To send content items to your account,
please confirm that you agree to abide by our usage policies.
If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account.
Find out more about sending content to .
To send content items to your Kindle, first ensure email@example.com
is added to your Approved Personal Document E-mail List under your Personal Document Settings
on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part
of your Kindle email address below.
Find out more about sending to your Kindle.
Note you can select to send to either the @free.kindle.com or @kindle.com variations.
‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi.
‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.
This commentary begins by briefly reviewing and expanding upon some relevant factors of personality disorders that present challenges for clinicians. These factors include: lack of routine screening and assessment of personality disorders in routine clinical care; the vast heterogeneity both between and within personality disorder diagnoses; the high rates of comorbid psychological disorders; and the ego-syntonic nature of many personality disorders, which leads many clients to seek treatment for problems other than their personality disorders. The remainder of the commentary then outlines recommendations for clinicians to follow in their treatment of clients with personality disorders. It provides recommendations for the assessment, case conceptualization, treatment goal and target formation, target hierarchy creation, intervention selection, implementation and evaluation, and the creation and maintenance of rapport and therapeutic alliance when working with personality-disordered clients.
This commentary focuses on the current state and recent developments within the field of research on drug treatments for borderline personality disorder. From an evidence-based medicine perspective, the relevance of the currently available evidence for clinical practice is critically discussed. Some research/practice gaps are highlighted, like polypharmacy and the widespread use of quetiapine, which both lack supporting, sufficiently reliable evidence. Sources for the lack of practically relevant research are outlined, and the example of recent research on Olanzapine for patients with borderline personality disorder is amplified. Last, new initiatives are presented which aim at improving the value of research, like the REWARD alliance, the AllTrials campaign, and the James Lind alliance that guide, inform, and support the design, conduct, and publication of studies that are of relevancy to consumers and clinicians, and have the potential to transform healthcare. Some first encouraging results of these endeavors are presented.
In recent years, several cognitive behavioral therapies have been developed to meet the specific challenges involved in treating personality disorders. Cognitive and behavioral treatment (CBT) is best represented as a family of therapies, including manualized treatment packages (or “branded” CBTs) and principle-driven interventions. This chapter reviews cognitive and behavioral intervention options for patients suffering from personality dysfunction. First, the authors provide an overview of the “branded” CBTs tested with personality disorder populations, including dialectical behavior therapy, schema focused therapy, and cognitive therapy for personality disorders. For clinicians who wish to use a cognitive behavioral approach, they then discuss how CBT case conceptualization can be used to inform a flexible and responsive treatment based on the empirically-supported treatments for personality disorders. In this approach, clinicians would formulate a treatment plan that applies cognitive and behavioral strategies, interventions, and principles of change from these empirically-supported “branded” CBTs. For example, the authors discuss ways in which the CBT principle of exposure may be considered for application across different personality disorders. Finally, they discuss the potential value in application of mindfulness and acceptance strategies with personality disorders.
In this commentary, the author highlights the contributions from Fonagy and colleagues in their chapter on contemporary psychodynamic treatments. Chief among these contributions are balance between a rich and nuanced historical presentation of the major traditions within the psychodynamic perspective and a focus on contemporary psychodynamic treatments such as Mentalization Based Therapy (MBT) and Transference-Focused Psychotherapy (TFP). Additionally, building on recent findings regarding the equivalence of outcomes for various treatments irrespective of theoretical orientation, Fonagy and colleagues articulate an interesting, timely, and integrative model of personality disorder that is consistent with and integrative of a psychodynamic approach. In an effort to highlight and elaborate the work of Fonagy and colleagues, the author of this commentary focuses on the unique contributions and utility of a psychodynamic approach.
This commentary gives an overview of two types of interaction between neuroscience and psychotherapy in BPD and beyond. First, neuroscientific research, particularly neuroimaging, can be used to better understand the mechanisms how successful psychotherapy exerts its effects. Since emotion dysregulation is one of the core features of BPD and the main target of Dialectical Behavior Therapy (DBT), neuroimaging studies have investigated emotional hyperreactivity and dysfunctional regulation before and after DBT. These studies found normalization of limbic hyper-reactivity as well as a decrease of dysfunctional pain-induced emotion regulation, which is assumed to underly self-injurious behavior. A second line of research tries to use neuroimaging in the development of new therapeutic approaches such as real-time fMRI neurofeedback. Preliminary studies revealed rapid normalization of amygdala hyperreactivity and restoration of the connectivity between amygdala and medial prefrontal cortex. This was accompanied by reductions of BPD symptomatology, affective instability, and startle response. With these new approaches, there is hope to better understand mechanisms of change in BPD treatment as well as to develop innovative therapy approaches for severe emotion dysregulation.
