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Proper technique, practiced over time, can transform an appointment from "medication management" to a serious change in behavior, as evidenced by the 5 examples featured in this article. 

5 Ways to Transform Health Behaviors

A. Develop insight into the way their childhood influences their current relationship dynamics

B. Repeat their schematized ways of reacting to relationships for limited re-parenting

C. Understand their object relations and tendency towards aggression

D. Gain capacity to reflect on what happens between themselves and others in relationships

What are the benefits of traditional psychoanalytic concepts and new discoveries of mentalization-based treatment?

Mini Quiz: Mentalization-Based Treatment Goals

Here's what's new in personality disorders: DBT treatment, DSM-5 criteria, borderline personality disorder, narcissistic personalities, and mentalization-based treatments.

The World of Personality Disorders in 6 Clinical Reports

Dialectical behavior therapy (DBT) is a comprehensive, modular, cognitive-behavioral treatment that was originally developed to treat chronically suicidal individuals with complex clinical presentations and is best known as a treatment for borderline personality disorder. Meta-analyses have identified standard DBT as the most studied treatment available for borderline personality disorder and suicidal behavior, and DBT is widely recommended as a front-line treatment for these problems in professional guidelines.

Standard DBT is typically delivered as a 1-year outpatient treatment modality with 4 modes (

). Standard DBT has primarily been evaluated as a treatment for individuals with borderline personality disorder. In this setting, it significantly decreases suicide-related outcomes (eg, suicide attempts, non-suicidal self-injury, suicide ideation), psychiatric hospitalization, use of emergency services, treatment discontinuation, depression, and substance use; it also increases social and global functioning.

DBT skills training is typically delivered in a group format to target the enhancement of patient capabilities. Specifically, the primary focus is teaching patients a set of behavioral skills and strengthening their ability to use those skills in their everyday lives (

In standard DBT, it takes 24 weeks to get through the full skills curriculum, which is often repeated to create a 1-year treatment program. Detailed descriptions of the skills and the structure of standard DBT skills training groups can be found in the recently revised DBT skills training manual and accompanying patient workbook.

DBT assumes that many of the problems exhibited by patients are caused by skills deficits. In particular, the failure to use effective behavior when it is needed is often a result of not knowing skillful behavior or when or how to use it. For example, deficits in emotion regulation skills are believed to be a core problem in individuals with borderline personality disorder, and these deficits result in maladaptive behaviors to regulate emotions (eg, suicide attempts, non-suicidal self-injury, substance use). Consistent with this skills deficit model, the use of DBT skills during standard DBT and DBT skills training has been found to fully or partially mediate improvements in suicidal behavior, non-suicidal self-injury, depression, anger control, emotion dysregulation, and anxiety.

A recent analysis evaluated the importance of the skills training component of DBT. Interventions that included skills training were found to be more effective in re­ducing non-suicidal self injury, depression, and anxiety.

 Taken together, these findings suggest that DBT skills are both a mechanism of change and a critical treatment component.

In clinical practice, DBT skills training has often been offered as a stand-alone or adjunctive intervention in settings where a comprehensive DBT program is not feasible or appropriate. Until recently, however, there was little research to support the use of DBT skills training separate from standard DBT or to guide clinicians in how to structure these interventions. DBT skills training interventions have now been evaluated in 13 published and peer-reviewed randomized clinical trials that have varied widely in the clinical population targeted, the duration of treatment, the specific skills taught, the degree to which skills were adapted, and the use of adjunctive treatment components. Emotion regulation and mindfulness are the most commonly taught skills modules, while interpersonal effectiveness is the most likely to be omitted. In addition, many studies included only a subset of skills within a larger module (see the 

,5 pages 110 to 122, for detailed skills curricula).

In these studies, DBT skills training interventions have improved a variety of conditions. (Monthly updates on the latest DBT research can be found on the Linehan Institute website: 

http://www.linehaninstitute.org/latestResearch

. Four trials have evaluated DBT skills training interventions for individuals with eating disorders, including binge eating disorder, chronic binging and purging, and subthreshold bulimia nervosa.

 Participants who received DBT skills training had greater reductions in binge eating or binge/purge behaviors than wait list controls and those in an active therapy group. In addition, DBT skills training was superior to active and non-active control therapy in reducing other types of eating-related pathology, including weight-related concerns, urges to eat when angry, eating restraint, eating concerns, preoccupation with food, and appetite awareness.

. Three trials have examined the efficacy of DBT skills training for individuals with MDD or bipolar I or II disorder. Harley and colleagues

 found significantly greater improvement among patients with treatment-resistant depression on stable antidepressant medication regimens who received DBT skills training compared with those on a wait list. A second study compared DBT skills training with antidepressant medication in a group of persons aged 60 years and older with MDD.

 The interventions were comparably effective in reducing depression at the end of treatment (28 weeks). Significant differences in favor of DBT skills training emerged at 6-month follow-up on clinician-rated depression remission rates. A third trial compared DBT skills training with a wait list for individuals with bipolar I or II disorder and found nonsignificant trends that favored DBT in reducing depression and mania.

Several trials have also evaluated the effect of DBT skills training on depression severity in samples selected for other primary problems. Four studies found DBT skills training to be superior to active and non-active control therapy in reducing depression among individuals with borderline personality disorder, subthreshold bulimia nervosa, and childhood abuse histories.

 Two trials did not find differences between DBT skills training and active treatment controls in reducing depression among persons with high levels of emotion dysregulation and binge eating disorder.

