<< Back Next >>
Salud Mental 2009; 32 (3)
Language: Spanish
References: 129
Page: 241-249
PDF size: 125.99 Kb.
ABSTRACT
Nowadays, psychotherapy is regarded as the treatment of choice for patients with Borderline Personality Disorder(BPD). A consensus has yet to be reached, however, despite various controlled studies undertaken to determine the most suitable form of treatment. At both public and private mental health institutions, there is a growing number of BPD patients seeking treatment. These patients pose a challenge for institutional programs because their demands usually exceed the «therapeutic capacity» of conventional forms of psychiatric treatment. Due to this heavy demand, various strategies have been examined in order to treat this type of patients properly. These include short group therapy. This article presents the results of a controlled clinical study comparing the effectiveness of treatment according to the composition of the groups: a homogeneous group, consisting solely of borderline patients and another in which only half had been diagnosed with BPD while the others only had Axis 1 disorders, with no seriou s personality pathology. The study considered the variables of psychiatric symptomatology, quality of life, self-esteem, «ego strength», perceived social support, social adjustment and inter-personal problems. Both groups contained female subjects only. The quantitative results of the mixed group show significant changes in the psychiatric symptoms as well as the evolution of interpersonal problems and current quality of life. At the same time, the homogeneous group showed changes in the ideal quality of life and the self-esteem scale. A comparison of the base and final scores showed that the BPD group showed no reduction in psychiatric symptomatology, nor was there a positive evolution in inter-personal relations. At the same time, when other groups were compared, it was obvious that patients in the mixed group showed greater changes in interpersonal problems and depression, anxiety, paranoid and hostility symptoms. As for qualitative results, the BPD group constituted a failed experience from the psychotherapeutic point of view. An analysis of the development of the process in the BPD group reveals three different stages. The first was characterized by the early emergence of numerous transfers based on the idealization/devaluation of colleagues and therapists. The splitting mechanism was clearly observed. This stage saw the emergence of high expectations of a «magical cure.» In Bion’s terms, the group was experiencing a moment of dependency. At that point, the issue of sexuality emerged, triggering an apparent process of identification linked to experiences of early sexual abuse among patients. The bases of incipient group cohesion seemed to be emerging. Nevertheless, «attacks» began to take place, together with the need to exclude the «healthiest» group member. Group members subsequently began to complain to the therapists about their «lack of sensitivity» and the fact that they failed to provide «solutions.» Negative transference became obvious, with hatred and suspicion prevailing. This stage may correspond to the process described by Bion as the attack and flight phase, characterized by intensely paranoid attitudes. The prevailing links were based on hatred, with nearly all expressions of love being stifled. The group eventually succumbed due to the spread of hostility triggered by the attacks of patients that participated in destructive alliances. This prevented the group from achieving cohesion and the stage of camaraderie, characterized by Bion as the emergence of loving feelings that usually neutralize hostile components. Two patients in this group, however, showed favorable changes in their attitudes that implied a process of elaborating conflicts primarily derived from feelings of dependence, passivity and anger in relation to parental figures. From the start, patients in the mixed group with and without BPD showed different degrees of participation. Patients with severe personality pathology participated less in the initial sessions, acting as spectators. They gradually joined the group and participated more actively. Patients without BPD, however, took the initiative regarding the issues to be dealt with during the sessions. In our view, this helped establish a «containment framework» for borderline patients. Later on, these patients’ conflicts became more obvious, being characterized by powerful ambivalence and the activation of primitive defense mechanisms, such as splitting, projective identification and denial. These expressions, however, found a cohesive group that provided them with acceptance and contention. This group evolved like other psycho-therapeutic groups of «neurotic patients» but with differences due to the problems commonly expressed by patients with BPD: suicidal ideation, sexual abuse, severe conflicts in their relationships with their partners, etc. Nevertheless, due to the atmosphere of camaraderie established, these patients were fully integrated, and in fact, their colleagues were unable to determine which ones belonged to which category. By the end of the treatment, group cohesion a nd positive dominant transference were obvious. The experience yielded by this study showed that in a psychotherapeutic group solely comprising BPD patients, situations arise that are extremely difficult to handle. The most important factor was negative transference, which created a hostile atmosphere that neutralized the psychotherapeutic interventions. This generalization should be viewed with caution, however, due to the small number of patients included in this study. The severity of the psychopathology of the patients included in each group was probably not the same. A propos of this last mechanism, it has been suggested that certain socio-demographic characteristics are associated with better social functioning. The homogeneous group contained more unemployed and single patients and/or patients with highly conflictive interpersonal relations. From the outset, patients in the mixed group displayed higher levels of social performance. Despite the fact that they all met the diagnostic characteristics for BPD according to the SCID-II, a more detailed personality study that would reveal significant differences in the patients’ psychic structure was not carried out. A retrospective analysis showed that histrionic, narcissistic and anti-social traits predominated in the homogeneous group; these traits may be included in the category of the malignant narcissistic syndrome described by Kernberg, in which the combination of these three traits produces a poor therapeutic prognosis. It has been established that these subjects tend to develop paranoid transferences and are unable to relate to others due to their inability to invest them with libidinal energy. At the same time, in the mixed group, borderline patients have phobic, dependent features, characteristics associated with a better prognosis, since better functioning is associated with a less primitive psychic structure and the capacity to establish less chaotic relationships. In any case, it seems quite clear that group therapy that combines a restricted number of borderline patients and subjects with Axis I disorders without serious personality disorders could prove a viable option in the search for institutional strategies for the psychotherapeutic treatment of patients with BPD.