The commentaries from Gold, Yen, Hughes and Rizvi highlight the challenges associated with using cognitive behavioral therapies to treat individuals with personality disorders (PDs). In this rejoinder, the authors extend upon these observations by arguing the importance of a modular, principle-driven approach to assessment and treatment of PDs. First, they discuss how there is a greater demand for treatments beyond the current “branded” CBTs and their empirical basis. In light of this limitation, clinicians need to flexibly use empirically-supported principles of change to treat processes underlying personality dysfunction. This approach requires careful case formulation and identification of behaviorally-specific targets of treatment using validated screening tools. This approach to treatment may be a useful way of meeting the demands for both patient care and current trends in national health care payor reform.
This rejoinder proposes how the five trait domain qualifiers of the ICD-11 personality disorder classification may capture personality dynamics, while also being feasible in various clinical settings. It is highlighted that the simple coding of one to five trait qualifiers may serve as a basic step in the process that leads to a clinical management plan; for clinicians with more resources, a second step may involve taking advantage of the 25 detailed DSM-5 AMPD subfacets for a more fine-grained case-formulation and treatment planning. Moreover, the ICD-11 trait domain qualifiers seem to take personality dynamics into account, which is exemplified by how different trait domain combinations may involve different situational and motivational trait domain expressions that demand different treatment implications.
This commenatry on Rosenthal, Wyatt, and McMahon’s review of cognitive and behavioral therapies (CBTs) for personality disorders (PDs) discusses implementation challenges to cognitive and behavioral approaches in real world settings. Multiple interventions show some empirical support for the treatment of PDs, including dialectical behavior therapy (DBT), schema-focused therapy (SFT), cognitive therapy for personality disorders, emotion regulation group therapy (ERGT), and systems training for emotional predictability and problem solving (STEPPS). Most of this work is restricted to borderline personality disorder (BPD) and DBT, whereas strong empirical support for other PDs is lacking. Here the authors discuss possible factors that may account for differential research support for the treatment of BPD relative to other PDs. For example, the BPD diagnosis includes suicidal and self-injurious behaviors among its criteria and is associated with DBT and its relevant training organizations and adaptations across multiple levels of care. Additionally, they provide examples in which interventions have been implemented ahead of the science. Finally, they discuss challenges to implementing CBTs for PDs in real world settings, such as diagnostic heterogeneity, comorbid presentations, and dual diagnosis, as well as the longstanding nature of problems associated with PDs.
Turner and colleagues (this volume) have written a thoughtful and comprehensive overview of theory and research across a vast literature: environmental and sociocultural influences on the development of personality disorders (PDs). They review behavioral genetics studies and studies on the prevalence of PDs in different countries and from different socioeconomic backgrounds. They describe a wide variety of theories of how PDs develop and review environmental risk factors from early childhood adversity to the quality of communities. This commentary, focusing on borderline PD (for which there is the most research), extends this work in two ways. First, the authors propose an overarching theory of environmental and sociocultural influences on the development of PDs. Second, they add empirical support for two of the theories that Turner and colleagues present: attachment and biosocial theories. In this way, the authors aim to identify processes underlying the development of PDs that may be the focus of interventions. An appropriate intervention at the level of the individual would include Young’s Schema Therapy (Young, 1994), and at the level of the family system the Family Connections Program (Hoffman et al., 2005).
