Clients diagnosed with Borderline Personality Disorder (BPD) interact with healthcare professionals in compelling ways. By virtue of the symptoms that define BPD, it is likely that the client will challenge the therapist with regards to their theoretical approach or therapeutic style. In addition, clients with BPD are likely to project their need for a therapeutic interaction that is both genuine, empathic and at the same time, flexible. In light of this, it is not uncommon for healthcare practitioners to consider clients with BPD as “difficult” in some way or the other. This study explores how clinical psychologists in Gauteng conceptualise and manage a “difficult” client presenting with Borderline Personality Disorder. Further, coping strategies of the clinician will also be explored. The qualitative study, couched in a social constructionist paradigm, involved interviewing seven clinical psychologists practicing in Gauteng, South Africa. The transcripts of the semi-structured interviews were thematically analysed. The findings of the current study indicated that the difficulties experienced are reflective of the general criteria of the disorder. The picture of the difficult client is painted by personal experience, as well as stereotypes gained from interactions with colleagues and other healthcare professionals. It was further found that management of these patients were viewed and implemented based on the nature of the disorder. In addition, management by the clinician often included supervision and leisure activities. / Psychology / M.A. (Clinical Psychology)

Borderline Personality Disorder (BPD) is a disabling condition characterized by chronic emotion dysregulation and behavioral impulsivity. Prospective studies that test proposed mechanisms of within-person change in BPD hold the key to improving symptom predictability and control in this disorder. A small body of evidence suggests that fluctuations in estradiol such as those occurring naturally at ovulation during the monthly female reproductive cycle may increase symptoms in women with BPD (DeSoto et al., 2003). Furthermore, there is preliminary evidence that both self-esteem and feelings of social rejection are highest at ovulation, when estradiol peaks (Durante and Hill, 2009; Eisenlohr-Moul et al., under review). Such feelings have been reliably linked to increases in BPD-related behavior in all individuals (e.g., Twenge et al., 2002). The purpose of this dissertation was to test a cyclical vulnerability model for women with BPD in which ovulatory estradiol shifts are associated with reductions in felt social acceptance, which in turn are associated with increased BPD symptom expression. 40 women, sampled to achieve a flat distribution of BPD symptoms, completed 28 daily diaries online, as well as four 1-hour weekly visits to the laboratory to complete longer assessments and provide saliva samples, which were assayed for estradiol. In addition, participants underwent the Structured Clinical Interview for the Diagnosis of BPD at the end of the study. Results of multilevel models revealed the opposite of the predicted effects of within-person changes in estradiol and their interaction with trait BPD. The data suggest a pattern in which women high in trait BPD show increases in felt acceptance and reductions in BPD symptom expression at higher levels of conception probability and higher-than-usual levels of estradiol. Women low in trait BPD show the opposite pattern in some cases. Several alternative moderators were tested, and results suggest that some risk factors for BPD (e.g., Neuroticism, Sexual Abuse) interact with high trait levels of estradiol to predict greater symptoms. Both average levels of estradiol and monthly fluctuations in estradiol may have relevance for women with BPD. It is recommended that future studies utilize clinical samples and additional physiological measures to further elucidate the mechanisms through which estradiol exerts clinically-relevant change.

Dans Creep show, un narrateur présente ses creeps, les malades de son entourage, des schizophrènes inadéquatement nommés, afin de les ramener à la vie par ses mots. En se souvenant de certains moments où la folie se manifestait à lui, il veut déterrer ses ensevelis, les faire parler en leur prêtant son écriture. Dans un récit morcelé pouvant évoquer une galerie de portraits en mouvement, les protagonistes sont présentés comme des monstres, des rêveurs ou des sources d’inspiration selon le moment relaté par un narrateur affecté qui se replonge littéralement dans un passé s’échelonnant entre l’enfance et l’âge de dix-huit ans. Portant autant sur la maladie mentale que sur la honte et la peur des mots, Creep show est un texte sur le silence et l’impuissance, sur l’incapacité de nommer adéquatement la folie ; il s’agit d’un court récit de dix-sept scènes encadrées par un prologue et un épilogue où l’écriture d’un traumatisme se vit comme une histoire d’amour. L’essai intitulé “Je est des autres.” De l’esthétique borderline chez Marie-Sissi Labrèche décrit la genèse d’une esthétique « borderline ». Dans une approche à la fois