderline and other severe personality disorders that is based on psychoanalytic object relations theory. The treatment contracting/setting the frame, managing countertransference, and the interpretative process are three critical components of TFP. We provide vignettes to illustrate these techniques and data that support their role in facilitating treatment outcome.

Refining the Borderline Personality Disorder Phenotype through Finite Mixture Modeling: Implications for Classification

Borderline personality disorder (BPD) is characterized by considerable heterogeneity. Prior approaches to resolving heterogeneity in BPD pathology have used factor and cluster analytic as well as latent class analysis strategies. These prior studies have been atheoretical in nature, but provide an initial empirical corpus for further sub-typing efforts in BPD. A model-based taxonomy for BPD that is supported by evidence from an advanced statistical methodology would enhance investigations of BPD etiology, pathophysiology, and treatment. This study applied finite mixture modeling analysis, in a model-guided fashion, to selected dimensions of pathology within a group of well-characterized BPD patients to determine if latent groups are harbored within the disorder. Subjects with BPD (N = 90) were examined on a variety of model-relevant psychopathology dimensions. We applied finite mixture modeling to these dimensions. We then evaluated the validity of the obtained solution by reference to a variety of external measures not included in the initial mixture modeling. Three phenotypically distinct groups reside within the overall BPD category. Group-1 is characterized by low levels of antisocial, paranoid, and aggressive features. Group-2 is characterized by elevated paranoid features, whereas Group-3 is characterized by elevated antisocial and aggressive features. External correlates reveal a pattern of differences consistent with the validity of this proposed grouping structure. A theory-guided finite mixture modeling analysis supports a parsing of the BPD category into three subgroups. This proposed BPD taxonomy represents an approach to reducing heterogeneity observed among BPD patients and it may prove useful in studies seeking to understand etiologic and pathophysiologic factors as well as treatment response in BPD.

Borderline personality disorder, bipolar disorder, depression, attention deficit/hyperactivity disorder, and narcissistic personality disorder: Practical differential diagnosis.

The challenge of accurate diagnosis remains at the heart of good psychiatric treatment. In the current state of psychiatry, a confluence of forces has increased this challenge for the clinician. These include practical pressures-such as limited time for diagnostic evaluation, the question of what is reimbursed by insurance, and the issue of directing patients to acute treatments-and also trends in nosology, such as the descriptive focus on signs and symptoms in the current official diagnostic system. The authors offer observations that we hope will help clinicians who have to make difficult diagnostic differentiations often under pressured circumstances. The paper is motivated both by the high frequency of diagnostic errors observed under such conditions and also by the belief that considering symptoms in the context of the patients sense of self, quality of interpersonal relations, and level of functioning over time will help guide the diagnostic process.

Narcissistic personality disorder: diagnostic and clinical challenges.

“Mr. A” is a 42-year-old married man presenting to a private-practice psychotherapist complaining of problemswithhiswife.He is a successful entrepreneur, highly competitive, who describes enjoying social gatherings, where he tends to be the center of attention, as well as challengesatwork,wherehebelieves thathehasa superior ability to solveproblems.Hecomesto treatmentbecausehe is wondering whether or not to stay in his marriage. Mr. A described having lost all sexual interest in his wife during their early years together. Throughout themarriage, he has maintained a series of lovers whom he has housed, supported, and then cut off and replaced. He feels that this arrangementhashadno impact onhis relationshipwithhis wife but wonders if he would do better with someone else. “Mr. B” is a 34-year-old single man with a history of cocaine and alcohol abuse, currently unemployed. He presented to the emergency department complaining of pain following a dental procedure and requesting Percocet (acetaminophen and oxycodone). Although he was initially ingratiating with the attending physician who took his history, when she explained that she would have to speak with his oral surgeon before writing a prescription for anarcotic,Mr.Bbegan to insult andbullyher. The attending spoke with Mr. B’s “girlfriend,” whose contact information he had provided. The girlfriend explained that she had recently broken things off withMr. B because he had been exploiting herfinancially; since being fired 1 year earlier from a high-paying financial job, he had been unable to find employment that met his lofty expectations for himself, preferring instead to live off money from his father and his girlfriend. “Mr. C” is a 29-year-old single man with a history of insulin-dependentdiabeteswhopresents toanoutpatient clinic for treatment of dysthymia and social phobia. He has held a series of low-level jobs that “have not worked out,” and he currently works part-time doing data entry. Mr. C described his mood as chronically “miserable.” Socially isolated and easily slighted, he has no interests, takespleasure innothing, androutinelywonders “whether life isworth living.”When feeling down, he often “forgets” to administer his insulin, resulting in multiple hospitalizations for hyperglycemia. He constantly compares himself with others, feeling envious and resentful, and describes himself as deficient and defective. At the same time, he resents that others fail to recognize all he has to offer. At times he engages in fantasies of his employer publicly acknowledging his special talents and promoting him; at other times, he has fantasies of humiliating his boss with a display of superior knowledge. “Ms. D” is a 44-year-old single woman referred to a group specializing in severe personality disorders. She complained of “refractory depression” for which shewas on medical disability. She had been treated for 10 years with every modality her local hospital could offer, including ECT. She portrayed her previous therapists in scathingly derogatory terms, seeming tofind gratification in their failed attempts to help her. Her group therapist diagnosed her with narcissistic personality disorder based on the gap between her self-image as an extremely gifted but unrecognized author and the reality that she had written almost nothing. Antisocial features consisted of chronic lying, a history of prostitution in her 20s, and “working the system” to obtain disability payments rather than taking onwork that shewas able to do. Therewere no neurovegetative symptoms of depression. When her new therapist raised the possibility of working toward employment,Ms. D coolly declared that shewould kill herself, orhim, ifhe interferedwithherabilitytoobtainherbenefits.