The chapter on psychoanalytic/psychodynamic approaches to personality disorders (this volume) particularly highlights Mentalization-Based Treatment (MBT), which has a number of striking commonalities with Dialectical Behavior Therapy (DBT). This commentary highlights commonalities of the two approaches in areas including structural properties, skills training, the approach to insight, and the emphasis on practitioner flexibility. While DBT and MBT have significant distinctions and are not equivalent treatments, the commonalities among the treatments may be indicative of best practices when treating individuals with BPD. Some candidates for what may be best practices include approaching treatment with a balanced combination of validation and change-based strategies which directly target severe behaviors such as suicidal behaviors and non-suicidal self-injury; providing a compassionate model of the pathology; actively building a strong, genuine, and validating therapeutic relationship; a central focus on emotions and how they are related to actions; use of a team based approach that promotes adherence to the treatment model; teaching skills that address the model of pathology; and promoting flexibility within the treatment approach to address the complexities of the clients’ problems.
The DSM-5 Alternative Model of Personality Disorders (AMPD) and the ICD-11 Classification of Personality Disorders allow clinicians to describe trait domains that contribute to the unique expression of personality dysfunction. Both diagnostic systems deliniate trait domain features of negative affectivity, detachment, antagonism/dissociality, disinhibition, and anankastia/compulsivity, which may inform clinicians about how to manage treatment. This chapter specifically describes how the DSM-5 and ICD-11 trait domains may be useful for establishing a favorable treatment alliance, doing therapeutic assessment, increasing the patient’s self-knowledge, providing psychoeducation, planning realistic treatment goals, and matching therapy to the patient’s personality. A key message of this chapter is that practitioners should not treat traits per se but the maladaptive expressions of traits.
Many people with psychosis experience persecutory delusions and report negative schematic beliefs and intrusive mental images which may be maintaining factors for psychotic symptoms.
This study examined the feasibility and acceptability of a new psychological therapy targeting schemas and images (iMAPS therapy).
The study used a randomised multiple baseline design. Participants with first episode psychosis were randomised using a multiple baseline design with 2–5 assessments. Six sessions of therapy, consisting of a combination of imagery techniques and imagery rescripting techniques, was used. In each session, participants completed a Mental Imagery in Psychosis Questionnaire (MIPQ) and imagery interview. Mood and delusional beliefs (PSYRATS) were also measured at each session.
Five participants with first episode psychosis completed the baseline visits and attended all therapy sessions. One participant declined the final assessment. Results demonstrated significant reductions in negative schematic beliefs, delusions, imagery distress and other measures of schema (YSQ, SMI). Although multiple baseline randomisation strengthens the study, it lacked a control arm and blind assessments.
iMAPS appears a feasible and acceptable treatment for psychosis, and further evaluation is indicated.
Acceptance and commitment therapy (ACT) has substantial support in adult populations but less among adolescents. To date, very little research has evaluated whether it can be delivered in a highly accessible school context. This study examined a 6-hour, weekly ACT-informed school-based group intervention for adolescent girls, focusing on anxiety, depression and building psychological flexibility. Participants (N = 10) who completed the intervention experienced significantly lowered levels of anxiety and increased psychological flexibility, with postintervention scores for all variables trending in the expected directions. Findings provide preliminary support for the efficacy of the intervention and encourages further evaluation of ACT delivered in schools.
Memory impairment is an important side-effect of electroconvulsive therapy (ECT). However, predicting which patients are at increased risk of developing this is difficult. The study by Sigström et al compares patients’ experience of memory difficulties before and after ECT and suggests that patients with negative expectations of ECT's memory effects are more likely to have subjective memory worsening post-ECT. This intriguing finding suggests that clinicians may be able to modify the risk of patients developing subjective memory difficulties post-ECT by providing appropriate information and addressing concerns prior to treatment, during the informed consent process.
A four- to seven-fold increase in the prevalence of current mood, anxiety, substance use and any mental disorders in Indigenous adults compared with non-Indigenous Australians has been reported. A lifetime prevalence of major depressive disorder was 23.9%. High rates of comorbid mental disorders indicated a transdiagnostic approach to treatment might be most appropriate. The effectiveness of psychological treatment for Indigenous Australians and adjunct Indigenous spiritual and cultural healing has not previously been evaluated in controlled clinical trials.
This project aims to develop, deliver and evaluate the effectiveness of an Indigenous model of mental healthcare (IMMHC). Trial registration: ANZCTR Registration Number: ACTRN12618001746224 and World Health Organization Universal Trial Number: U1111-1222-5849.
