Article Review: Early Identification of and Treatment for Borderline Personality Disorder

 

Sharp and Fonagy (2015) offer a review of the phenomenology, prevalence, etiology, clinical problems, and interventions for adolescents with BPD. Borderline personality disorder (BPD) is said to capture the core of personality pathology (Sharp & Fonagy, 2015).  The symptoms of BPD usually manifest in adolescence (Chanen & Kaess, 2012, as cited in Sharp & Fogay, 2015); yet many clinicians are hesitant to diagnose personality pathology in children due to the presumed normal emotional liability during this developmental period.  Interesting though, this period of turmoil has received only limited support in the research (Cicchetti & Rogosch, 2002, as cited in Sharp & Fonagy, 2015).  Furthermore, a poor prognosis is often associated with individuals that have problems throughout adolescence, and as cited by Paris (2015), pathological symptoms greater than one year should not be dismissed and may likely be associated with BPD.   Regardless, the symptoms of BPD compared to typical adolescence are often more severe, pervasive, long-standing, and reflected in both internalizing and externalizing disorders.

 

Sharp and Fonagy (2015) report that studies for early detection of BPD in adolescence have shown that “chronic feelings of emptiness and inappropriate, intense anger” are considered the “most stable symptoms,” whereas identity disturbance, affective instability, and intense anger have the “greatest predictive power for development of BPD” (p. 1268). These characteristics are said to be consistent across age groups.  Additionally, for boys, paranoid ideation, and in girls, identity disturbance, have shown to be discriminating symptoms of BPD in adolescents.  Persistent self-harm behaviors are known to distinguish BPD from other disorders. Similar to adults with BPD, risk factors in adolescents with BPD are general impulsivity, risky behaviors, difficulty dealing with stress, and negative affect.  Impairment in social and academic functioning is also common.

 

As cited in Sharp and Fonagy (2015), Chanen & Kaess (2012) describe BPD as a developmental disorder. Research has indicated a mean age of onset at 18, with a standard deviation of 5- 6 years. Adolescence is said to be a critical period for the development of BPD due to the social demands (e.g., establishing stable friends, remaining close to family).  Furthermore, the social and emotional development in adolescence is associated with functional and structural brain changes.  While, BPD symptoms appear in adolescence, they are known to peak in early adulthood, with a decline in impulsive symptoms over time. Affective symptoms are more likely to persist.  Sharp and Fonagy (2015) have shown evidence for heterotypic developmental course, meaning that there is “coherence in the underlying organization or meaning of behaviors over time” (p. 1271).

 

Regarding comorbidity, BPD in adolescence is highly associated with internalizing and externalizing disorders. Sharp and Fonagy (2015) cite that around 70% of adolescents with BPD have comorbid mood disorders, 67% have anxiety disorders, and 60% have externalizing disorders.  Thus, the authors argue that BPD is a confluence of both externalizing and internalizing disorders, and is not a female expression of antisocial personality disorder.  Additionally, there is evidence that constitutional factors (i.e., temperament) and environmental factors have a role in BPD etiology.

 

Yet, it is also difficult to distinguish BPD from other clinical disorders. For identification of BPD, several measures have shown clinical utility (See Sharp & Fonagy, 2015, for a more comprehensive review).  Clinical assessment along with an objective measures is thought to be best clinical practice for precision in diagnosis. Regarding intervention, there is not a wealth of information available.  Programs such as Helping Young People Early (HYPE) and Dutch Emotion Regulation Training (ERT) are early intervention efforts for BPD.  They are based on cognitive analytic therapy and cognitive-behavioral elements and skills training, respectively. Cognitive-analytic therapy integrates psychoanalytic object relations theory and cognitive psychology and has demonstrated effectiveness and rapid recovery.  Mentalization-based treatment for adolescents has similar components to cognitive analytic therapy and has shown effectiveness by “improved mentalizing and reduced attachment avoidance” (p. 1281).  Dialectical behavior therapy (DBT) has also been adapted for treatment of BPD in adolescents. DBT targets emotional dysregulation, distress tolerance, and interpersonal difficulties.  Transference-focused psychotherapy is grounded in object relations theory and has been adapted for adolescents, but has not underwent RCT to assess its effectiveness.

