Psychotherapy in borderline and narcissistic personality disorder

Minimal emotional dysfunctions (MED) in personality disorders

The concept of minimal emotional dysfunctions (MED) refers to traditional psychopathology in order to describe, classify, and understand personality disorders. Emotional dysfunctions encompass disorders of affect predominance, production, expression, experience, modulation, and regulation. MED can explain the dimensional nature of personality disorders, their multidimensionality and problems with categorical classifications. It can stimulate research on the etiology of personality disorders in reference to modern developmental brain research and trauma psychology. It can guide new developments in pharmacotherapy and psychotherapy. It is suggested to focus on MED in future developments of the description and classification of personality disorders.

Psychological treatment for personality disorders

There is encouraging evidence that some patients with personality disorder are treatable. Psychotherapeutic interventions show promise, although interpretation of the literature is problematic: the number of patients in most trials is small, outcome measures are questionable, follow-up is limited, and treatments are multifaceted, complex interventions in which the effective components are unclear. The evidence base can be assessed according to efficacy and generalisability, and when both are taken into account the best verification is for psychodynamic therapy. However, there is inadequate evidence to make specific recommendations for any particular therapy.

A model for an integrated psychotherapy service

A model psychotherapy service is proposed, integrated in the double sense of combining different psychotherapeutic modalities in a single psychological treatment service, and forging close links with general psychiatry. The four limbs of the service extend into supporting counsellors in general practice, providing psychotherapeutic input into the treatment of the severely mentally ill, managing patients with personality disorders, and supplying psychotherapeutic aspects of a liaison service. The advantages of this model in the current managerial climate are discussed.

Management of difficult personality disorder patients

Ten per cent of the general adult population have a diagnosable personality disorder (Zimmerman & Coryell, 1990) and in 4% this is clinically severe (Tyrer, 1988). The clinical management of such patients may be difficult. However, much clinical difficulty is generated by interpersonal aspects deriving from the particular interaction of the patient and psychiatrist involved and the respective roles they play.

Principles of managing patients with personality disorder

The management of individuals with personality disorder is one of the most challenging and sometimes controversial areas of psychiatry. This paper describes the principles involved in identifying the clinical problems and formulating a management plan for patients with personality disorder in everyday clinical practice. It demonstrates that the principles of assessing and managing personality disorders and the clinical skills required are no different from those of treating any other chronic mental disorder.

Commentary

Anthony Winston reviews and describes current perspectives on the aetiology of borderline personality disorder, covering areas such as the role of traumatic factors, attachment theory and self-psychology. The author links these to the psychopathology of the borderline patient who experiences difficulties such as regulation of affect, impulse control and cognitive capacity to both think and reflect. The psychological function of splitting is considered along with other defence mechanisms as having adaptive potential for the borderline patient. Winston describes in a helpful way the links between human development, psychodynamics and psychopathology as he reveals some of the more recent contributions to the field of BPD. At the beginning of his article, he emphasises the problems encountered when attempting to treat or manage patients with BPD. He centres these difficulties on the counter-transference of the clinician, pointing out how such feelings can “all too easily be transformed into therapeutic nihilism”. His article can easily be read as an attempt to counter such a state of mind and he appears to try to generate a more hopeful if not optimistic outlook. In doing so, I fear that he goes beyond his own account of the research evidence for the effectiveness of treatment. Such enthusiasm or optimism can readily be understood as a reactive polar opposite to nihilism or pessimism. I would like to consider further Winston's statements germane to this aspect of his article and raise for further discussion some other ideas which extend beyond the narrower confines of aetiology and psychological therapy.