psychanalytique et narratologique, fondée sur les concepts de la mélancolie, du kitsch et de la crypte, l’analyse tente de montrer quel type de construction thématique et formelle soutient cette esthétique. À partir d’éléments représentatifs de l’univers de Marie-Sissi Labrèche (la question de la limite, la pulsion de mort, le rapport au corps et l’instabilité), l’essai s’intéresse à la façon dont la narratrice de Borderline (2000) donne à lire une identité sédimentaire, un autoportrait masqué-fêlé, où « Je est [des] autre[s] ». En regard de ces éléments, l’hypothèse d’une machine textuelle fonctionnant – thématiquement et formellement – dans et par l’instabilité et l’altérité oriente la réflexion vers l’idée d’une écriture du trauma qui pourrait représenter une tentative de réappropriation identitaire passant par l’esthétique dite « borderline ». / In Creep show, the narrator presents his creeps – some family members who are schizophrenics and inadequately appointed – and revives them by its words. By remembering certain moments when the insanity showed itself to him, he wants to dig up the buried and make them speak by lending them his writing. In a split narrative, which could evoke a collection of portraits in movement, the protagonists are presented as monsters, dreamers or sources of inspiration according to the narrator who literally dives back into the past. Presenting mental illness as the shame and the fear of the words, Creep show is a novel about silence and about the importance to understand adequately the insanity; it is a short narrative of seventeen scenes where the writing of a traumatism is experienced as a love story. The essay entitled “Je est des autres.” De l’esthétique borderline chez Marie-Sissi Labrèche describes the genesis of a “borderline” aesthetic. In a psychoanalytical and narratological approach established on the concepts of the melancholy, the kitsch and the crypt, the analysis tries to show which type of thematic and formal construction supports this aesthetic. With representative elements of the universe of Marie-Sissi Labrèche (the question of the limit, the death drive, the body obsession and the instability), the essay is interested in the way the narrator of Borderline ( 2000 ) offers a reading of the sedimentary identity and a misleading self-portrait. According to these elements of reflection, the hypothesis of a textual machine working in and by the instability (and the otherness) leads the analysis to the idea that writing the trauma could represent an attempt at reclaiming identity through the aesthetic called “borderline”.

The current study investigated the criterion validity of the Minnesota Multiphasic Personality Inventory - 2 (MMPI-2) by comparing participants' profiles with other variables, including diagnosis, length of hospitalization, and chronicity. The specific diagnostic groups investigated were depressed (major depressive disorder; dysthymic disorder; and bipolar disorder, depressed), schizophrenic (schizophrenia, schizophreniform disorder, and schizoaffective disorder), and borderline personality disorder (BPD). Statistical analyses included use of univariate analyses of variance (ANOVAs), multivariate analyses of variance (MANOVAs), regression analyses, and measures of sensitivity, specificity, positive predictive power (PPP), and negative predictive power (NPP). MANOVA results indicated significant differences between diagnostic groups on Scales F, 2, 3, 4, 7, ANX. FRS. DEP. BIZ. M f i , LSE, and FAM. There were considerable differences between males and females when separate MANOVAs were performed for gender groups. Cutoff see ires for classification by diagnosis resulted in significant specificity rates and negative predictive power, but sensitivity rates and positive predictive power were not significant.

La représentation que se font les patients souffrant d’un trouble de personnalité limite (TPL) de leur expérience de tristesse est un domaine de recherche important tant pour la conceptualisation du trouble que pour son traitement. Ces patients sont connus pour vivre une grande détresse qui se manifeste à travers divers symptômes (Bland, Williams, Scharer, & Manning, 2004). Un nombre élevé de patients présentant un TPL se suicident (Paris, 2002), font au moins une tentative de suicide au cours de leur vie (Oldham, 2006) et s’automutilent (p.ex., Brown, Williams, & Collins, 2007). La recherche sur la souffrance du TPL s’entend sur un paradoxe : ces patients souffrent beaucoup, mais ils vivent peu de tristesse. Leur souffrance prend une forme distincte en qualité, celle-ci demandant à être davantage étudiée empiriquement et théoriquement. L’objectif de cette thèse est d’explorer la représentation de la tristesse de participants souffrant d’un TPL. Alors qu’à notre connaissance aucune étude n’a encore poursuivi cet objectif spécifique, différentes pistes de réflexion ont été soulevées dans la documentation scientifique pour expliquer la nature de la souffrance du TPL en ce qui a trait au tempérament, au fonctionnement mental, à la dépression, à l’organisation de la personnalité et aux événements