REFERENCES
Gunderson JG, Zanarini MC. Current overview of borderline diagnosis.
J Clinical Psychiatry 1987;48:5-11.
Higgitt A, Fonagy P. Psychotherapy in the borderline and narcissistic
personality disorders. British J Psychiatry 1992;992(161):23-43.
Castañeda AR, Franco H. Sex and ethnic distribution of borderline personality
disorder in inpatient sample. Am J Psychiatry 1985;142:1202-1203.
Amador-Simán JRH. Confiabilidad entre la forma autoaplicable y la forma
aplicada por el clínico de la Entrevista Clínica Estructurada para el
diagnóstico de trastornos de la personalidad en pacientes deprimidos
con trastornos de ansiedad. Tesis para obtener el Diploma de Especialista
en Psiquiatría. México, DF: UNAM; 2001.
Grain P, Lemus V. Prevalencia del trastorno límite de la personalidad.
Tesis para obtener el título de Licenciado en Psicología. México, DF: Universidad
Páez F, Rodríguez R, Pérez V, Colmenares E, Coello F et al. Prevalencia
comunitaria de los trastornos de la personalidad: Resultados de un estudio
piloto. Salud Mental 1997;20:19-23.
Kernberg OF. Desórdenes fronterizos y narcicismo patológico. Barcelona:
Kernberg OF. Trastornos graves de la personalidad. México, DF: El Manual
Livesly J. Handbook of personality disorders. Theory, research and treatment.
USA: Guilford Press; 2001.
Macaskill NA. The narcissistic core as a focus in the group therapy of
the borderline patient. British J Medical Psychology 1980;53(2):137-143.
Macaskill NA. Therapeutic factors in group therapy with borderline
patient. International J Group Psychotherapy 1982;32(1): 61-73.
Yalom ID. Teoría y práctica de la psicoterapia de grupo. México, DF:
Fondo de Cultura Económica; 1986.
Budman SH, Cooley S, Demby A, Kopenaal G, Koslog J et al. A model
of time-effective group psychotherapy for patients with personality disorders:
The clinical model. International J Group Psychotherapy 1996;
Budman SH, Demby A, Soldz S, Merry J. Time-limited group psychotherapy
for patients with personality disorders: Outcomes and dropouts.
International J Group Psychotherapy 1996;46:357-377.
Marziali E, Munroe B, McLeary L. The contributions of group cohesion
and group alliance to the outcome of group psychotherapy. International
J Group Psychotherapy 1997;47(4):475-498.
Marziali E, Munroe B, McLeary L. The effects of the therapeutic alliance
on the outcomes of individual and group psychotherapy with borderline
personality disorders. Psychotherapy Research 1999;9(4):424-436.
Horowitz L. A group-centered approach to group psychotherapy. International
J Group Psychotherapy 1977;27(4):423-439.
Schmideberg M. The treatment of psychopathic and borderline patient.
Am J Psychotherapy 1974;1:45-71.
Mohan R. Treatments for borderline personality disorders: Integrating
evidence into practice. International Review Psychiatry 2002;14:42-51.