 

Sharp and Fonagy (2015) conclude that successful interventions should contain extensive efforts to maintain engagement in treatment, have an evidence-based model of developmental pathology, and have an active therapist role, with a focus on validation and modeling of empathy, as well as the development of a strong attachment. Additionally, there should be a facilitation of trust and belief that something can be learned in therapy.  Treatment should focus on emotional processing and the connection between action and feelings, have structure to promote activity, proactivity, and self-agency, as well as be manualized, with supervision for deviations from the manual.   There should be a commitment to the approach in treatment between both the therapist and client.

 

Evidence-based treatments for BPD have common treatment characteristics (Bateman, Gunderson, & Mulder, 2015). They are structured (manual directed) and they encourage clients to control themselves (agency). Therapists help connect feelings and actions and are active, responsive, and validating. They also discuss cases with others (i.e., supervision and/or consultation).

 

Overall, there is a delicate balance in assessing BPD in adolescents compared to recognizing the potential for emotional liability during this developmental period. Yet, understanding the clinical picture, as well as the distinguishing pervasive features of BPD, will help differentiate it from either normal turmoil and/or other disorders.  Finally understanding treatment options can help clinicians gain confidence in identifying and providing subsequent treatment for adolescents with BPD.

 

 

References
Bateman, A. W., Gunderson, J., & Mulder, R. (2015). Treatment of personality disorder. The Lancet, 385, 735-743.

 

Sharp, C., & Fonagy, P. (2015). Practitioner review: Borderline personality disorder in adolescence – recent conceptualization, intervention and implications for clinical practice. The Journal of Child Psychology and Psychiatry, 56(12), 1266-1288.

 

Dannie S. Harris, MA
WKPIC Doctoral Intern

Friday Factoids Catch-Up: Memory, the Real McCoy?

Memories develop starting at birth and continue to develop throughout the life cycle as we age. The brain remembers by association, strengthening neural connections through repetition (“use it or lose it principle”) (Willingham, 2007).  Research has shown that, although memory is often considered to be a singular ability in and of its self, it is actually a process of at least three inter-related functions: encoding, storage, and retrieval.  The first step to creating a memory is encoding, a crucial step involving the conversion of the perceived item of interest into a construct that can be stored, and then later recalled through retrieval processes, from either short- or long-term memory at some point in the future.  The process of storage occurs between encoding and retrieval, when the memory exists only as a possibility for remembrance. (Arbuthnott, et al., 2001)  Memories are, in a sense, us; they chart our life details.  There are several types of memory processes that deal with differing aspects of how memories are formed.  Short- and long-term memory are the two most common forms people tend to recognize, but there are others, such as associative, elaborative, and autobiographical, that come into play.

 

The study of memory in early childhood is centered around development as it relates to the cognitive self, and a particularly important aspect of early memory centers on childhood amnesia, specifically the fading ability to recall events that occur during early childhood.  Although children may remember events prior to ages 3-4, those memories also tend to fade with time as we age. (Goleman, 1993; Willingham, 2007)  Most adults remember very little prior to age 3 or 4, since this is the age at which our cognitive memory first begins to truly function.  Prior to that age, the cognitive and language skills that are necessary for the processing of external events are not yet developed fully enough to allow this processing to occur, which is essential to the storing of events as memories. (Kihlstrom, 1994)   As aging occurs and cognitive and language skills improve, new knowledge is also being acquired, as well as the establishment of a sense of self.  During the aging process in children, major developments occur in the expansion of memory, perhaps with less processing being required to enable long-term storage.  According to a study published by the New York Times, memories that are autobiographical in nature begin when children learn about themselves and their early years through their parents. (Goleman, 1993)  Over time, as we navigate through the aging process, some memories fade, some are lost, and others are distorted as a natural result of the progression of time and aging.

 

Traditionally, faulty memory has often been associated with either the elderly or those who have suffered a traumatic brain injury, but the ongoing research that has occurred over the last couple of decades tells a different story.  There are certainly instances where people’s memories are obviously faulty, and often this is due to such factors as dementia, Alzheimer’s, concussion, or some other such factor exerting an influence on the brain’s ability to manifest an effective and accurate recall of prior events.  However, the distortion of memories, from the changing of details to the outright planting of false memories, has become an area of real interest and research due to the fact that the accuracy of memories can have much greater implications than just those that directly affect the individual in their quest for resolution of a particular psychological issue.  The likelihood of false memories, in conjunction with the fact that there is still much about the mind that we do not yet understand, make it a dangerous prospect for the therapist to suggest too much.  The evidence exists that people can be led to believe that they have experienced events in their lives that are patently untrue, or at the least, highly unlikely to ever have occurred. (Loftus, 2004)  One particular study showed that even a brief exposure to a false memory of a childhood event serves to boost their confidence that the event actually occurred. (Sharman, Powell, 2012; Garry, et al., 1996; Sharman, et al., 2005)  This was attributed to a phenomenon called imagination inflation.  The study participants were asked to rate their confidence levels on a range of childhood events that occurred prior to 10 years of age.  They were then asked two weeks later to imagine events that they indicated did not occur, and rate their confidence of the event occurrences a second time.  The confidence ratings of the events that did not happen were rated higher in confidence of their occurrence the second time around than the events that actually occurred, which were used as control events.