traumatiques. La première étude de cette thèse vise à réfléchir théoriquement et cliniquement à la tristesse, afin d’en raffiner la définition, entre autres par opposition à la détresse. Elle propose une distinction tant au plan métapsychologique que phénoménologique de ces deux expériences, en se basant sur des théories évolutionnistes des émotions et sur différentes conceptions psychanalytiques du fonctionnement mental et des relations objectales. Une vignette clinique illustre cette réflexion. La seconde étude vise à explorer, par une démarche qualitative, les principaux thèmes abordés par des participants souffrant d’un TPL lorsqu’ils racontent des épisodes de tristesse. Sept participants avec un diagnostic de TPL évalué à l’aide du SCID-II (First, Gibbon, Spitzer, & Williams, 1997) ont participé à une entrevue semi-dirigée visant le rappel de deux épisodes relationnels de tristesse. Suivant la méthode d’analyse phénoménologique interprétative (Smith, 1996), une analyse thématique de quatorze épisodes de tristesse a été effectuée conjointement par deux candidates au doctorat pour décrire la représentation de la tristesse de ces participants. Cinq thèmes ont été identifiés : 1) agression, 2) relation brisée par l’autre, 3) affectivité négative indifférenciée, 4) soi défectueux et 5) débordement. Les résultats suggèrent que la représentation de la tristesse du TPL n’est pas associée à la perte, mais plutôt à l’impression d’avoir été endommagé par une attaque infligée par quelqu’un d’autre. Il s’agit d’une expérience peu mentalisée que l’individu semble tenter de réguler dans la sphère interpersonnelle. Cette expérience ne représenterait pas de la tristesse à proprement parler. Les conclusions ont permis d’élaborer une nouvelle hypothèse de recherche : l’expérience de tristesse des patients souffrant d’un TPL ne correspond pas à la tristesse proprement dite, mais à une forme de détresse interpersonnelle impliquant à la fois des déficits du fonctionnement mental et une organisation particulière de la personnalité. Les implications cliniques et théoriques sont discutées. / The exploration of the phenomenology of sadness in patients with Borderline Personality Disorder (BPD) is relevant to the understanding of the pathology and to its treatment. BPD patients tend to experience distress intensely and frequently, and inefficient attempts at regulating this emotional experience is known to be associated with symptoms, such as suicidal or parasuicidal gestures (Bland, Williams, Scharer, & Manning, 2004; Brown, Williams, & Collins, 2007; Oldham, 2006; Paris, 2002). The literature on psychological suffering in BPD reveals an apparent contradiction: these patients experience a large amount of suffering, but they appear to not experience sadness. The nature of their suffering seems to be distinct from sadness, and has yet to be more fully explored empirically and theoretically. The present thesis aims at exploring the phenomenology of sadness in BPD. To our knowledge, no research has specifically attempted to investigate this particular topic, but some etiological pathways for understanding BPD suffering have been explored: temperament, mental functioning, depression, personality organization and traumatic events. The first study proposes a theoretical and clinical investigation of the concept of sadness and defines it in opposition to distress. This distinction between sadness and distress focuses on phenomenological and metapsychological perspectives, and is in line with evolutionary theories of emotion and psychoanalytic formulations on mental functioning and object relationships. A case study illustrates this investigation. The second study aims at exploring the phenomenology of sadness through an investigation of the major themes that BPD participants talk about when they are asked to recall episodes of sadness. Seven individuals with a diagnosis of BPD on the SCID-II (First, Gibbon, Spitzer, & Williams, 1997) participated in a semi-structured interview. Following the Interpretative Phenomenological Analysis principles (Smith, 1996), a thematic analysis of 14 transcripts was performed by two doctoral students in order to outline the representation of sadness of BPD participants. Five themes were found: 1) aggression, 2) relationship broken off by the other, 3) undifferentiated negative affect, 4) self being defective, and 5) overwhelming experience. The results suggest that ‘sadness’ in those episodes is not associated with a representation of loss, but with a state of being ‘damaged’ by the aggression and/or the breaking off of the relationship inflicted by the other. This is a non-mentalized experience that the participants tend to regulate in the interpersonal field. This experience should not be conceptualized as sadness proper. In conclusion, a new hypothesis emerges: the experience of sadness for BPD patients is not really sadness, but a form of interpersonally-focused distress. This emotional experience is characterized by a deficit in mental functioning and by a particular personality organization. Clinical and theoretical implications are discussed.