The global problem of child maltreatment: Perspectives on mechanisms of influence and illness presentation

Child abuse and neglect negatively impact both neurological and psychological development. Patterns of abuse are learned and repeated in families. Adverse childhood experiences are a risk factor for psychopathology later in life, including borderline personality disorder (BPD). BPD is prevalent in clinical populations in the United States, but its prevalence has not been well-documented in most other parts of the world. The aim of this paper is to explore the impact of culture upon the intergenerational transmission of childhood maltreatment and the clinical presentation of abused children. To facilitate this exploration, we will consider the cases of four adolescent girls in unique socioeconomic and cultural settings around the world: Liberia, El Salvador, India, and a Congolese immigrant in France. Each of these girls endorsed some features of BPD, but only two met full criteria. In societies in which externalizing behaviors are not acceptable, children may internalize their distress or separate from their families. Defining BPD in terms of internal experience makes it more difficult to identify, but it would allow for the inclusion of cases in which symptoms may manifest differently while the underlying problem is similar.

Focus Group Research

This article considers the philosophical underpinnings that have shadowed the emergence of focus group methods as a counterpoise to positivist research design. Examples of the application of focus group methods are drawn from two studies where the voices of marginalized groups were facilitated: 1) focus groups with patients diagnosed with personality disorder; and 2) focus groups with gypsy travellers. In both groups there were varying degrees of coherence in communication although particular attention here is paid to the role of dissonance and `negative dialectics' in the formation of opinion. Data generation in focus groups is considered in relation to group size, structure and clinical techniques.

Practitioner Review: Borderline personality disorder in adolescence--recent conceptualization, intervention, and implications for clinical practice

BACKGROUND

The past decade has seen an unprecedented increase in research activity on personality disorders (PDs) in adolescents. The increase in research activity, in addition to major nosological systems legitimizing the diagnosis of borderline personality disorder (BPD) in adolescents, highlights the need to communicate new research on adolescent personality problems to practitioners.

SCOPE

In this review, we provide up-to-date information on the phenomenology, prevalence, associated clinical problems, etiology, and intervention for BPD in adolescents. Our aim was to provide a clinically useful practitioner review and to dispel long-held myths about the validity, diagnostic utility, and treatability of PDs in adolescents.

FINDINGS AND CONCLUSION

Alongside providing up-to-date information on the phenomenology, prevalence, and etiology, we also report on associated clinical problems and interventions for adolescent BPD. It is only through early active assessment and identification of youngsters with these problems that a lifetime of personal suffering and health system burden can be reduced or altogether avoided. A variety of evidence-based approaches are now available to treat BPD and related clinical problems in young people. Future research should focus on establishing optimal precision in the diagnostic processes in different treatment settings.

ESCAP Expert Article: borderline personality disorder in adolescence: an expert research review with implications for clinical practice

Borderline personality disorder (BPD) has onset in adolescence, but is typically first diagnosed in young adulthood. This paper provides a narrative review of the current evidence on diagnosis, comorbidity, phenomenology and treatment of BPD in adolescence. Instruments available for diagnosis are reviewed and their strengths and limitations discussed. Having confirmed the robustness of the diagnosis and the potential for its reliable clinical assessment, we then explore current understandings of the mechanisms of the disorder and focus on neurobiological underpinnings and research on psychological mechanisms. Findings are accumulating to suggest that adolescent BPD has an underpinning biology that is similar in some ways to adult BPD but differs in some critical features. Evidence for interventions focuses on psychological therapies. Several encouraging research studies suggest that early effective treatment is possible. Treatment development has just begun, and while adolescent-specific interventions are still in the process of evolution, most existing therapies represent adaptations of adult models to this developmental phase. There is also a significant opportunity for prevention, albeit there are few data to date to support such initiatives. This review emphasizes that there can be no justification for failing to make an early diagnosis of this enduring and pervasive problem.