 

There are several techniques that have been used to attempt to determine the validity of false memories through “planting” of events that were false and never actually occurred, including hypnosis, guided imagery/imagination, dream interpretation, and picture cuing, and all proved successful at inducing false memories in research study participants in statistically significant numbers.  One of the earliest studies that specifically attempted to plant false memories for an entire event used a technique that came to be called the “lost in the mall” technique, which utilized stories about events that happened to participants as related by their parents, and included one wholly false story that was verified as having never occurred, usually lost in a mall, or, alternatively, spilling punch on a bride’s parents at a wedding or having a serious accident.  Based on the results of a series of interviews that utilized memory recovery techniques, 20%-25% of the study participants confirmed a memory of these false events even though they never actually occurred. It was also determined that these false memories exhibited high levels of detail and emotional responses in those that developed them. (Laney, Loftus, 2013)

 

Scoboria et al. (2004) posited a model for autobiographical beliefs and memories that, based on their research, indicated the memories, thoughts, and beliefs concerning plausibility of an event are of a “nested” format.  For a person to remember an event, they necessarily have to believe that it occurred, meaning that the memory itself is nested within confidence.  It also needs to be personally plausible, so confidence is nested within personal plausibility.  The event has to be plausible generally, so personal plausibility is nested within general plausibility. While the research shows that false beliefs and memories will increase due to repeated exposures, brief exposure to false events does not increase confidence or implant false memories. (Sharman, Powell, 2012)

 

The research on false memory has firmly established that people can be led to believe that they have experienced events that have never actually occurred.  Not only can these false memories be wrapped in exquisite detail and sensory associations of recollection, conveying all the characteristics of being the genuine article, but they can be extremely far-fetched in their subject matter such that they are extremely unlikely to be true, yet people will still insist on having experienced them.  The consequences of false memories can have far-reaching, and often unintended, consequences.  There are documented cases of people having spent decades of their lives in prison based on testimony that relied on what turned out to be an instance of false memory, and were only exonerated because of DNA evidence.  While this is an extreme example of the consequences of reliance on memory to be infallible, it clearly illustrates that memory is fluid, malleable, and completely vulnerable to improper influence and subsequent dubious recall.  As a Clinical Psychology student, I previously held to the belief that a memory which is uncovered during therapy is more than likely to be true.  After all, why would a profession devoted to helping people end up doing harm by implanting false memories?  In my opinion, it is not intentional harm on the part of the therapist but, rather, a misuse of techniques which can, and sometimes does, lead to disastrous consequences.  Knowing that memories can become twisted and confused should be reason enough to become skeptical of any method of regression treatment or therapy.

 

References
Arbuthnott, K. D., Arbuthnott, D. W., Rossiter, L. (2001). “Guided imagery and memory: implications for Psychotherapists”. Journal of Counseling Psychology Vol. 48, No. 2, 123-132. Retrieved from Ebscohost, November 17, 2016.

 

Durbin, P. G., Ph.D. Beware false memories in regression hypnotherapy. Retrieved November 16, 2016, from http://alchemyinstitute.com/false-memory.html

 

Goleman, D. (1993, April 6). Studying the secrets of childhood memory. The New York Times. Retrieved from http://www.nytimes.com

 

Kihlstrom, J. E. (1994). “Hypnosis, delayed recall and the principles of memory”. The International Journal of Clinical & Experimental Hypnosis. 1994, Vol. XLII, No. 4, 337-344. Retrieved from Ebscohost, November 15, 2016.

 

Laney, C., Loftus, E. F. (2013). “Recent advances in false memory research”. South African Journal of Psychology 43(2) 137-146. Retrieved from Ebscohost, November 17, 2016.

 

Loftus, Elizabeth F. (2004). ”Memories of things unseen”. Current Directions in Psychological Science. 2004. Vol. 13, No. 4, 145-147. Retrieved from Ebscohost, November 15, 2016.