Introdução: O Transtorno Afetivo Bipolar (TAB) e o Transtorno de Personalidade Borderline (TPB) apresentam características clínicas em comum que frequentemente tornam difícil seu diagnóstico diferencial, podendo implicar em indicações terapêuticas inadequadas. Assim, é importante ampliar o conhecimento diagnóstico sobre esses transtornos mentais buscando identificar marcadores que auxiliem sua diferenciação. A história de estresse precoce, associada à vulnerabilidade individual no desenvolvimento de transtornos mentais relatada na literatura, pode representar um fator de diferenciação entre TAB e TPB, assim como sua associação com manifestações clínicas e respostas neuroendócrinas específicas a cada um desses diagnósticos. Objetivo: Avaliação e comparação de pacientes com diagnóstico de TAB e TPB buscando indicadores de seu diagnóstico diferencial, relacionados a fatores associados a sua sintomatologia, etiopatogênese e marcadores neuroendócrinos. Metodologia: A amostra do estudo foi composta por 51 mulheres, distribuídas em 3 grupos constituídos por pacientes com diagnóstico clínico de TAB (n=16) e TPB (n=20), e controles saudáveis (n=15). Para sua avaliação, foram utilizados instrumentos para confirmação diagnóstica e entrevista semiestruturada para delineamento do perfil sócio-demográfico e clínico. A gravidade da sintomatologia psiquiátrica foi avaliada através dos instrumentos de Beck para avaliação de ansiedade, depressão, desesperança e ideação suicida, além de escalas de avaliação de sintomas maníacos e impulsividade. A história de estresse precoce foi investigada pelo Questionário de Traumas na Infância (CTQ), e classificada segundo os subtipos abuso emocional, abuso físico, abuso sexual, negligência emocional e negligência física. O funcionamento do eixo hipotálamo- hipófise-adrenal (HHA) foi avaliado pela dosagem de cortisol basal plasmático. Os resultados das avaliações foram analisados em um segundo momento de acordo com a presença ou ausência de estresse precoce. Resultados: A amostra de pacientes com diagnósticos de TAB e TPB analisadas apresentaram diferenças significativas em relação à idade e tempo de tratamento, maiores no grupo TAB. A análise da sintomatologia psiquiátrica indica maior gravidade de ansiedade, impulsividade, depressão, desesperança e ideação suicida no grupo TPB. A história de estresse precoce foi identificada como mais prevalente e significativamente mais grave nas pacientes do que em controles saudáveis, nos escores de CTQ total, abuso emocional, negligência emocional e negligência física, que também diferenciaram os grupos diagnósticos, sendo maiores no TPB comparado ao TAB. A partir da presença do estresse precoce em níveis de moderado a extremo, o subtipo negligência física diferenciou significativamente os diagnósticos, indicando ser mais grave quando associado ao TPB. A avaliação endócrina indicou diferenças entre os diagnósticos TAB e TPB em relação aos controles saudáveis, com níveis mais baixos de cortisol apresentados pelas pacientes. A presença de estresse precoce em pacientes com TAB demonstrou diferença significativa com menores níveis de cortisol em relação aos controles. O cortisol mensurado nas pacientes com TPB foi significativamente menor comparado ao dos controles na presença de negligência emocional e negligência física. O cortisol apresentou correlações significativas e opostas nos grupos diagnósticos com o abuso sexual, sendo uma correlação de Pearson negativa no TAB e positiva no TPB. A presença de estresse precoce associada ao diagnóstico de TPB revelou ainda correlação significativa negativa do cortisol com a negligência física. Discussão: Considerando a necessidade de uma análise multifatorial, o diagnóstico diferencial entre TAB e TPB pode ser facilitado pela análise dos sintomas psiquiátricos e da história de estresse precoce. O diagnóstico de TPB se associa a sintomatologia mais grave de ansiedade, impulsividade, depressão, desesperança e ideação suicida; assim como, a maior prevalência e gravidade da história de estresse precoce em geral e em relação aos subtipos abuso emocional, negligência emocional e, especialmente, negligência física quando presente em maior gravidade. O funcionamento do eixo HHA avaliado pelo cortisol sugere diferenciar-se em ambos os diagnósticos, na associação com experiências estressantes precoces no TAB e, especialmente, com história de negligência física no TPB. Conclusão: Assim, a análise integrada dos parâmetros relacionados a psicopatologia, ao estresse precoce e funcionamento neuroendócrino fornecem indicadores úteis na diferenciação entre os diagnósticos de TAB e TPB, mas que necessitam ser melhor explorados e compreendidos através de futuros estudos. / Introduction: Bipolar Disorder (BD) and Borderline Personality Disorder (BPD) have clinical features in common that often make it difficult differential diagnosis , and may result in inadequate therapeutic indications. Thus , it is important to expand knowledge diagnosis on these mental disorders in order to identify markers that make clear the differences. The history of early stress associated with individual vulnerability to develop mental disorders can be a difference factors between BD and BPD , as its association with clinical and neuroendocrine responses. Objective: To assess and compare patients with BD and BPD seeking indicators of differential diagnosis, related to factors associated with its etiology and pathogenesis, symptoms and neuroendocrine markers. Methodology: The study sample consisted of 51 women , distributed in 3 groups: patients diagnosed with BD (n=16) and BPD (n=20) and healthy controls (n=15). We confirm the diagnosis with SCID I and SCID II; and semi-structured interview for delineating the socio-demographic and clinical features. Severity of psychiatric symptoms was assessed using the Beck instruments for assessment of anxiety , depression , hopelessness and suicidal ideation, as scales of impulsivity and manic symptoms. The history of early stress was investigated by the Childhood Trauma Questionnaire (CTQ), and classified according to subtypes emotional abuse, physical abuse, sexual abuse, emotional neglect and physical neglect. The functioning of the hypothalamic- pituitary- adrenal (HPA) axis was evaluated by measurement of basal plasma cortisol. Results were analyzed in a second time according to the presence or absence of early stress. Results: A sample of patients with