. No studies have evaluated DBT skills training interventions for primary anxiety disorder. However, several studies have found DBT skills training to be more effective than active treatment controls in reducing anxiety severity among individuals with borderline personality disorder, high levels of emotion dysregulation, and a history of childhood abuse.

In addition, a component analysis found that DBT interventions that included a skills training component were more effective than those without skills training in reducing anxiety severity among suicidal and self-injuring individuals with borderline personality disorder.

. Two studies that used active treatment controls demonstrated the effectiveness of DBT skills training for attentional difficulties. In the earlier trial, DBT skills training led to a greater reduction of ADHD symptoms than a semistructured discussion group for individuals who maintained a stable medication regimen and completed treatment.

 A recent study of college students compared skills training with self-study handouts.

 Symptoms of inattention were significantly reduced in the DBT group by the end of follow-up; mindfulness and quality of life improvements were evident at the end of treatment, and improvement in mindfulness persisted through the follow-up period.

. Two trials have evaluated DBT skills training interventions among persons with borderline personality disorder. Soler and colleagues

 compared 3 months of a stand-alone DBT skills training group to standard group therapy for individuals with moderate to severe borderline personality disorder. The results demonstrated the superiority of DBT skills training in reducing treatment dropout, depression, anxiety, general psychiatric symptoms, anger, feelings of emptiness, and emotional instability. The 2 treatments did not differ in their effect on global borderline personality disorder severity, suicide attempts, non-suicidal self-injury, or emergency department visits.

A recent component analysis compared the efficacy of 1 year of standard DBT, DBT group skills training with individual case management, and DBT individual therapy with an activities group for suicidal and self-injuring women with borderline personality disorder.

 All 3 treatments resulted in similar improvements in suicide-related outcomes (attempts, ideation, use of crisis services due to suicidality, and reasons for living). The treatment conditions that included skills training (standard DBT and DBT group skills training plus case management) were superior to DBT individual therapy in reducing non-suicidal self-injury, depression, and anxiety. There were no significant differences between standard DBT and DBT group skills training plus case management conditions, although there were trends in favor of standard DBT for treatment retention and follow-up year suicide attempts and use of crisis services.

The available research suggests that DBT skills training is a critical component and mechanism of action in DBT and can be effective as a stand-alone or adjunctive intervention for a variety of conditions. The strongest evidence exists for brief DBT skills training as a stand-alone intervention for binge eating disorder and bulimia nervosa. In addition, moderate evidence exists for the efficacy of brief DBT skills training as an adjunctive intervention to antidepressant medication for individuals with MDD, as well as a stand-alone intervention for ADHD. Two trials have shown promising results for DBT skills training for borderline personality disorder, but the findings require replication because of the notable differences between trials in treatment length, the use of adjunctive treatment components, and the severity of illness.

Additional research with larger samples and consistent DBT skills training curricula is needed to draw firm conclusions. Nevertheless, the effectiveness of DBT skills training appears to be robust despite variations in treatment length and skills content, which suggests that such training in multiple forms is likely to be useful for different clinical populations.

We would like to acknowledge the work of Drs Marsha Linehan, Linda Dimeff, Erin Miga, and Kelly Koerner in compiling a list of DBT randomized controlled trials at Behavioral Tech, LLC.

Dr Harned is Director of Research and Development and Dr Botanov is a Postdoctoral Fellow at Behavioral Tech LLC in Seattle, WA. Behavioral Tech LLC is a private company that provides training and consultation in dialectical behavioral therapy. Dr Harned reports that she receives federal grants to research dialectical behavior therapy.

 Stoffers JM, m BA, RÃ¼cker G, et al. Psychological therapies for people with borderline personality disorder. 

 Tarrier N, Taylor K, Gooding P. Cognitive-behavioral interventions to reduce suicide behavior: a systematic review and meta-analysis. 

 Klonsky ED. Borderline Personality Disorder. Society of Clinical Psychology; 2015. 

http://www.div12.org/psychological-treatments/disorders/borderline-personality-disorder/

 SAMHSA’s National Registry of Evidence-based Programs and Practices. Intervention Summary: Dialectical Behavior Therapy. 2015. 

http://legacy.nreppadmin.net/ViewIntervention.aspx?id=36

. 2nd ed. New York: Guilford Press; 2015.

DBT® Skills Training Handouts and Worksheets

 Linehan MM, Korslund KE, Harned MS, et al. Dialectical behavior therapy for high suicide risk in individuals with borderline personality disorder: a randomized clinical trial and component analysis. 

 Hill DM, Craighead LW, Safer DL. Appetite-focused dialectical behavior therapy for the treatment of binge eating with purging: a preliminary trial. 

 Safer DL, Telch CF, Agras WS. Dialectical behavior therapy for bulimia nervosa. 

 Safer DL, Robinson AH, Jo B. Outcome from a randomized controlled trial of group therapy for binge eating disorder: comparing dialectical behavior therapy adapted for binge eating to an active comparison group therapy. 

 Telch CF, Agras WS, Linehan MM. Dialectical behavior therapy for binge eating disorder. 

 Harley R, Sprich S, Safren S, et al. Adaptation of dialectical behavior therapy skills training group for treatment-resistant depression. 

 Lynch TR, Morse JQ, Mendelson T, Robins CJ. Dialectical behavior therapy for depressed older adults: a randomized pilot study. 