 

Sharman, S. J., Powell, M. B. (2012). “Do cognitive interview instructions contribute to false beliefs and       memories?”. Journal of Investigative Psychology and Offender Profiling. 10: 114-124 (2013).

 

Willingham, D. T. (2007). Cognition: The thinking animal (3rd ed.). Upper Saddle River, New Jersey: Pearson.

 

Teresa King
Pennyroyal Doctoral Intern

 

Friday Factoids Catch-Up: Heroin and Fentanyl–A Match Made in Hell

 

Heroin use has always been a serious issue where drug abuse is concerned, but in the last few years it has become even more deadly due to fentanyl being added to give it more “kick”.  Dealers have begun including fentanyl to improve the potency of their product; however, the equipment they use to measure out amounts for trafficking don’t usually measure at levels fine enough to ensure that the amount of fentanyl that has been added stays below overdose levels.  To add to the danger, fentanyl sold at the street level is usually manufactured in “underground” labs which produce a far less pure product than pharmaceutical-grade labs, which can cause unpredictable effects on the body (Bond, 2016).

 

Heroin is classified by the DEA (Drug Enforcement Agency) as a Schedule I drug, while fentanyl is classified as a Schedule II drug.  Both are opioid derivatives; however, while heroin is synthesized directly from morphine, fentanyl is a synthetic opioid analgesic, with a potency of 50x to 100x that of morphine (NIDA, 1969, 2011, 2014).  While both have a high potential for abuse, there is a wide gulf between the two drugs with regard to the amount required to induce an overdose.  An average sized adult male would take around 30g of heroin to produce an overdose situation, roughly an amount similar to 7 packets of sugar.  By contrast, it would only take around 3g of fentanyl (little more than a ½ packet) to produce an overdose (Bond, 2016).

 

Fentanyl-laced heroin quickly reached crisis levels as it began to gain popularity among users.  In March of 2015, the (DEA) issued a nationwide alert in response to a surge in overdose deaths from heroin laced with fentanyl (19 March 2015).  While heroin has been recognized as having a high potential for abuse since the mid-1900s, fentanyl wasn’t added as a Schedule II substance until 2015, after recognizing that a variant, acetyl fentanyl, was being manufactured by Mexican cartels and smuggled stateside for distribution (10 September 2015).  The problem has surged so much that “the National Forensic Laboratory Information System, which collects data from state and local police labs, reported 3,344 fentanyl submissions in 2014, up from 942 in 2013” (Leger, 2015).

 

Due to the resurgence in popularity of heroin among IV drug users in recent years, it would seem that fentanyl-laced heroin and the associated use risks and health issues with regard to overdosing are going to be an issue for some time to come.

 

References
Bond, A. (2016, September 29). Why fentanyl is deadlier than heroin, in a single photo. Retrieved November 10, 2016, from https://www.statnews.com/2016/09/29/fentanyl-heroin-photo-fatal-doses/

 

DEA Issues Alert on Fentanyl-Laced Heroin as Overdose Deaths Surge Nationwide – Partnership for Drug-Free Kids. (2015, March 19). Retrieved November 10, 2016, from http://www.drugfree.org/news-service/dea-issues-alert-fentanyl-laced-heroin-overdose-deaths-surge-nationwide/

 

Fentanyl-Laced Heroin Worsening Overdose Crisis, Officials Say – Partnership for Drug-Free Kids. (2015, September 10). Retrieved November 10, 2016, from http://www.drugfree.org/news-service/fentanyl-laced-heroin-worsening-overdose-crisis-officials-say/

 

Leger, D. L. (2015, March 18). DEA: Deaths from fentanyl-laced heroin surging. Retrieved November 10, 2016, from http://www.usatoday.com/story/news/2015/03/18/surge-in-overdose-deaths-from-fentanyl/24957967/

 

NIDA (2011). Fentanyl. Retrieved November 10, 2016, from https://www.drugabuse.gov/drugs-abuse/fentanyl

 

NIDA (1969, rev. October 2014). Heroin. Retrieved November 10, 2016, from https://www.drugabuse.gov/publications/drugfacts/heroin

 

Teresa King
Pennyroyal Doctoral Intern

 

Friday Factoids Catch-Up: New Treatments For Tic Disorders Associated With Tourette’s

 

Tics, which are characterized by sudden, repetitive, non-rhythmic body movements and/or vocalizations associated with tic disorders and Tourette’s syndrome, are involuntary movements that may involve the hands, shoulder shrugging, eye blinking, etc.  In many cases, these tics do not get in the way of living a relatively normal life and consequently little if any treatment is required.  At the other end of the spectrum, the tics may be so severe that they require treatment with medication and behavioral therapy, especially if they are causing pain/injury, are interfering with a normal daily routine in one’s education, job performance, or social life, or are responsible for inducing excessive stress. Prior to the treatment of the presenting tics, the presence of other movement-related disorders like chorea, dystonia, as well as the movements displayed by those with autism (stereotypic movement disorder), or those movements manifested as compulsions of OCD or seizure-related activity, must be ruled out to ensure the patient receives the proper care and treatment that is best suited to address his or her needs.