diagnoses of BD and BPD were analyzed and showed significant differences in relation to age and treatment time , higher in BD. The analysis of psychiatric symptoms indicating greater severity of anxiety, impulsivity, depression, hopelessness and suicidal ideation in the group BPD. The history of early life stress has been identified as the most prevalent and significantly worse in patients than in healthy controls, in scores of CTQ total emotional abuse, emotional neglect and physical neglect, which also differentiated the diagnostic groups and were higher BPD compared BD. From the presence of early life stress the subtypes physical neglect differed significantly , indicating higher severity when associated with the BPD. The endocrine evaluation indicated differences between diagnoses BD and BPD compared to healthy controls , with lower levels of cortisol presented by patients. The presence of early stress in patients with BD showed significant difference with lower cortisol levels compared to controls. Cortisol measured in patients with BPD was significantly lower compared to controls in the presence of emotional neglect and physical neglect. Cortisol was significantly correlated and opposite in diagnostic groups with sexual abuse , being a Pearson correlation negative in BD, and positive BPD. The presence of early stress associated with the diagnosis of BPD also showed a significant negative correlation of cortisol with physical neglect. Discussion: Considering the need for a multifactorial analysis, differential diagnosis between BD and BPD can be facilitated by analysis of psychiatric symptoms and history of early life stress. The diagnosis of BPD is associated with more severe symptoms of anxiety, impulsivity, depression, hopelessness and suicidal ideation, as well as the increased prevalence and severity of history of early life stress in general and in relation to subtypes emotional abuse, emotional neglect, and especially , physical neglect when present in greater severity . The functioning of the HPA axis measured by cortisol suggests differentiate the diagnosis and association with early stressful experiences in BD and particularly with a history of physical neglect in BPD. Conclusion: Thus, the integrated analysis of the parameters related to psychopathology, stress and neuroendocrine function provide early indicators useful in differentiating between diagnoses of BD and BPD, but these need to be better explored and understood by future studies.

Borderline-Persönlichkeitsstörung (BPS) ist eine schwere psychiatrische Störung, die durch tiefgreifende Probleme in Emotionsregulation und zwischenmenschlichen Beziehungen gekennzeichnet ist. Die gestörten Beziehungsmuster werden als ein Kernmerkmal von BPS betrachtet, obwohl die empirische Evidenz dafür weitestgehend fehlt. Bisherige Ergebnisse sind auf behavioraler und neuronaler Ebene bei BPS durch das häufig komorbide Auftreten einer posttraumatischen Belastungsstörung (PTBS) verzerrt. Eine vielversprechende Möglichkeit, die Beziehungsstörung von Patienten mit BPS näher zu untersuchen, bietet das multidimensionale Konzept der Empathie. Daher konzentriert sich die vorliegende Arbeit auf die Identifizierung behavioraler und neuronaler Korrelate kognitiver und emotionaler Empathie bei BPS Patienten und den Einfluss einer komorbiden PTBS auf diese. Die Ergebnisse zeigen, dass Patienten mit BPS Einschränkungen in beiden Facetten von Empathie zeigen, aber komorbide PTBS, intrusive Symptomatik und sexuelle Traumatisierung in der Vergangenheit mit schlechterer kognitiver Empathie einhergehen. Außerdem ist unter kognitiver Empathie die neuronale Aktivität im linken superior temporal Sulcus/Gyrus (STS/STG) bei BPS Patienten reduziert und mit der Ausprägung ihrer intrusiven Symptomatik assoziiert. Während emotionaler Empathie zeigen Patienten mit BPS im rechten insulären Kortex mehr Aktivität, die mit dem Hautleitwiderstand der BPS Patienten assoziiert ist. Die hier dargestellten Ergebnisse unterstützen ein Bild von BPS als eine Störung der emotionalen und kognitiven Empathie. Eine komorbid diagnostizierte PTBS scheint sich dabei zusätzlich verschlechternd auf die Fähigkeit zur kognitiven Empathie auszuwirken. Die veränderte Funktion von STS/STG und Insula könnte einen pathophysiologischen Vermittlungsmechanismus auf neuronaler Ebene für BPS darstellen, dabei scheinen die intrusiver Symptomatik und dem Grad der Erregung der Patienten eine wesentliche Rolle zu spielen. / Borderline personality disorder (BPD) is a severe psychiatric malfunction, which involves deficits in emotion regulation and interpersonal relationships. Especially the interpersonal problems are seen as a core feature in BPD, even if there is only weak empirical evidence. Furthermore, the current results on behavioral and functional alterations of patients with BPD are biased by the high rate of comorbidity with posttraumatic stress disorder (PTSD). The multidimensional concept of empathy seems to be an eligible framework for the interpersonal problems of patients with BPD. Hence, the present work focuses on the identification of behavioral and neural correlates of cognitive (i.e., social cognition) and emotional (i.e., empathic concern) empathy in patients with BPD. Moreover the influence of comorbidities (e.g., PTSD) on the behavioral and neural alterations of patients with BPD was explored. Patients with BPD showed impairments in both facets of empathy, but comorbid PTSD, intrusive symptoms, and history of sexual trauma were only associated with outcomes in cognitive empathy. In this condition the brain responses were significantly reduced in BPD patients compared to controls in the left superior temporal sulcus and gyrus (STS/STG), where this reduction was associated with levels of intrusive symptomatology in the BPD group. During emotional empathy, patients with BPD exhibited greater brain activation than controls in the right middle insular cortex, a response that was associated with skin conductance responses in the patients. Thus, these findings support a conceptualization of BPD as involving deficits in emotional as well as in cognitive empathy. A comorbid PTSD seems to impair the cognitive empathic outcome additionally. Findings at the neural level indicate that altered functioning of the STS/STG and insula represents pathophysiological mediators for BPD, with an important role for intrusive symptomatology and levels of arousal.