 Van Dijk S, Jeffrey J, Katz MR. A randomized, controlled, pilot study of dialectical behavior therapy skills in a psychoeducational group for individuals with bipolar disorder. 

 Soler J, Pascual JC, Tiana T, et al. Dialectical behaviour therapy skills training compared to standard group therapy in borderline personality disorder: a 3-month randomised controlled clinical trial. 

 Bradley RG, Follingstad DR. Group therapy for incarcerated women who experienced interpersonal violence: a pilot study. 

 Neacsiu AD, Eberle JW, Kramer R, et al. Dialectical behavior therapy skills for transdiagnostic emotion dysregulation: a pilot randomized controlled trial. 

 Hirvikoski T, Waaler E, Alfredsson J, et al. Reduced ADHD symptoms in adults with ADHD after structured skills training group: results from a randomized controlled trial. 

 Fleming AP, McMahon RJ, Moran LR, et al. Pilot randomized controlled trial of dialectical behavior therapy group skills training for ADHD among college students. 

The latest research on DBT for treating psychiatric disorders, such as ADHD, bipolar disorder, eating disorders, and depression.

Dialectical Behavior Therapy Skills Training Is Effective Intervention

Clarification of the molecular and biological underpinnings of borderline personality disorder (BPD) is imperative for a more thorough understanding of the disorder, one that anchors our quest for effective treatment. This article provides a brief overview of the neurobiology of BPD. Anatomical structures are reviewed as well as genetic and epigenetic factors that contribute to the pathophysiology and, potentially, to the treatment of this disorder.

Over the past decade, much of the literature concerning the biological basis of BPD has shifted to direct visualization of brain structure and function using neuroimaging. Most of the findings pertain to brain regions involved in emotional processing, such as the amygdala, insula, posterior cingulate cortex, hippocampus, anterior cingulate cortex, and prefrontal regulatory regions (

). These include the orbital frontal cortex, dorsal lateral prefrontal cortex, and ventral lateral prefrontal cortex.

. A meta-analysis of brain volume-which comprised 281 persons with BPD and 293 healthy controls-and 19 imaging studies noted left amygdala and right hippocampus gray volume decreases in persons with BPD.

 Volume studies in adolescent-onset BPD populations also exist but are limited by small sample size, discrepant imaging techniques, and highly comorbid presentations. They do not reproduce the volume differences reported in studies of adult BPD.

. A meta-analysis of functional MRI (fMRI) findings in persons with BPD revealed heightened activation during processing of negative emotional stimuli in the left amygdala, left hippocampus, and posterior cingulate cortex as well as diminished activation in prefrontal regions (including the dorsal lateral prefrontal cortex).

 Another meta-analysis showed heightened activity in the insula and less activation in the subgenual anterior cingulate cortex in persons with BPD but did not find amygdala hyperactivity.

Conflicting amygdala results are believed to result from the medication status of research participants because psychoactive drugs attenuate limbic activity. Pharmacologic probes have also shown decreased metabolic activity in the anterior cingulate cortex and orbital frontal cortex in response to serotonergic challenge in impulsive-aggressive and affectively unstable BPD populations, and decreased coupling of resting metabolism between the orbital frontal cortex and the ventral anterior cingulate cortex has been reported.

 (DBT) was found to attenuate amygdala hyperactivity at baseline, which correlated with changes in a measure of emotion regulation and increased use of emotion regulation strategies.

 Taken together, these findings highlight that dysfunctional circuits involving hyperactive limbic regions and hypoactive prefrontal modulation-most pronounced in the dorsal lateral prefrontal cortex-represent the anatomical corollaries to BPD.

. Connectivity studies developed over the past 2 years introduced novel research strategies that heavily rely on fMRI. Connectivity can be described in terms of anatomical and functional connectivity. Diffusion tensor variables of mean diffusivity and fractional anisotropy are measures of white matter integrity and anatomical connections. While such work in BPD is in its infancy, initial data suggest that deficits in frontolimbic connections relate to the severity of symptoms such as affective instability, avoidance of abandonment, and anger.

Functional connectivity analyses provide information about which brain regions are co-activated and can be studied using seed-based correlations (most often with the amygdala and dorsal anterior cingulate cortex) and independent component analysis. The 3 networks most salient in BPD are:

• The default mode: a network activated when the brain is at rest in the absence of goal-directed activity; it is influenced by the medial prefrontal cortex and posterior cingulate cortex and is responsible for self-referential thinking

• The salience network, including the orbital frontal insula and the dorsal anterior cingulate cortex

• The medial temporal lobe network, which is responsible for processing negative emotions

In BPD, there are alterations in the connections between these 3 networks with particularly problematic connectivity between salience detection and self-referential encoding. This results in misidentification with neutral stimuli as well as a failure to integrate salience information with internal representations.

These networks can be mapped on fMRI, which shows dampening of the negative correlations between the dorsal anterior cingulate cortex and the posterior cingulate cortex as well as increased connectivity of the amygdala and rostral anterior cingulate cortex. Connectivity is also heightened between the amygdala and parahippocampus as well as the ventral anterior cingulate cortex and insula. In a study that examined neural correlates of emotional distraction, persons with BPD showed positive connectivity between the amygdala and prefrontal regions (right default mode prefrontal cortex and left dorsolateral prefrontal cortex).

Symptoms of BPD are typically categorized into 4 phenotypes-the “borderline sectors”-that coexist in varying degrees within individuals with BPD and, often, in their family members.