Early experience, structural dissociation, and emotional dysregulation in borderline personality disorder: the role of insecure and disorganized attachment

Persistent problems in emotional regulation and interpersonal relationships in borderline patients can be understood as developing from difficulties in early dyadic regulation with primary caregivers. Early attachment patterns are a relevant causal factor in the development of Borderline Personality Disorder (BPD). Links between attachment issues, early history of neglect, and traumatic experiences, and symptoms observed in patients with BPD as per the DSM-5 classification (American Psychiatric Association: Diagnostic and statistical manual of mental disorders: DSM-5 (Fifth ed.). Washington, D.C; (2013)) are described in this article, while delineating possible pathways from attachment disruptions to the specific symptomatology of these patients. The theory of structural dissociation of the personality (TSDP) provides an essential framework for understanding the processes that may lead from insecure early attachment to the development and maintenance of BPD symptoms. Dyadic parent-child interactions and subsequent modulation of emotion in the child and future adult are considered closely related, but other factors in the development of BPD, such as genetic predisposition and traumatic experiences, should also be considered in conceptualizing and organizing clinical approaches based on a view of BPD as a heterogeneous disorder.

Empathy in narcissistic personality disorder: from clinical and empirical perspectives

Narcissistic personality disorder (NPD) is associated with an assortment of characteristics that undermine interpersonal functioning. A lack of empathy is often cited as the primary distinguishing feature of NPD. However, clinical presentations of NPD suggest that empathy is not simply deficient in these individuals, but dysfunctional and subject to a diverse set of motivational and situational factors. Consistent with this presentation, research illustrates that empathy is multidimensional, involving 2 distinct emotional and cognitive processes associated with a capacity to respectively understand and respond to others' mental and affective states. The goal of this practice review is to bridge the gap between our psychobiological understanding of empathy and its clinical manifestations in NPD. We present 3 case studies highlighting the variability in empathic functioning in people with NPD. Additionally, we summarize the literature on empathy and NPD, which largely associates this disorder with deficient emotional empathy, and dysfunctional rather than deficient cognitive empathy. Because this research is limited, we also present empathy-based findings for related syndromes (borderline and psychopathy). Given the complexity of narcissism and empathy, we propose that multiple relationships can exist between these constructs. Ultimately, by recognizing the multifaceted relationship between empathy and narcissism, and moving away from an all or nothing belief that those with NPD simply lack empathy, therapists may better understand narcissistic patients' behavior and motivational structure.

The state of the evidence base for psychodynamic psychotherapy for children and adolescents

This article reviews outcomes of psychodynamic psychotherapy (PP) for children and adolescents reported in articles identified by a comprehensive review of the literature on treatment evaluations of psychological and medical interventions for mental disorders in pediatric populations. The review identified 48 reports based on 33 studies. While there is evidence of substantial clinical gains associated with PP, in almost all the studies, when contrasted with family-based interventions, PP fares no better and appears to produce outcomes with some delay relative to family-based therapies. Further rigorous evaluations are needed, but evidence to date suggests that the context in which PP is delivered should be extended from the traditional context of individual therapy and parents should be included in the treatment of children.

Defense mechanisms in schizotypal, borderline, antisocial, and narcissistic personality disorders

Numerous authors have theorized that defense mechanisms play a role in personality disorders. We reviewed theoretical writings and empirical studies about defenses in schizotypal, borderline, antisocial, and narcissistic personality disorders, developing hypotheses about these differential relationships. We then examined these hypotheses using dynamic interview data rated for defenses in a study of participants (n = 107) diagnosed with these four personality disorder types. Overall, the prevalence of immature defenses was substantial, and all four disorders fit within the broad borderline personality organization construct. Defenses predicted the most variance in borderline and the least variance in schizotypal personality disorder, suggesting that dynamic factors played the largest role in borderline and the least in schizotypal personality. Central to borderline personality were strong associations with major image-distorting defenses, primarily splitting of self and other's images, and the hysterical level defenses, dissociation and repression. Narcissistic and antisocial personality disorders shared minor image-distorting defenses, such as omnipotence or devaluation, while narcissistic also used splitting of self-images and antisocial used disavowal defenses like denial. Overall, differential relationships between specific defenses and personality disorder types were largely consistent with the literature, and consistent with the importance that the treatment literature ascribes to working with defenses.