Die vorliegende kumulative Promotion umfasst drei veröffentlichte Publikationen, die im Rahmen der Berliner Borderline Versorgungsstudie (BBV-Studie) durchgeführt wurden. In Studie 1 wurde die effectiveness der ambulanten Dialektisch-Behavioralen Therapie (DBT) an N = 47 Patienten mit einer Borderline Persönlichkeitsstörung (BPS), die das DBT-Behandlungsjahr vollständig durchlaufen haben, untersucht. Im Prä-Post-Vergleich zeigten sich für die untersuchten Symptombereiche signifikante Veränderungen und die Effektstärken lagen überwiegend im mittleren Bereich. 77% der Patienten erfüllten nach einem Jahr DBT nicht mehr die diagnostischen Kriterien für eine BPS. In Studie 2 wurden die Krankheitskosten von N = 55 BPS-Patienten in dem Jahr vor der ambulanten DBT umfassend aus einer gesellschaftlichen Perspektive erhoben. Die durchschnittlichen Kosten lagen bei €26.882 (SD = €32.275). Davon gingen mit €17.976 (SD = €23.867) etwa 66% auf die direkten, mit €8.906 (SD = €15.518) knapp 34% auf die indirekten Kosten zurück. In Studie 3 wurden für die N = 47 DBT- compleater die Krankheitskosten im Jahr vor der Therapie mit denen während des DBT-Behandlungsjahres und mit denen während des ersten Katamnesejahres (N = 33) verglichen. Die durchschnittlichen Krankheitskosten lagen im Jahr vor der DBT bei €28.026 (SD = €33.081), während des DBT-Jahres bei €18.758 (SD = €19.450) und sanken innerhalb des Katamnesejahres weiter auf €14.750 (SD = €18.592). Die deutlichsten Kostenreduktionen zeigten sich im stationären Bereich. Hingegen konnten die indirekten Kosten kaum gesenkt werden. Insgesamt weist die vorliegende Promotion darauf hin, dass die ambulante DBT auch unter Versorgungsbedingungen in Berlin wirksam ist. Zudem besitzt die BPS auch in Deutschland eine hohe gesellschaftliche Relevanz. Die Krankheitskosten können deutlich gesenkt werden, wenn BPS-Patienten in einem DBT-Netzwerk behandelt werden. Hieraus ergeben sich erste Hinweise auf die Effizienz der ambulanten DBT. / This thesis includes three publications that were conducted as part of a Berlin wide treatment study (“Berliner Borderline Versorgungsstudie“). In study 1, we examined the effectiveness of dialectical behavior therapy (DBT) for borderline personality disorder (BPD) under the routine health care situation in Berlin. N = 47 patients completed the one-year treatment and provided data. Our findings demonstrate significant improvements on all measures with medium effect sizes. Moreover, at the end of the first treatment year, 77% of the patients no longer met the criteria for a BPD diagnosis. In Study 2, BPD-related cost-of-illness 12 months prior to outpatient DBT was assessed in a sample of N = 55 BPD-patients from a societal perspective. Total cost-of-illness was €26882 (SD = €32275) per patient. €17976 (SD = €23867; 66%) were direct costs and €8906 (SD = €15518; 34%) were calculated as indirect costs. In study 3, societal cost-of-illness of the N = 47 DBT completers was calculated for 12 months prior to DBT and further investigated during DBT-treatment year and during the following year. Total mean annual cost-of-illness was €28026 (SD = €33081) during pre-treatment, €18758 (SD = €19450) during the DBT treatment year and €14750 (SD = €18592) during the follow-up year for the N = 33 patients who participated in the final assessment. Cost savings were mainly due to marked reductions of inpatient treatment costs, while indirect costs barely decreased. In sum, the present thesis shows that outpatient DBT under routine mental health care conditions in Berlin leads to positive results. Furthermore, mean annual cost-of-illness of German BPD-patients exceed those of many other mental disorders meaning that BPD poses a high economic burden. Importantly, treatment of BPD patients with an outpatient DBT program is associated with substantial overall cost savings. Correspondingly, outpatient DBT has the potential to be an efficient treatment.