Biagini Alarcón M, Torruco Salcedo M, Carrasco Fernández B. Apego al
tratamiento psicoterapéutico grupal en pacientes con trastorno límite
de la personalidad. Estudio en pacientes de 18 a 24 años. Salud Mental
Rice AH. Interpersonal problems of persons with personality disorders
and group outcomes. International J Group Psychotherapy 2003;53(2):
APA. Diagnostic and statistical manual of mental disorders. Cuarta edición.
Washington, DC: American Psychiatric Press; 1994.
First MB, Gibbon M, Spitzer R, Williams JBW, Benjamin LS. Structured
clinical interview for DSM-IV Axis II (SCID-II). Washington DC: American
Cruz Fuentes CS, López Bello L, Blas García C, González Macías L,
Chávez Balderas RA. Datos sobre la validez y confiabilidad de la
Symptom Check List (SCL90) en una muestra de sujetos mexicanos.
Salud Mental 2005;28(1):72-81.
Derogatis LR, Lipman RS, Covi L. SCL-90: An outpatient rating scale,
preliminary report. British J Psychiatry 1965;111(480):1043-1049.
Guy W. Early clinical drug evaluation program. Hopkins Symtom Checklist.
Assessment Manual. Rockville: National Institute of Mental Health;
Lara Muñoz C, Espinosa de Santillana I, Cárdenas ML, Fócil M, Cavazos
J. Confiabilidad y validez de la SCL-90 en la evaluación de la psicopatología
en mujeres. Salud Mental 2005;28(3):42-50.
Dunbar GC, Stoker MJ, Hodges TCP, Beaumont G. The development of
SBQOL-a unique scale for measuring quality of life. British J Medical
Economics 1990;54:221-228.
Stoker MJ, Dunbar GC, Beaumont G. The SmithKline Beecham «quality
of life» scale: A validation and reliability study in patients with affective
disorders. Quality Life Research 1992;1:385-395.
Coopersmith S. The antecedents of self esteem. Freeman WH, San Francisco:
Hataway SR, McKinley JC. Inventario Multifásico de la Personalidad,
MMPI-2. México, DF: El Manual Moderno; 1994.
Zimet GD, Dahlem NW, Zimet SG, Farley GK. The multidimensiomal scale
of percibed social support. J Personality Assessment 1988;52(1):30-41.
Bosc M, Dubini A, Polin V. Development and validation of a social functioning
scale: The social adaptation self-evaluation scale. European Neuropsycho
Pharmacology 1997;7(1):57–70.
Horowitz LM, Rosenber SE, Baer BA, Ureño G, Villaseñor VS. Inventory
of interpersonal problems: Psychometric properties and clinical
applications. J Consulting Clinical Psychology 1988;56(6): 885-892.
Horowitz LM, Alden LE, Wiggins JS, Pincus AL. Inventory of interpersonal
problems. USA: The Psychological Corporation; 2000.
Bion WR. Experiencias en grupos. México, DF: Editorial Paidós; 1990.
Gunderson JG, Zanarini MC. Current overview of borderline diagnosis. J Clinical Psychiatry 1987;48:5-11.
Higgitt A, Fonagy P. Psychotherapy in the borderline and narcissistic personality disorders. British J Psychiatry 1992;992(161):23-43.
Castañeda AR, Franco H. Sex and ethnic distribution of borderline personality disorder in inpatient sample. Am J Psychiatry 1985;142:1202-1203.
Amador-Simán JRH. Confiabilidad entre la forma autoaplicable y la forma aplicada por el clínico de la Entrevista Clínica Estructurada para el diagnóstico de trastornos de la personalidad en pacientes deprimidos con trastornos de ansiedad. Tesis para obtener el Diploma de Especialista en Psiquiatría. México, DF: UNAM; 2001.
Grain P, Lemus V. Prevalencia del trastorno límite de la personalidad. Tesis para obtener el título de Licenciado en Psicología. México, DF: Universidad Intercontinental; 1999.
Páez F, Rodríguez R, Pérez V, Colmenares E, Coello F et al. Prevalencia comunitaria de los trastornos de la personalidad: Resultados de un estudio piloto. Salud Mental 1997;20:19-23.
Kernberg OF. Desórdenes fronterizos y narcicismo patológico. Barcelona: Editorial Paidós; 1976.
Kernberg OF. Trastornos graves de la personalidad. México, DF: El Manual Moderno; 1987.
Livesly J. Handbook of personality disorders. Theory, research and treatment. USA: Guilford Press; 2001.
Macaskill NA. The narcissistic core as a focus in the group therapy of the borderline patient. British J Medical Psychology 1980;53(2):137-143.