The IMMHC will be based on transdiagnostic cognitive–behaviour therapy co-designed with the Indigenous community to ensure it is socially and culturally appropriate for Indigenous Australians. The IMMHC will be evaluated in a randomised controlled trial with 110 Indigenous adults diagnosed with a current diagnosis of depression. The primary outcome will be the severity of depression symptoms as determined by changes in Beck Depression Inventory-II score at 6 months post-intervention. Secondary outcomes include anxiety, substance use disorder and quality of life. Outcomes will be assessed at baseline, 6 months post-intervention and 12 months post-intervention.
The study design adheres to the Consolidated Standards of Reporting Trials (CONSORT) statement recommendations and CONSORT extensions for pilot trials. We followed the Standard Protocol Items for Randomised Trials statement recommendations in writing the trial protocol.
This study will likely benefit participants, as well as collaborating Aboriginal Medical Services and health organisations. The transdiagnostic IMMHC has the potential to have a substantial impact on health services delivery in the Indigenous health sector.
The benefits of cognitive-behavioral treatment (CBT) and positive psychology therapy (PPT) in patients with cardiovascular disease are still not well defined. We assessed the efficacy of CBT and PPT on psychological outcomes in coronary artery disease (CAD) patients.
Randomized controlled trials evaluating CBT or PPT in CAD patients published until May 2018 were systematically analyzed. Primary outcomes were depression, stress, anxiety, anger, happiness, and vital satisfaction. Random effects meta-analyses using the inverse variance method were performed. Effects were expressed as standardized mean difference (SMD) or mean differences (MD) with their 95% confidence intervals (CIs); risk of bias was assessed with the Cochrane tool.
Nineteen trials were included (n = 1956); sixteen evaluated CBT (n = 1732), and three PPT (n = 224). Compared with control groups, depressive symptoms (13 trials; SMD −0.80; 95% CI −1.33 to −0.26), and anxiety (11 trials; SMD −1.26; 95% CI −2.11 to −0.41) improved after the PI, and depression (6 trials; SMD −2.08; 95% CI −3.22 to −0.94), anxiety (5 trials; SMD −1.33; 95% CI −2.38 to −0.29), and stress (3 trials; SMD −3.72; 95% CI −5.91 to −1.52) improved at the end of follow-up. Vital satisfaction was significantly increased at follow-up (MD 1.30, 0.27, 2.33). Non-significant effects on secondary outcomes were found. Subgroup analyses were consistent with overall analyses.
CBT and PPT improve several psychological outcomes in CAD patients. Depression and anxiety improved immediately after the intervention while stress and vital satisfaction improve in the mid-term. Future research should assess the individual role of CBT and PPT in CAD populations.
Thromboembolic disorders are the second leading cause of death in breast cancer. Antiplatelet therapy combined with cancer therapy is a potential treatment strategy against cancer-associated thromboembolic disorders; however, the efficacy of such dual treatment has not been established. This study reports novel findings on the response of hormone-dependent breast cancer cell lines (MCF7/T47D) following 24 h treatment with Anastrozole, combined with Aspirin and Clopidogrel cocktail; and Atopaxar. Neutral red and lactate dehydrogenase assays were conducted to assess viability and cytotoxicity respectively. Flow cytometric Annexin-V/PI assay was used to assess the mode of cell death. Morphological alterations were studied using scanning electron microscopy. Statistical analysis was conducted using Statistica V13. Definitive outcomes were established with flow cytometric detection of phosphatidylserine exposure and propidium iodide staining, complemented with ultrastructural analysis. Results showed that a few cells were undergoing death mainly through secondary necrosis. Morphological features suggesting induced cell motility (pseudopodia/ruffled membranes) were observed in both cell lines; notably, T47D cells presented pronounced features than MCF7 cells. Overall, these findings suggest that such combined treatment may differentially promote cell survival, inducing a more aggressive breast cancer phenotype.
No evidence-based therapy for borderline personality disorder (BPD) exhibits a clear superiority. However, BPD is highly heterogeneous, and different patients may specifically benefit from the interventions of a particular treatment.
From a randomized trial comparing a year of dialectical behavior therapy (DBT) to general psychiatric management (GPM) for BPD, long-term (2-year-post) outcome data and patient baseline variables (n = 156) were used to examine individual and combined patient-level moderators of differential treatment response. A two-step bootstrapped and partially cross-validated moderator identification process was employed for 20 baseline variables. For identified moderators, 10-fold bootstrapped cross-validated models estimated response to each therapy, and long-term outcomes were compared for patients randomized to their model-predicted optimal v. non-optimal treatment.