 The affective sector includes emotions that are characteristically challenging for patients with BPD. These include loneliness, emptiness, inappropriate and intense anger, and quick fluctuations in mood.

The interpersonal sector of BPD refers to these patients’ penchant for intense and volatile relationships and their tendency to be at once manipulative, entitled, and devaluing as well as dependent, idealizing, and fearful of abandonment.

 The cognitive sector encompasses distressing perceptual disturbances, including dissociation and paranoia during times of stress.

The behavioral sector of BPD describes risky, impulsive behaviors as well as self-injury and threats of self-harm common in this population.

It is thought that the phenotypic expression of each of these sectors represents a confluence of genetic and environmental influences.

 conducted a family study to investigate the degree to which BPD clustered within families as well as how much of this clustering was attributable to genetic predispositions for borderline sectors as opposed to the disorder itself. In their study, the prevalence of BPD among relatives of probands with BPD was 14.1% compared with 4.9% in the family members of controls. The relative risk that if one family member had BPD, so too would another was 3.9 (95% confidence interval, 1.7 - 9.0) when compared with controls. Aggregation of BPD in families occurred in this study more than aggregation of any of the sectors, which supports a common pathway model of inheritance. In this model, borderline traits concentrate in families because of a genetic predisposition for the disorder rather than for the sectors themselves.

While family studies provide convincing evidence that BPD is inherited, twin studies have been invaluable to the study of heritability, the phenotypic variance attributable to genetic rather than environmental influences. A 2011 web-based study looked at the heritability of the disorder using responses to well-validated personality questionnaires.

 Study participants included 542 same-sex twin pairs, 441 of whom were monozygotic. The 4 dimensions of BPD loaded as one factor and provided further support for the common pathway model used by Gunderson and colleagues.

 Findings from the study indicate a heritability of 60%. This is similar to other twin and extended twin studies that estimate heritability to fall somewhere between 40% and 70%.

Molecular genetic studies have focused on the rate-limiting enzyme in serotonin (5-hydroxytryptamine [5-HT]) synthesis, as well as 5-HT receptor and transporter genes. 5-HT derives from tryptophan through a process mediated by tryptophan hydroxylase. Tryptophan hydroxylase 2 (TPH2) is a neuron-specific enzyme responsible for producing 5-HT in the CNS. Single nucleotide polymorphism and haplotype analyses have revealed that a gene encoding a specific TPH2 isoform is associated with higher rates of anxiety, depression, and suicidal behavior.

 genotyped patients with BPD and compared them with patients who had other personality disorders and healthy controls. They found that the previously identified TPH2 risk haplotype was more prevalent in patients with BPD (P < .05) than in controls. Subjects with the TPH2 risk haplotype exhibited higher aggression and emotional lability scores and increased suicidal behavior.

Of the serotonin receptor genes, polymorphisms in 

 have been most closely correlated with BPD. Variants of the 5HT2A receptor are known to correlate with suicide, affective lability, and impulse control. 5HTR2A polymorphisms correlate with borderline traits.

 analyzed polymorphisms in serotonin receptor genes in patients with BPD and matched controls. Their results showed an association between BPD and the 

 gene. Moreover, subjects who were homozygous for the 

 genotype had a higher frequency of the TPH2 “risk” haplotype. Taken together, the data suggest that a TPH2 “risk” haplotype may change serotonin in a way that predisposes to BPD. Patients may be more susceptible to a specific variant of 5HTR2C, which may further contribute to the pathogenesis of BPD.

Genetic and epigenetic changes to the oxytocin system, especially the oxytocin receptor (

) gene on chromosome 3p25.3, are associated with the pathophysiology of BPD (

). Polymorphisms, genotypes, and haplotypes within this gene are variably linked with both aggressive and prosocial behaviors.

 allele are more likely to perceive others negatively, experience loneliness, and endorse subjective symptoms of psychological stress with correspondingly high cortisol and other stress-related biomarkers. Prosocial behaviors, such as empathy, confidence, and positivity, decrease.

Just as genetics may predispose an individual to the development of BPD, epigenetic changes are also likely to play a role. Epigenetic modifications influence gene expression without altering DNA sequences and are dynamically shaped through environmental factors (eg, trauma). Epigenetic modifications often occur via methylation of 5´-cytosine-phosphate-guanine-3´ (CpG) dinucleotide pairs. CpG methylation within the first 3 exons of the 

 gene reduces transcription of the OXTR protein, thereby diminishing the effects of oxytocin.

 The unavailability of OXT receptors may account for the unexpectedly low treatment response to oxytocin administration in patients with BPD.

Oxytocin is believed to regulate social cognition through the frontolimbic system, in which structural and functional differences have been identified in persons with BPD.

 In facial recognition studies, individuals with BPD are more likely to perceive negative and untrustworthy emotions, which suggests that oxytocin’s role in the salience network influences interpersonal hypersensitivity in BPD.

 Oxytocin is also involved in regulating the hypothalamic-pituitary-adrenal axis, helping to habituate the fear circuitry and extinguish the startle response in the face of previously emotionally charged stimuli. Lastly, oxytocin’s modulation of attachment and affiliative systems may influence the anger, impulsivity, and emotional lability exhibited by persons with BPD in response to perceived insult.