Recovery in Borderline Personality Disorder (BPD): a qualitative study of service users' perspectives

BACKGROUND

Symptom improvement in Borderline Personality Disorder (BPD) is more common than previously hypothesised. However, it remains unclear whether it reflects service users' personal goals of recovery. The present study aimed to explore what service users with BPD view as recovery.

METHODS

48 service users were recruited from secondary mental health services and their views on their personal goals and the meaning of recovery were explored in in-depth semi-structured interviews. The study drew on grounded theory and thematic analysis.

RESULTS

Service users believed that recovery involved developing self-acceptance and self-confidence, gaining control over emotions, improving relationships, employment, and making progress in symptoms like suicidality and self-harming. They felt that psychotherapies for BPD often had an extreme focus on specific areas, like self-harming or relationships, and that some of their goals were neglected. Although full recovery was seen as a distant goal, interviewees felt that they could learn how to deal with their problems in more effective ways and make meaningful progress in their lives.

CONCLUSIONS

Specialist therapies for BPD explicitly address some of the recovery goals that are important to service users, whereas other goals are only indirectly or poorly addressed. Professionals might need to work with service users towards devising comprehensive individualised case formulations, including all treatment targets that are important to service users, their priorities, and long-term plans on how their targets might be met and which services might be involved.

[Minimal emotional dysfunction and first impression formation in personality disorders]

"Minimal cerebral dysfunctions" are isolated impairments of basic mental functions, which are elements of complex functions like speech. The best described are cognitive dysfunctions such as reading and writing problems, dyscalculia, attention deficits, but also motor dysfunctions such as problems with articulation, hyperactivity or impulsivity. Personality disorders can be characterized by isolated emotional dysfunctions in relation to emotional adequacy, intensity and responsivity. For example, paranoid personality disorders can be characterized by continuous and inadequate distrust, as a disorder of emotional adequacy. Schizoid personality disorders can be characterized by low expressive emotionality, as a disorder of effect intensity, or dissocial personality disorders can be characterized by emotional non-responsivity. Minimal emotional dysfunctions cause interactional misunderstandings because of the psychology of "first impression formation". Studies have shown that in 100 ms persons build up complex and lasting emotional judgements about other persons. Therefore, minimal emotional dysfunctions result in interactional problems and adjustment disorders and in corresponding cognitive schemata.From the concept of minimal emotional dysfunctions specific psychotherapeutic interventions in respect to the patient-therapist relationship, the diagnostic process, the clarification of emotions and reality testing, and especially an understanding of personality disorders as impairment and "selection, optimization, and compensation" as a way of coping can be derived.

What makes narcissists bloom? A framework for research on the etiology and development of narcissism

Narcissism is a dynamic form of personality characterized by a pervasive sense of grandiosity and self-importance, and by a need to obtain continuous self-validation from others. Very little is known about its etiology and development. What factors (e.g., temperament, parenting experiences) and processes (e.g., transactions between these factors over time) cause some children to become more narcissistic than others? When does narcissism first emerge, and how does narcissism develop over time? This article describes a framework for research on the etiology and development of narcissism, and recommends ten research priorities. This research should yield fundamental knowledge and should inform intervention efforts to minimize the negative impact narcissistic individuals have on themselves and on others.

A developmental, mentalization-based approach to the understanding and treatment of borderline personality disorder