Made available in DSpace on 2016-07-27T14:21:40Z (GMT). No. of bitstreams: 1 Ana Carolina Aquino de Sousa.pdf: 859405 bytes, checksum: 012e102cd1c0ae09167374dd9968980d (MD5) Previous issue date: 2004-12-03 / This research is an effort to explore, from a functional analytic perspective, the feelings that dealing with borderline clients causes in therapists. First, the therapeutic relationship is described as an instrument that can promote changes in the client s repertoires. This approach considers that if an individual behaves in relation to a therapist in the same way as he behaves in his daily life in relation to other people, these settings are functionally identical. So, changes in one context, will affect the others. Besides, the client s behaviors cause feelings in the therapist (a phenomenon known in psychotherapy literature as counter-transference) that can be used as cues about how other people feel in the client s daily life. So, the therapeutic relationship would be a context that makes in-vivo learning possible for the client, since the behavior can be immediately reinforced or weakened after its occurrence. Four behavioral therapists, who worked with borderline clients, took part in this research. The sessions were conducted weekly and lasted one hour each. Reports by the therapists concerning their feelings were recorded during semistructured interviews and during monthly supervisions with each therapist separately. All recordings were transcribed and explored according the methods of grounded theory. The results indicate that the therapists noted the occurrence of clinically relevant behaviors and countertransference in the therapeutic relationship. During supervision it was tried to lead the participants to use their own feelings (about the client) as cues to promote changes in clients behaviors. They reported that their clients punished many of their new behaviors they were coerced to continue reacting in ways that were complementary to the client s behaviors. The therapists what went back to behave in a way that was safe for them reinforced the problem behaviors of their clients. This counter-therapeutic behavior seems related to experiential avoidance. The results suggest that particular attention to interpersonal interactions during the session is important. It could avoid that the therapeutic relationship maintains the client s problems and can make it possible to take better advantage of the therapist s private responses. / O presente trabalho é um esforço em explorar sentimentos que o atendimento ao cliente borderline provoca em terapeutas, a partir de uma visão analítico-funcional. Primeiro, a relação terapêutica é descrita como um instrumento de mudança que pode promover mudanças no repertório do cliente. Esta abordagem parte do pressuposto de que se o indivíduo se comporta em relação ao terapeuta da mesma maneira que o faz no seu dia a dia com outras pessoas, esses ambientes são funcionalmente idênticos, e que, portanto, se um deles for mudado, esta alteração afetará os demais. Além disso, os sentimentos que os comportamentos do cliente provocam no terapeuta (fenômeno conhecido na literatura psicoterápica como contra-transferência) podem servir como dicas sobre o que outras pessoas do seu cotidiano sentem. Desta forma, a relação terapêutica seria um contexto que possibilita o aprendizado ao vivo para o indivíduo, já que o comportamento pode ser reforçado ou enfraquecido imediatamente após a sua ocorrência. Participaram deste trabalho, quatro terapeutas comportamentais que atendiam clientes borderlines. Elas realizavam os atendimentos semanalmente com sessões de uma hora de duração. Relatos de sentimentos dos terapeutas foram gravados durante entrevistas semiestruturadas e durante supervisões mensais com cada terapeuta separadamente. Todas as gravações foram transcritas e exploradas de acordo com os métodos da teoria fundamentada nos dados. Os resultados apontaram que os terapeutas percebem a ocorrência de comportamentos clinicamente relevantes e de contra-transferência na relação terapêutica. Tentou-se, nas supervisões, levar as participantes a utilizar dos seus próprios sentimentos em relação ao cliente, como dicas para atuar de modo a promover mudanças no repertório do cliente. Elas relataram que muitos dos novos comportamentos adotados por elas, foram punidos pelos seus clientes sendo isto coerção para continuar reagir de forma complementar aos seus comportamentos. As terapeutas, que voltavam a se comportar de modo mais seguro para si reforçaram os comportamentos problemáticos dos clientes. Tal comportamento contra-terapêutico parece relacionado com a esquiva experiencial. Os resultados sugerem que atenção particular para os padrões interpessoais durante a sessão poderia evitar que a relação terapêutica chegasse a manter os problemas do cliente e que um melhor proveito das respostas encobertas do terapeuta para este fim é possível.