Three studies support the use of oxytocin in the treatment of BPD. Simeon and colleagues

 concluded that oxytocin moderately decreased stress reactivity, measured from subjective reports of dysphoria and objective measurements of plasma cortisol, in response to the Trier Social Stress Test. Bertsch and associates

 demonstrated that oxytocin decreased threat hypersensitivity, measured via eye fixation and amygdala activity, in response to angry faces. BrÃ¼ne and colleagues

 also found reduced attention and avoidant reactions to angry faces in subjects with BPD after oxytocin administration. Their data suggest that oxytocin administration may interfere with trust in patients with BPD, especially in those who have been exposed to trauma.

In addition to supplementary trials that directly examine the effects of oxytocin administration in patients with BPD and the influence of epigenetics on the oxytocin system, future research is warranted regarding oxytocin’s role as adjunctive treatment to current modalities. For example, oxytocin might be used to augment individual and group DBT by increasing social cognition while decreasing hypermentalization and interpersonal hypersensitivity.

Another potential area for research is oxytocin’s role in the prevention of BPD. It is possible that oxytocin can increase attachment and enhance psychosocial interventions among struggling parents, thereby mitigating maladaptive responses to childhood trauma.

During most of the 20th century, BPD was conceptualized in psychodynamic terms: a pattern of primitive defenses adaptive in aversive childhood experiences but increasingly maladaptive in adulthood. Despite the tremendous toll BPD takes on patients and society, its existence is frequently questioned and patients are stigmatized. Research clearly demonstrates that BPD evolves from a complex interaction between environmental, anatomical, functional, genetic, and epigenetic factors. There are many risk factors, and each one serves to strengthen the others.

To treat BPD more effectively, it helps to conceptualize the major symptoms as neuropsychiatric. fMRI findings have revealed tracking changes in connectivity between complex brain networks, and epigenetic research has shown that environment influences gene expression, perpetuating maladaptive cognitions and behaviors at the neurobiological level. While functional imaging and genetic studies are beginning to gain momentum, these preliminary findings await replication with larger sample sizes, longitudinal capacities, and more refined methodologies.

Drs Pier, Marin, and Goodman are psychiatrists at Icahn School of Medicine at Mount Sinai in New York. Dr Pier is a third-year resident, Dr Marin is a second-year resident, and Dr Goodman is Clinical Professor. Dr Goodman is also the Director of Dialectical Behavioral Therapy & Suicide Prevention Studies Clinical and Research Program at the James J. Peters Veterans Affairs Medical Center, and Mental Illness Research Education and Clinical Center (MIRECC), in Veterans Integrated Service Network (VISN) 3. Ms Wilsnack is a Research Coordinator for the VISN 3 MIRECC. The authors report no conflicts of interest concerning the subject matter of this article.

 Ruocco AC, Amirthavasagam S, Choi-Kain LW, McMain SF. Neural correlates of negative emotionality in borderline personality disorder: an activation-likelihood-estimation meta-analysis. 

 Goodman M, Perez-Rodriguez M, Siever L. The neurobiology of adolescent-onset borderline personality disorder. In: Sharp C, Tackett JL, eds. 

Handbook of Borderline Personality Disorder in Children and Adolescents

. New York: Springer Science and Business Media; 2014.

 Schulze L, Schmahl C, Niedtfeld I. Neural correlates of disturbed emotion processing in borderline personality disorder: a multimodal meta-analysis. 

 New AS, Hazlett EAB, Buchsbaum AS, et al. Amygdala-prefrontal disconnection in borderline personality disorder. 

 Goodman M, Carpenter D, Tang CY, et al. Dialectical behavior therapy alters emotion regulation and amygdala activity in patients with borderline personality disorder. 

 Krause-Utz A, Winter D, Niedtfeld I, Schmahl C. The latest neuroimaging findings in borderline personality disorder. 

 Gunderson JG, Zanarini MC, Choi-Kain LW, et al. Family study of borderline personality disorder and its sectors of psychopathology. 

 Kendler KS, Myers J, Reichborn-Kjennerud T. Borderline personality disorder traits and their relationship with dimensions of normative personality: a web-based cohort and twin study. 

 Perez-Rodriguez M, Weinstein S, New AS, et al. Tryptophan-hydroxylase 2 haplotype association with borderline personality disorder and aggression in a sample of patients with personality disorders and healthy controls. 

 Amad A, Ramos N, Thomas P, et al. Genetics of borderline personality disorder: systematic review and proposal of an integrative model. 

 Ni X, Chan D, Chan K, et al. Serotonin genes and gene-gene interactions in borderline personality disorder in a matched case-control study. 

Prog Neuropsychopharmacol Biol Psychiatry

 Meyer-Lindenberg A, Domes G, Kirsch P, Heinrichs M. Oxytocin and vasopressin in the human brain: social neuropeptides for translational medicine. 

 Puglia MH, Lillard TS, Morris JP, Connelly JJ. Epigenetic modification of the oxytocin receptor gene influences the perception of anger and fear in the human brain. 

 Ebert A, Kolb M, Heller J, et al. Modulation of interpersonal trust in borderline personality disorder by intranasal oxytocin and childhood trauma. 

 Herpertz SC, Bertsch K. A new perspective on the pathophysiology of borderline personality disorder: a model of the role of oxytocin. 

 Simeon D, Bartz J, Hamilton H, et al. Oxytocin administration attenuates stress reactivity in borderline personality disorder: a pilot study. 

 Bertsch K, Gamer M, Schmidt B, et al. Oxytocin and reduction of social threat hypersensitivity in women with borderline personality disorder. 