The precise nature and etiopathogenesis of borderline personality disorder (BPD) continues to elude researchers and clinicians. Yet, increasing evidence from various strands of research converges to suggest that affect dysregulation, impulsivity, and unstable relationships constitute the core features of BPD. Over the last two decades, the mentalization-based approach to BPD has attempted to provide a theoretically consistent way of conceptualizing the interrelationship between these core features of BPD, with the aim of providing clinicians with a conceptually sound and empirically supported approach to BPD and its treatment. This paper presents an extended version of this approach to BPD based on recently accumulated data. In particular, we suggest that the core features of BPD reflect impairments in different facets of mentalization, each related to impairments in relatively distinct neural circuits underlying these facets. Hence, we provide a comprehensive account of BPD by showing how its core features are related to each other in theoretically meaningful ways. More specifically, we argue that BPD is primarily associated with a low threshold for the activation of the attachment system and deactivation of controlled mentalization, linked to impairments in the ability to differentiate mental states of self and other, which lead to hypersensitivity and increased susceptibility to contagion by other people's mental states, and poor integration of cognitive and affective aspects of mentalization. The combination of these impairments may explain BPD patients' propensity for vicious interpersonal cycles, and their high levels of affect dysregulation and impulsivity. Finally, the implications of this expanded mentalization-based approach to BPD for mentalization-based treatment and treatment of BPD more generally are discussed.

Perspectives on the prevalence and treatment of personality disorder

Personality disorder (PD) is the most prevalent psychiatric disorder. A methodical literature search identified that PD is under researched compared with other mental health problems such as depression or schizophrenia. Social and psychotherapeutic approaches emerge as dominant treatment approaches with PD where there is good evidence of efficacy. Collaborative group-based therapeutic approaches appear to offer a therapeutic counterpoise to the anti-social traits often prevalent in PD. A retrospective analysis of formal group therapy on acute inpatient units (treating PD patients among other mental health disorders) reveals only one violent incident in over 40,000 treatment hours of formal group therapy. It is argued that group-based and social therapy should be the recommended treatment approach because these approaches have been shown to create a safe and contained milieu, establishing a good base for therapeutic gain with PD patients. The case for widening the scope of collaborative group and community-based therapies is considered and the merits and shortcomings of a key worker system with PD patients are critiqued.

Trust as a foundation for the therapeutic intervention for patients with borderline personality disorder

A qualitative, exploratory, descriptive and contextual study using an 'interpretive descriptive approach' was undertaken in order to develop a practice-level model for the facilitation of mental health of patients diagnosed as having Borderline Personality Disorder by the community psychiatric nurse. The context of the study was the in the Psychiatric Community Services in the greater Johannesburg region, South Africa. Individual and focus group interviews were conducted with patients and mental health clinicians representing the multidisciplinary team with experience in managing the condition, either in a personal capacity or as professional mental health practitioners. Themes extrapolated from the transcribed interviews were further explored and a practice-based theory was constructed. This article reports on the first theme 'Trust', the concept identified by both patients and clinicians as crucial for the establishment and maintenance of the therapeutic relationship that forms the vehicle for care of patients with this disorder in psychiatric mental health care.

The Personality Disorders Institute/Borderline Personality Disorder Research Foundation randomized control trial for borderline personality disorder: rationale, methods, and patient characteristics

The Personality Disorder Institute/Borderline Personality Disorder Research Foundation randomized control trial (PDI/BPDRF RCT) is a controlled outcome study for borderline personality disorder (BPD), in which 90 participants were randomized to one of three manualized and monitored, active psychosocial treatment conditions. These treatments are: (a) Transference-Focused Psychotherapy (TFP; Clarkin, Yeomans, & Kernberg, 1999), a treatment for BPD based on object-relational and psychoanalytic principles first applied to BPD by Kernberg (1996), notable for its particular emphasis on interpretation of object relations activated in the ongoing therapeutic relationship; (b) Dialectical Behavior Therapy (DBT; Linehan, 1993), a popular treatment for BPD, with evidence of efficacy (Linehan, Armstrong, Suarez, Allmon, & Heard, 1991) that emphasizes a balance between acceptance and change in its combination of cognitive-behavioral and Zen principles; and (c) supportive psychotherapy (Rockland, 1992), another object-relational and psychoanalytically based treatment for BPD which, in contrast to TFP, eschews transference interpretation and places primary emphasis on development of a collaborative engagement with the patient to foster identity development. Patients received medication, if clearly indicated, according to the treatment algorithm developed by Soloff (2000). This article describes the significance and rationale of the study and the overall design, methods, plan of analysis, and demographic characteristics of the recruited sample of patients.