 

There are various methods for treating the tics that are so often associated with Tourette’s syndrome, including medication, behavioral therapies, and habit reversal.  While medication is most often the go-to panacea for controlling tics, the medications themselves may carry side effects that are as bad, or even worse, than the condition that they may be used to treat.  Behavioral therapies can also be effective as well by teaching those with Tourette’s to manage their tics.  While these can be effective in reducing the number, severity, and impact of the tic behaviors, it is important to realize that behavioral therapy is not a cure, and that although effective it does not mean that tics are merely psychological in their nature.  While these treatment methods are effective in aiding the treatment of, and helping to manage, the tic symptoms of Tourette’s syndrome, it is important to note that they are varied in their efficacy, are not one-size-fits-all in their nature, and in the case of medication, may produce unwanted side effects ranging from mild to debilitating in and of themselves.

 

One of the most promising methods recently developed for the treatment of tics associated with Tourette’s is the Comprehensive Behavioral Intervention for Tics, or CBIT.  This new, evidence-based therapy includes the use of education, teaching relaxation techniques, and habit reversal in a combination that is shown to be effective in reducing symptoms of tics and their related impairments, and seems to work equally well for both children and adults. CBIT involves those with Tourette’s working with a therapist to gain a greater understanding of their particular type of tic and learning to recognize situations that worsen tic symptoms.  When possible, a change in environment may be initiated, and using habit reversal, a new behavior is modeled so that when the urge to tic occurs, the new behavior is substituted.  This method helps to lessen tic occurrences through substituting the new behavior for the tic through repetition, under the guidance of an experienced therapist.

 

Over the last few years, the number of health professionals that have come to know and appreciate the benefits and effectiveness of CBIT has increased; however, there are still relatively few therapists that have the specific training in these methods of treatment targeted specifically at tic disorders and Tourette’s, and work is currently being done by The Tourette Association of America and the Centers for Disease Control and Prevention to provide education for more health professionals with the training necessary to incorporate and apply this method in their treatment approach to managing the symptoms of Tourette’s and other tic disorders.

 

References

  1. Cook CR, Blacher J. Evidence-based psychosocial treatments for tic disorders. Clin Psychol: Science and Practice. 2007;14(3):252–67.
  2. Piacentini J, Woods DW, Scahill L, Wilhelm S, Peterson AL, Chang S. Behavior therapy for children with Tourette disorder: a randomized controlled trial. JAMA. 2010;303(19):1929–37.
  3. Harris, Elana, MD, PhD. Children with tic disorders: How to match treatment with symptoms. Current Psychiatry. 2010 March; 9(3):29-36
  4. Qasaymeh MM, Mink JW. New treatments for tic disorders. Current Treat Options Neurol. 2006 Nov;8(6):465-473

 

Teresa King
Pennyroyal Intern

 

Interviewing at WKPIC

 

WKPIC’s staff has begun the process of reviewing applications for the 2017-2018 intern year. We’re excited!

 

Soon, letters will go out, and we hope that we will meet many of you who applied to our program. If you accept, you’re probably wondering what our interview will be like.

 

For basic info, check out our Interview Information section. Note the “wear comfortable shoes” bit, if you plan to participate in the tour of the 165+ year-old Western State Hospital.

 

No, you really don’t have to study or prepare. We trust you have done that in graduate school. Ours is not a cut-throat or competitive process. We want you to see if you could be happy here and learn from us, and we want to see if we can teach you, and if you would enjoy being in our area and having the experiences we can offer. Seriously, you can wear comfortable shoes. If you Match with us, you’ll definitely want to wear them to work, too!

 

Just brings yourselves, and what you’ve learned. That’s enough. We look forward to meeting you!

 

 

Susan R. Redmond-Vaught, Ph.D.
Director of Psychology, Western State Hospital
Director, WKPIC