 BrÃ¼ne M, Ebert A, Kolb M, et al. Oxytocin influences avoidant reactions to social threat in adults with borderline personality disorder. 

 Torgersen S, Kringlen E, Cramer V. The prevalence of personality disorders in a community sample. 

There is more to BPD than meets the eye. A complex interaction exists between environmental, anatomical, functional, genetic, and epigenetic factors. 

The Neurobiology of Borderline Personality Disorder

Mentalization-based treatment (MBT) is an evidence-based psychotherapeutic approach for borderline personality disorder. MBT is derived from both traditional psychoanalytic concepts and new discoveries from attachment and social cognition research. Mentalization simply describes the common psychological process that people use to understand mental states (ie, emotions, beliefs, desires-intentions that underlie interpersonal interactions). It covers a wide territory of psychological activity that determines the way people manage their emotions and thoughts coherently; effectively respond to their own experience and that of others; maintain satisfying relationships; and understand themselves, thereby stabilizing their sense of self (ie, identity). The stability, flexibility, benevolence, and honesty with which people mentalize underpins how their psychology works, or how their personality functions. Mentalization therefore lies at the root of psychological health and resilience as a common process relevant to all psychotherapies.

MBT’s simple, common-sense approach has practical advantages over dialectical behavioral therapy (DBT). Those who use MBT need little formal training to be effective.

 DBT requires skills coaching, a skills training curriculum with numerous handouts and worksheets, weekly individual therapy, and a consultation team to support therapists.

DBT formulates borderline personality disorder as a problem of emotional dysregulation and lack of skills to manage distress and relationships. MBT centralizes instability of attachment and its developmental byproduct, mentalization, as the core dysfunction. Fonagy and Allison

 extended the formulation of borderline personality disorder and personality disorders in general as a problem of epistemic trust, the capacity to “trust in the authenticity and personal relevance” of information presented in an interpersonal context. This revised notion explains the rigidity of thinking that individuals with borderline personality disorder (as well as those with other personality disorders) have with interpersonal relationships. Because of a tendency toward epistemic mistrust, individuals with borderline personality disorder have difficulty learning and changing despite repeated patterns of painful interpersonal problems and efforts by others to teach them how to manage less destructively.

According to attachment research and theory, infants activate attachment by communicating emotional distress to their caretakers. When all goes well, the caretaker responds in a way that re-regulates the infant. The first step of the optimal caretaking response is to recognize the infant’s distress and then reinstate confidence with soothing and optimistic encouragement to explore the environment (ie, via a secure base). Secure attachment facilitates self-regulation in terms of emotions, attentional control, and behavior. Early attachment also provides a template for expec­tations of oneself and others in relationships.

Secure attachment embodies a developmental process whereby the caretaker manages to reasonably imagine and interpret the mental states of the child, responding in a way that helps the child understand and manage his or her own distress. This is the process by which secure attachment facilitates the development of mentalization (

). For example, when a child falls and bursts into tears, a caretaker may respond in a marked contingent way with a sympathetic frown, underpinned by the idea “Poor baby, you fell and are hurt and scared.” An unmarked response might involve the caretaker actually mirroring the child and crying in distress. A noncontingent response would be completely nonresonant with the child’s experience: for example, an angry response with underlying cognitions such as “Why do you have to be so clumsy?”

If the caretaker is able to provide marked and contingent mirroring when the child is emotionally distressed, the child begins to develop a coherent sense of his own experience. This kindles the child’s ability to mentalize, allowing him to begin to understand the relationship between actions and mental states in an interpersonal interaction. This process ultimately becomes the basis of epistemic trust, which provides an openness to learn from others in a relational process. (See Bateman and Fonagy

 for a review of empirical data that support this model.)

The attachment styles most common in borderline personality disorder include preoccupied, fearful, and disorganized types that combine oscillatory, dependent, mistrustful, hostile, and incoherent features. The individual with borderline personality disorder has a tendency to engage (or make attachment bids to) others with disorganized, confusing, and controlling strategies, which in turn elicits disorganized, confusing, controlling tendencies in return.

This attachment transaction not only fails to regulate and re-establish a sense of safety, but also creates additional distress, increasing vulnerability and need in the child as well as the risk of dysregulation and burnout in the caretaker. As depicted in 

, this vicious cycle of distress and ineffective attachment functioning leads to a “hyperactivated” attachment, in which mentalizing in both child and caretaker is likely to be overwhelmed in favor of behavioral means of communication and problem solving.

While the clinical theories and neuroscientific evidence integrated in MBT’s formulation of borderline personality disorder are sophisticated, the techniques involved in MBT are simple and direct. At the base of the mentalizing stance is a position of curiosity, of being interested in exploring different perspectives of the patient’s experience both in relationships outside treatment and with the therapist. The job of the therpista is to encourage patients to mentalize, rather than do it for them by providing interpretations or by instructing them on how to manage behavior or distress. The only agenda is to sustain the mentalizing process to optimize the patient’s capacity to arrive at autonomous insight or behavioral change.

Mentalization is prone to go off­line in situations of stressful arousal (eg, intense emotion) and hyperactivated attachment. The MBT therapist intervenes when mentalizing becomes compromised. Detecting prementalistic states (

) prompts the clinician to recognize that the patient is unlikely to be able to understand her or others’ mental states realistically, benevolently, or flexibly. The clinician uses MBT techniques to broaden and thereby stabilize the patient’s capacity for empathy. According to this model, a common mistake in psychotherapeutic practice is to assume that the patient can mentalize when emotionally activated. Offering complex interpretations or behavioral plans when the patient is too vulnerable is useless because the patient is incapable of trusting the therapist or of making use of any interventions.