Developing services for people with dangerous and severe personality disorders

This paper describes the conflicting attitudes that exist within wider society and the people who deliver services for people with dangerous and severe personality disorder. The importance of recognizing the nature of these conflicting attitudes that are based on the desire for ' punishment', ' keeping society safe' and ' treatment and care' is discussed. Potential ways of resolving these conflicts at an organizational and practice level are explored. The resolution might involve replacing the notions and associated practices of ' punishment' and ' safety' with ' containment', and ' treatment and care' with psychosocial therapy and rehabilitation.

Attachment and borderline personality disorder. A theory and some evidence

An attachment theory approach to severe personality disorder is described. Evidence is presented that suggests that representations of attachment relationships and attachment behaviors of patients with this diagnosis are commonly disorganized in character. It is argued that the capacity to develop mental representations of mental states in self and other (reflective function) develops in the context of attachment relationships and that disorganization of attachment undermines this process. Such disorganization can be associated with trauma but may also be linked to other biological and psychosocial deficits. Many of the clinical characteristics of patients with borderline personality disorder may be seen as consequences of disordered self-organization and a limited rudimentary capacity to think about behavior in mental state terms. The relevance of this model for the practice of psychotherapy with this group of patients is discussed.

Swimming against the tide? A review of the therapeutic community

OBJECTIVE

The therapeutic community is an established psychiatric treatment method which may be in decline. This paper reviews the nature of inpatient therapeutic community treatment, and re-evaluates its role.

METHOD

The principles and practice of such treatment are summarised, with a focus on the functions of staff.

RESULTS

The inpatient therapeutic community is conceptualised as combining sociotherapeutic treatment, psychotherapeutic treatment, and the advantages of the inpatient setting. This unique treatment environment allows for therapeutic regression while mitigating against anti-therapeutic behavioural regression. Research evidence supports the efficacy of therapeutic community treatment for patients with borderline personality disorder.

CONCLUSION

Further research is needed to assess its efficacy for other diagnostic groups. This intensive treatment approach may be most appropriate for patients who have proved treatment resistant by other means. Possible reasons for the marginalization of therapeutic community treatment are considered. Access to quality inpatient therapeutic community treatment is essential in the provision of a comprehensive psychiatric service.

The structure and development of borderline personality disorder: a proposed model

BACKGROUND

The theory of cognitive analytic therapy is extended to offer an understanding of borderline personality disorder (BPD).

METHOD

A structural model (the multiple self states model) and a classification of different levels of developmental damage are proposed.

RESULTS

The model offers an explanation of the phenomenology of BPD.

CONCLUSIONS

The multiple self states model provides insights that will be useful for clinicians involved in the psychotherapy and management of BPD patients.

Borderline personality disorder: study in adolescence

The study of the presentation, symptomatology and family characteristics of an exclusively adolescent sample of patients with borderline personality disorder (BPD) was undertaken. Twenty-four cases of borderline personality disorder, 20 females, 4 males, identified using chart review and meeting the criteria of the Diagnostic Interview for Borderlines (DIB) and DSM III-R, were matched with psychiatric controls. Adolescents with borderline personality disorder were found to have high rates of affective symptomatology with Axis I diagnosis of major depressive disorder MDD (DSM-III-R), and high rates of interpersonal psychopathology, i.e., manipulation, devaluation, and a pervasive sense of boredom. The latter seem to be characteristic as for adults with borderline personality disorder. The families were particularly angry and volatile.

Psychotherapy assessment and treatment selection

BACKGROUND

Current acceptance of the need for a wide range of treatments and growing pressure for cost-effectiveness suggest the need for a more discriminating approach to assessment of psychotherapy.

METHOD

Medline and manual literature searches, and personal experience of over 1000 assessments in a district psychotherapy service.