Macaskill NA. Therapeutic factors in group therapy with borderline patient. International J Group Psychotherapy 1982;32(1): 61-73.
Yalom ID. Teoría y práctica de la psicoterapia de grupo. México, DF: Fondo de Cultura Económica; 1986.
Budman SH, Cooley S, Demby A, Kopenaal G, Koslog J et al. A model of time-effective group psychotherapy for patients with personality disorders: The clinical model. International J Group Psychotherapy 1996; 46:329–355.
Budman SH, Demby A, Soldz S, Merry J. Time-limited group psychotherapy for patients with personality disorders: Outcomes and dropouts. International J Group Psychotherapy 1996;46:357-377.
Marziali E, Munroe B, McLeary L. The contributions of group cohesion and group alliance to the outcome of group psychotherapy. International J Group Psychotherapy 1997;47(4):475-498.
Marziali E, Munroe B, McLeary L. The effects of the therapeutic alliance on the outcomes of individual and group psychotherapy with borderline personality disorders. Psychotherapy Research 1999;9(4):424-436.
Horowitz L. A group-centered approach to group psychotherapy. International J Group Psychotherapy 1977;27(4):423-439.
Schmideberg M. The treatment of psychopathic and borderline patient. Am J Psychotherapy 1974;1:45-71.
Mohan R. Treatments for borderline personality disorders: Integrating evidence into practice. International Review Psychiatry 2002;14:42-51.
Biagini Alarcón M, Torruco Salcedo M, Carrasco Fernández B. Apego al tratamiento psicoterapéutico grupal en pacientes con trastorno límite de la personalidad. Estudio en pacientes de 18 a 24 años. Salud Mental 2005;28(1):52-60.
Rice AH. Interpersonal problems of persons with personality disorders and group outcomes. International J Group Psychotherapy 2003;53(2): 155-175.
APA. Diagnostic and statistical manual of mental disorders. Cuarta edición. Washington, DC: American Psychiatric Press; 1994.
First MB, Gibbon M, Spitzer R, Williams JBW, Benjamin LS. Structured clinical interview for DSM-IV Axis II (SCID-II). Washington DC: American Psychiatric Press; 1997.
Cruz Fuentes CS, López Bello L, Blas García C, González Macías L, Chávez Balderas RA. Datos sobre la validez y confiabilidad de la Symptom Check List (SCL90) en una muestra de sujetos mexicanos. Salud Mental 2005;28(1):72-81.
Derogatis LR, Lipman RS, Covi L. SCL-90: An outpatient rating scale, preliminary report. British J Psychiatry 1965;111(480):1043-1049.
Guy W. Early clinical drug evaluation program. Hopkins Symtom Checklist. Assessment Manual. Rockville: National Institute of Mental Health; 1976.
Lara Muñoz C, Espinosa de Santillana I, Cárdenas ML, Fócil M, Cavazos J. Confiabilidad y validez de la SCL-90 en la evaluación de la psicopatología en mujeres. Salud Mental 2005;28(3):42-50.
Dunbar GC, Stoker MJ, Hodges TCP, Beaumont G. The development of SBQOL-a unique scale for measuring quality of life. British J Medical Economics 1990;54:221-228.
Stoker MJ, Dunbar GC, Beaumont G. The SmithKline Beecham «quality of life» scale: A validation and reliability study in patients with affective disorders. Quality Life Research 1992;1:385-395.
Coopersmith S. The antecedents of self esteem. Freeman WH, San Francisco: 1967.
Hataway SR, McKinley JC. Inventario Multifásico de la Personalidad, MMPI-2. México, DF: El Manual Moderno; 1994.
Zimet GD, Dahlem NW, Zimet SG, Farley GK. The multidimensiomal scale of percibed social support. J Personality Assessment 1988;52(1):30-41.
Bosc M, Dubini A, Polin V. Development and validation of a social functioning scale: The social adaptation self-evaluation scale. European Neuropsycho Pharmacology 1997;7(1):57–70.
Horowitz LM, Rosenber SE, Baer BA, Ureño G, Villaseñor VS. Inventory of interpersonal problems: Psychometric properties and clinical applications. J Consulting Clinical Psychology 1988;56(6): 885-892.
Horowitz LM, Alden LE, Wiggins JS, Pincus AL. Inventory of interpersonal problems. USA: The Psychological Corporation; 2000.
Bion WR. Experiencias en grupos. México, DF: Editorial Paidós; 1990.
Full text