MBT begins with assessment and formulation of the patient’s problems and treatment goals within a mentalizing framework. The therapist and patient collaboratively explore presenting problems to establish joint attention to a shared understanding of the therapeutic work. This first step provides a secure base from which issues can be addressed as treatment unfolds.

Assessment of the patient’s overall mentalizing capacities starts with inviting a general account of problems that were the catalyst to seek treatment. Particular attention is paid to how breakdowns in mentalizing are linked to suicidal or self-destructive behaviors, and these vulnerability points are targeted as a central focus in the treatment. The therapist explores the patient’s capacity to maintain and recover mentalizing when challenged by emotionally laden interpersonal events, such as misunderstandings, disagreements, rejections (real or perceived), or intensification of intimacy. Important developmental events and attachment figures, past and present, are discussed to elucidate how robustly a person can mentalize within close relationships and where this capacity breaks down.

While probing these areas, the therapist scans for spontaneous descriptions of particular nonmentalizing modes that are overly disconnected from emotion (pretend mode), unreasonably certain (psychic equivalence: “I worry I can’t manage being alone; therefore, I can’t”), or concrete (teleological mode: “He doesn’t like me because he didn’t call me back right away”). Poor mentalizing is seen when extremes arise in the patient’s focus and the therapist intervenes with “contrary moves.” The patient is invited to incorporate the missing vantage point into a more balanced perspective, which allows assessment of the patient’s ability to broaden overly rigid, reactive, unrealistic, or emotionally vacant perspectives.

The initial assessment yields a general understanding of how presenting problems stem from fluctuations in mentalizing capacities related to the level of emotional arousal and attachment system activation. The therapist summarizes her findings in an openly shared, plainspoken manner. Patients are asked to think about and revise the formulation of emotional and relational patterns, to foster an ever-evolving and enhanced self-understanding. The initial phase of treatment also incorporates an explanation of the appropriate diagnosis and psychoeducation about concepts of mentalization, evolutionary functions of basic emotions, attachment styles, and the relevance of mentalizing for treatment.

Within structured MBT programs, an 8- to 12-week introductory MBT group is the primary vehicle for providing psychoeducation and pre-treatment engagement for patients who are considering or entering the program. This preliminary group segues into a longitudinal weekly MBT group that runs parallel to weekly individual therapy sessions. Patients are informed that individual and group therapists-in addition to psychiatrists who provide medication management and any other team members-meet regularly as a group to review case formulations, progress, and challenges arising in treatment as well as to expand clinicians’ individual perspectives on each patient through the collective mentalizing of the treatment team.

Basic mentalizing stance and hierarchy of interventions

For patients in a position of epistemic mistrust, therapeutic attempts aimed at probing, sympathetic support, and self-reflection can inadvertently destabilize mentalization by escalating emotional arousal and hyperactivating insecure or disorganized attachment processes. These iatrogenic disruptions are minimized by deploying a basic mentalizing stance that serves as a “secure base” from which the therapist promotes good mentalizing and facilitates its recovery when it is lost (

Therapists monitor the levels of mentalizing, emotional arousal, and attachment activation as they fluctuate over the course of the session. The aim is to stimulate just enough emotional responsiveness so that the exploration of new perspectives becomes meaningful, but not so much that mentalizing collapses due to unmanageable arousal.

As the treatment progresses, MBT carefully balances support strategies to develop the appropriate levels of trust and emotional arousal needed for good mentalizing. Initially, supportive strategies with empathic validation maneuvers are used to clarify and elaborate the patient’s perspectives. More challenging interventions help patients make sense of emotional undercurrents and relational dynamics implicit within the therapeutic relationship, which generally reflect similar dysfunction in relationships outside of treatment.

Adherence to the MBT model is enhanced by the therapist’s affect focus, frequent use of challenge, and integration of patients’ experiences across individual and group sessions. For example, imagine a patient who describes a situation in which she yelled at her child and felt guilty about it. In the session, the patient seems anxious and hypervigilant to the therapist’s response. The therapist would focus on the affect the patient experiences about how the therapist is mentalizing about her. This helps the patient understand not only her own affect but also her experience of talking about what is on her mind in the presence of another person. The therapist develops an inquiry and exploration in vivo, so the patient can conceptualize and express her affect within the interpersonal context. The ultimate goal of MBT is not merely to broaden patients’ perspectives on particular relational events, but to expand their reflective receptivity to new learning in interpersonal contexts outside of treatment.

MBT is an integrative treatment approach for borderline and other severe personality disorders. It combines ideas from both psychoanalysis and modern research and is based on the unique human capacity to mentalize, or understand mental states underlying one’s own actions as well as those of others. MBT appears to be widely applicable to various types of patients, at different developmental stages and with psychiatric diagnoses. It has been adapted and empirically validated in an adolescent format (MBT-A) and modified to treat eating disorders, depression, PTSD, and antisocial personality disorder.

Public health interests to augment access to care inform our view that MBT should be taught to trainees of various clinical disciplines, especially psychiatry residents, as a psychotherapy approach to treating “difficult to reach” patients with personality disorders. As the empirical basis for psychoanalytic treatment of most major psychiatric disorders remains slim and the demands for psychoanalytic training remain lengthy and time consuming, MBT presents a compromise to bridge the valuable history of psychoanalytic ideas to both modern psychiatric research as well as present public health needs and practice.