Significant moderators surviving the two-step process included psychiatric symptom severity, BPD impulsivity symptoms (both GPM > DBT), dependent personality traits, childhood emotional abuse, and social adjustment (all DBT > GPM). Patients randomized to their model-predicted optimal treatment had significantly better long-term outcomes (d = 0.36, p = 0.028), especially if the model had a relatively stronger (top 60%) prediction for that patient (d = 0.61, p = 0.004). Among patients with a stronger prediction, this advantage held even when applying a conservative statistical check (d = 0.46, p = 0.043).
Patient characteristics influence the degree to which they respond to two treatments for BPD. Combining information from multiple moderators may help inform providers and patients as to which treatment is the most likely to lead to long-term symptom relief. Further research on personalized medicine in BPD is needed.
Increased amygdala responsiveness is the hallmark of fear and a characteristic across patients with anxiety disorders. The amygdala is embedded in a complex regulatory circuit. Multiple different mechanisms may elevate amygdala responsiveness and lead to the occurrence of an anxiety disorder. While top-down control by the prefrontal cortex (PFC) downregulates amygdala responses, the locus coeruleus (LC) drives up amygdala activation via noradrenergic projections. This indicates that the same fearful phenotype may result from different neural mechanisms. We propose a mechanistic model that defines three different neural biomarkers causing amygdala hyper-responsiveness in patients with anxiety disorders: (a) inherent amygdala hypersensitivity, (b) low prefrontal control and (c) high LC drive. First-line treatment for anxiety disorders is exposure-based cognitive behavioural therapy, which strengthens PFC recruitment during emotion regulation and thus targets low-prefrontal control. A treatment response rate around 50% (Loerinc et al., 2015, Clinical Psychological Reviews, 42, 72–82) might indicate heterogeneity of underlying neurobiological mechanisms among patients, presumably leading to high variation in treatment benefit. Transforming insights from cognitive neuroscience into applicable clinical heuristics to categorise patients based on their underlying biomarker may support individualised treatment selection in psychiatry. We review literature on the three anxiety-related mechanisms and present a mechanistic model that may serve as a rational for pathology-based diagnostic and biomarker-guided treatment selection in psychiatry.
The aim of this study was to analyze the profile of chest injuries, oxygen therapy for respiratory failure, and the outcomes of victims after the Jiangsu tornado, which occurred on June 23, 2016 in Yancheng City, Jiangsu Province, China.
The clinical records of 144 patients referred to Yancheng City No.1 People’s Hospital from June 23 through June 25 were retrospectively investigated. Of those patients, 68 (47.2%) sustained major chest injuries. The demographic details, trauma history, details of injuries and Abbreviated Injury Scores (AIS), therapy for respiratory failure, surgical procedures, length of intensive care unit (ICU) and hospital stay, and mortality were analyzed.
Of the 68 patients, 41 (60.3%) were female and 27 (39.7%) were male. The average age of the injured patients was 57.1 years. Forty-six patients (67.6%) suffered from polytrauma. The mean thoracic AIS of the victims was calculated as 2.85 (SD = 0.76). Rib fracture was the most common chest injury, noted in 56 patients (82.4%). Pulmonary contusion was the next most frequent injury, occurring in 12 patients (17.7%). Ten patients with severe chest trauma were admitted to ICU. The median ICU stay was 11.7 (SD = 8.5) days. Five patients required intubation and ventilation, one patient was treated with noninvasive positive pressure ventilation (NPPV), and four patients were treated with high-flow nasal cannula (HFNC). Three patients died during hospitalization. The hospital mortality was 4.41%.
Chest trauma was a common type of injury after tornado. The most frequent thoracic injuries were rib fractures and pulmonary contusion. Severe chest trauma is usually associated with a high incidence of respiratory support requirements and a long length of stay in the ICU. Early initiation of appropriate oxygen therapy was vital to restoring normal respiratory function and saving lives. Going forward, HFNC might be an effective and well-tolerated therapeutic addition to the management of acute respiratory failure in chest trauma.