Studying the treatment contract in intensive psychotherapy with borderline patients.

A pilot study on the process of psychodynamic psychotherapy of borderline personality disorder at the Cornell University Medical College is designed to investigate the teaching and application of a specific model of treatment for borderline patients (Clarkin et al. 1992; Kernberg and Clarkin 1992). The project has involved teaching a group of self-selected trainees and faculty the manualized therapy (Kernberg et al. 1989); taping each of the twice-weekly therapy sessions over a period of 2 years; and rating (1) each therapists adherence to the manual (Koenigsberg et al. 1985), (2) each therapists skill, and (3) patient change. The patients are women with borderline personality disorder, between 20 and 40 years of age, diagnosed by DSM-III-R criteria (American Psychiatric Association 1987), SCID-II (Spitzer et al. 1987), and a self-report questionnaire for level of personality organization. At regular intervals, the patients are evaluated for symptom status, change in BPD criteria, and functioning. The therapists are evaluated for adherence to the manual and level of therapeutic skill. In teaching and carrying out the manualized therapy, it became clear that a critical moment in the treatment was the setting up of the treatment contract. A study was organized to look systematically at the adherence of the therapists to the model of treatment with regard to this initial phase of the therapy.

Transference-Focused Psychotherapy for Borderline Personality Disorder: A Clinical Guide

Preface. The nature of normal and abnormal personality organization. Empirical development of transference-focused psychotherapy. Strategies of transference-focused psychotherapy. Assessment phase: clinical evaluation and treatment selection. Establishing the treatment frame: contracting, medication, and adjunctive treatments. Techniques of treatment: moment-to-moment interventions and mechanisms of change. Tactics of treatment and clinical challenges. Early treatment phase: tests of the frame, impulse containment, and identifying dyads. Midphase of treatment: movement toward integration with episodes of regression. Advanced phase of treatment and termination. Trajectories of change in transference-focused psychotherapy. References. Index.

The Efficacy of Psychotherapy: Focus on Psychodynamic Psychotherapy as an Example

The growing number of individuals seeking treatment for mental disorders calls for intelligent and responsible decisions in health care politics. However, the current relative decrease in reimbursement of effective psychotherapy approaches occurring in the context of an increase in prescription of psychotropic medication lacks a scientific base. Using psychodynamic psychotherapy as an example, we review the literature on meta-analyses and recent outcome studies of effective treatment approaches. Psychodynamic psychotherapy is an effective treatment for a wide variety of mental disorders. Adding to the known effectiveness of other shorter treatments, the results indicate lasting change in many cases, especially for complex and difficult to treat patients, ultimately reducing health-care utilization. Research-informed health care decisions that take into account the solid evidence for the effectiveness of psychotherapy, including psychodynamic psychotherapy, have the potential to promote choice, increase mental health, and reduce societys burden of disease in the long run.

Comorbid mood disorders as modifiers of treatment response among inpatients with borderline personality disorder.

Structured clinical interviews of 63 female inpatients diagnosed with borderline personality disorder were used to study the relations of comorbid mood disorders to treatment response. Diagnostic information was gathered using the Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II) and the Structured Clinical Interview for DSM-III-R-Patient Version (SCID-P). Information about psychotic symptoms was also based upon responses to the SCID-P. Treatment response was assessed through weekly ratings on the Symptom Checklist-90-Revised over 25 weeks of hospitalization. Initial depression but not initial or previous bipolar disorder was found to predict treatment course. Initial psychotic symptoms were also found to predict treatment course among patients with initial bipolar disorder and tended to modify the trajectory of symptoms over time among patients with initial depression. Possible explanations for these findings are explored and discussed.

Change in Attachment and Reflective Function in Borderline Patients with and without Comorbid Narcissistic Personality Disorder in Transference Focused Psychotherapy

Abstract Research has consistently found high rates of comorbidity between narcissistic personality disorder (NPD) and borderline personality disorder (BPD). Patients with this complex clinical presentation often present formidable challenges for clinicians, such as intense devaluation, entitlement, and exploitation. However, there is a significant gap in the literature in identifying the clinical characteristics of these NPD/BPD patients. In this article, we present recent research describing patients with comorbid NPD/BPD, as compared with patients with BPD without NPD (BPD), from two randomized clinical trials for the treatment of borderline personality disorder, with a particular emphasis on attachment status and mentalization. We anchor our discussion of these patients in object relations and attachment theory, and we describe our treatment approach, transference focused psychotherapy (TFP). We conclude by using case material to illustrate our research findings, highlighting the significant differences between patients with NPD/BPD and BPD/non-NPD in terms of their attachment classification.

New developments in the investigation of psychodynamic psychotherapy

Psychodynamic psychotherapy, a field that once lagged behind other areas in psychiatry with regard to empirical studies, has gone through a culture change. Methods of research that were once felt to be, at best, an awkward fit with psychodynamic therapy are being applied with positive results. Major efforts have been made in instrument development, the manualization of therapies, and process and outcome studies. There is also increasing dialogue with other fields, such as neurobiology, reflecting sophisticated attempts to link a psychodynamic understanding of pathology and treatment to physiological underpinnings. This review discusses the large variety of current research efforts and highlights some important recent developments.