Dr Choi-Kain is Director of the Adult Borderline Center and Training Institute at the McLean Hospital in Belmont, MA; she is also Medical and Program Director and Dr Unruh is Assistant Medical Director at McLean Gunderson. Dr Choi-Kain reports that she is Course Director and receives royalties from HMS Continuing Education, and she receives royalties from Springer as author and editor of Borderline Personality and Mood Disorders. Dr Unruh reports no conflicts of interest concerning the subject matter of this article.

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Handbook of Mentalizing in Mental Health Practice

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MBT presents a compromise to bridge the valuable history of psychoanalytic ideas to both modern psychiatric research as well as present public health needs and practice.

Mentalization-Based Treatment: A Common-Sense Approach to Borderline Personality Disorder

At the end of the 1970s there would have been substantial discussion about whether personality disorders were worth the effort of a 

. There were disagreements as to whether personality disorders were “real” psychopathology in contrast to the axis I mental states, or whether they were simply retained in DSM to garner support from psychodynamic psychiatrists for the more atheoretical (and perhaps more biological) leanings of DSM-III. The then categorical diagnoses of personality disorders were relegated to axis II, an axis separate from the mental states.

[[{"type":"media","view_mode":"media_crop","fid":"46035","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_6840338713557","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"5309","media_crop_rotate":"0","media_crop_scale_h":"142","media_crop_scale_w":"150","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":" ","typeof":"foaf:Image"}}]]The idea of an axis II (in the then 5-axes model of DSM) was a way to have clinicians pay attention to the possibility of a primary or a comorbid personality disorder as part of a diagnostic assessment. If clinicians were to consider an entry on each of the 5 axes, they might pause and ask which patients might possibly harbor a personality disorder-something many of us interested in personality disorders thought useful. However, probably because of time constraints, insurance company requirements, and possibly many in the field not thinking that the concept of personality disorders was useful (there were then no effective treatments save perhaps for psychodynamic or psychoanalytic approaches), most clinicians did not linger very long on personality disorders. Instead, they opted for “Axis II, deferred” or “Personality Disorder Not Otherwise Specified.”

This problem was addressed by the DSM-5 Personality and Personality Disorders Work Group, which suggested new ways of approaching personality disorders so that clinicians might pause and consider the presence or absence of a personality disorder as either a primary diagnosis or as a major confounding comorbidity to a mental state disorder. Although the Work Group’s somewhat controversial suggestions were wise, they did not make it into the main body of DSM-5 but were placed in Section 3 of DSM-5.

When I attempted to decide what topics might be included in this Special Report, the choices were numerous. I tried to choose a few topics that would be relevant to most clinicians who work with patients with personality disorders. I first turned to borderline personality disorder (BPD), which seems to give clinicians the most angst. Patients with BPD use more services than those with other personality disorders and in general compose the majority in community treatment for a primary personality disorder.

Over the past 25 years a number of effective treatments have been subjected to rigorous trials. In Part 2 of this Special Report, we review one from the cognitive-behavioral therapy (CBT) camp, 

, though there are other effective treatments in both the CBT and psychodynamic camps.

Turning from these effective psychotherapeutic treatments, we explore issues that cut across the personality disorders in general while staying close to issues prevalent among patients with BPD. The first is narcissism and 

. The section here is not only well-written but illuminates some of the issues, controversies, and differing views of that concept. While narcissism is considered a diagnosis in its own right, it also cuts across the personality disorders, especially the cluster B disorders. The article adds a decent dollop of clinical wisdom about narcissism and its various presentations and permutations.

Two other articles also deal with concepts that cut across the personality disorders while resting quite comfortably close to BPD. The first deals with 

 and the risk of and perhaps predictors of suicidal ideation and behaviors among these patients. As is the problem with most suicide research, although the results and behaviors are terrifying, the actual base rate is low, and it is hard to gather sufficient data to make more solid predictions. Nonetheless, we are reminded of its importance-something we should always pay attention to even when we might think the statements and behavior are manipulative.

neurobiology of patients with personality disorders

, also in Part 2. Almost unheard of 25 years ago, studies of neurobiological mechanisms, both ordered and disordered, among patients with personality disorders are growing rapidly. Information from neurotransmitters, genetics, all forms of neuroimaging and, recently, work on attachment and pain has begun to come together to give us a greater understanding of the biological complexities that underlie some of the difficult issues we struggle with in the treatment of patients with personality disorders.

The increasing number of academic journals that address personality disorders illustrates the growing interest in this subject. While for decades academic journals on personality existed, such as 

ournal of Personality and Social Psychology

 (American Psychological Association), and 

An exploration topics that are relevant to most clinicians who work with patients with personality disorders. 

Personality Disorders

5 Ways to Transform Health Behaviors

Mini Quiz: Mentalization-Based Treatment Goals

The World of Personality Disorders in 6 Clinical Reports

Dialectical Behavior Therapy Skills Training Is Effective Intervention

The Neurobiology of Borderline Personality Disorder

Mentalization-Based Treatment: A Common-Sense Approach to Borderline Personality Disorder

Introduction: An Essential Part of the Mental Health Evaluation

New Insights Into Narcissistic Personality Disorder

Comorbid Clinical and Personality Disorders: The Risk of Suicide

Psychobiological Aspects of Antisocial Personality Disorder, Psychopathy, and Violence