RESULTS

There is substantial evidence for the general efficacy of psychotherapy; differential benefits are beginning to be identified. Short-term treatments are appropriate in a wide variety of situations and can be surprisingly effective. Chronic/complex psychopathology is likely to need longer term therapy.

CONCLUSIONS

Effective use of scarce psychotherapy resources requires knowledge of the research evidence of treatment effectiveness, careful assessment of the patient and a logical and collaborative approach to treatment planning.

The efficacy of a nursing challenge to patients: testing a new intervention to decrease self-harm behaviour in severe personality disorder

This paper describes the study of a new intervention, which was intended to increase therapeutic engagement with patients and to decrease self-harm behaviour. As a result of nursing observations in a unit that specialized in severe personality disorders, a psychodynamic perspective to treatment was introduced in the form of a nursing challenge. The intervention was evaluated in a new service for young adults at a psychiatric hospital in the south of England, as part of a clinical research apprenticeship. The care and treatment of persons with severe personality disorders present a major challenge to coherent and cohesive teamwork. A test and retrospective comparison study is described and its findings reported. Data from the study point to the need for more than a single challenge, to achieve a sustained reduction in self-harm, along with staff training to ensure working knowledge of a particular framework.

Creativity and psychopathology. A study of 291 world-famous men

BACKGROUND

This investigation sought to determine the prevalences of various psychopathologies in outstandingly creative individuals, and to test a hypothesis that the high prevalence of mental abnormalities reported in prominent living creative persons would not be found in those who had achieved and retained world status.

METHOD

The family background, physical health, personality, psychosexuality and mental health of 291 famous men in science, thought, politics, and art were investigated. The membership of the six series of scientists and inventors, thinkers and scholars, statesmen and national leaders, painters and sculptors, composers, and of novelists and playwrights was determined by the availability of sufficiently adequate biographies. Extracted data were transformed into diagnoses in accordance with DSM-III-R criteria, when appropriate.

RESULTS

All excelled not only by virtue of their abilities and originality, but also of their drive, perseverance, industry, and meticulousness. With a few exceptions, these men were emotionally warm, with a gift for friendship and sociability. Most had unusual personality characteristics and, in addition, minor 'neurotic' abnormalities were probably more common than in the general population. Severe personality deviations were unduly frequent only in the case of visual artists and writers. Functional psychoses were probably less frequent than psychiatric epidemiology would suggest, and they were entirely restricted to the affective varieties. Among other functional disorders, only depressive conditions, alcoholism, and, less reliably, psychosexual problems were more prevalent than expected in some professional categories, but strikingly so in writers.

CONCLUSIONS

Similar findings have been reported for living artists and writers, and this suggests that certain pathological personality characteristics, as well as tendencies towards depression and alcoholism, are causally linked to some kinds of valuable creativity.

What are the borders of borderline personality disorder?

It is argued that the usefulness of borderline personality disorder in clinical and research practice is largely because the borders of the diagnosis are so flexible. The diagnosis overlaps with other personality disorders, disturbances of mood and intermittent abnormal behavior. As almost all behavior likely to lead to consultation with mental health professionals is included among the elements of personality disorder, it is not surprising that it is almost the most common condition seen by specialists in the field. An attempt is made to define the borders of the condition in this review. It is concluded that these are so far-reaching that they negate the notion that borderline conditions are personality disorders. It is argued that the borderline state is a coaxial diagnosis of personality and mental state disorder and to continue to describe the concept as a personality disorder is wrong and misleading.

The Emanuel Miller Memorial Lecture 1992. The theory and practice of resilience

The aim of this paper is to identify a theoretical framework which may provide a meaningful context for developing practical interventions to build upon the concept of resilience. In so doing I shall briefly consider the importance of the concept, what is known about it, and then focus on a specific facet of the problem: intergenerational transmission of maladaptive relationship patterns and resilience to such a threat.