Submitted by Maicon Juliano Schmidt (maicons) on 2015-04-15T18:41:58Z No. of bitstreams: 1 Edilson Pastore.pdf: 1708498 bytes, checksum: cb7f365a867bba996d379bf77353991f (MD5) / Made available in DSpace on 2015-04-15T18:41:58Z (GMT). No. of bitstreams: 1 Edilson Pastore.pdf: 1708498 bytes, checksum: cb7f365a867bba996d379bf77353991f (MD5) Previous issue date: 2012-01-31 / Nenhuma / A presente dissertação de Mestrado investigou o desempenho cognitivo de participantes com Transtorno de Personalidade Borderline (TPB) com e sem histórico de tentativas de suicídio. A apresentação da revisão de literatura e dos resultados empíricos deste trabalho foi descrita em um artigo teórico e um artigo empírico sobre o TPB, suicídio e funções cognitivas. Primeiramente, apresenta-se o artigo teórico, que traz uma revisão assistemática e crítica da literatura sobre o transtorno, abordando as particularidades do desenvolvimento dessa patologia e discutindo sobre os aspectos cognitivos. Essa revisão teve como foco as funções executivas, especialmente: atenção, concentração, tomada de decisões, organização do pensamento e memória operacional, sugerindo que déficits nessas funções podem ser fatores de risco para o suicídio em pacientes com esse diagnóstico. As conclusões do artigo teórico apontam para a existência de déficits específicos na cognição, especialmente na área de execução em participantes com diagnóstico de TPB. Discutiram-se artigos atuais encontrados sobre a temática e problematizou-se a necessidade e relevância de investigações e achados dessa natureza. O artigo empírico apresenta os resultados de uma pesquisa quantitativa, transversal e de comparação entre grupos realizada com uma amostra de 82 pacientes (M=31,80; DP=0,96) diagnosticados com TPB internados em uma clínica psiquiátrica de Porto Alegre, Rio Grande do Sul, Brasil. Foi aplicada a Escala Wechsler de inteligência para adultos (WAIS III), a Escala Barratt de Impulsividade, a Escala Beck de Suicídio e a Escala FAST, além de um questionário contendo dados sociodemográficos. Não foi encontrada diferença significativa em termos de QI total entre os participantes com TPB com e sem histórico de tentativas de suicídio, indicando assim que a heterogeneidade dos pacientes que apresentam esse diagnóstico, assim como o grande número de comorbidades apresentadas por essa população, podem ter sido fatores importantes para explicar esse resultado. Entretanto, verificou-se que pacientes com histórico de tentativas de suicídio apresentam índice de impulsividade mais elevado, especialmente abaixo de 30 anos de idade, o que salienta que nesta idade pacientes com TPB podem ser mais vulneráveis tanto para tentativas de suicídio quanto para sua efetivação. Embora não se tenha encontrado diferença significativa entre os grupos, as médias na Escala Wechsler (funções cognitivas) quanto ao QI total situaram-se dentro do nível médio de funcionamento cognitivo com QI de 92,73 (DP=14,39) para o grupo dos pacientes com histórico de tentativa de suicídio e 96,06 (DP=17,8) para o grupo sem tentativas de suicídio. Os níveis de impulsividade foram maiores no grupo de pacientes com histórico de tentativas de suicídio, assim como o grau de adaptação medido pela Escala FAST se mostrou mais prejudicado no mesmo grupo. Os resultados desta dissertação elucidam aspectos sobre o TPB e permitem refletir sobre adequadas formas de tratamento. Fica também evidenciada a necessidade da realização de outros estudos dentro dessa mesma temática, em virtude da carência de pesquisas neuropsicológicas ou sobre funções cognitivas em pacientes com diagnóstico de TPB no Brasil. / The objective of the present Master's thesis was to investigate the cognitive performance of participants with Borderline Personality Disorder (BPD) with and without a history of suicide attempts. The review of the literature and the empirical results of this study were described in a theoretical article and an empirical article about BPD, suicide, and cognitive functions. The theoretical article consisted of an asystematic and critical review of the literature on the disorder, addressing the characteristics of the development of this pathology and discussing its cognitive aspects. This review of the literature focused on executive functions, especially: attention, concentration, decision making, organization of thought, and working memory, suggesting that deficits in these functions may be risk factors for suicide in patients with this diagnosis. The conclusions of the theoretical article indicate the presence of specific cognition deficits, mainly in the executive functions of the participants diagnosed with BPD. We discussed recent articles on the topic and approached the need and relevance of further studies and similar findings. The empirical article presents the results of a quantitative, cross-sectional and comparative study conducted with a sample of 82 patients (M=31.80, SD=0.96) diagnosed with BPD and admitted to a psychiatric clinic in Porto Alegre, Rio Grande do Sul, Brazil. The Wechsler Adult Intelligence Scale (WAIS III), the Barratt Impulsiveness Scale, the Beck Suicide Scale, the FAST scale, and a questionnaire containing sociodemographic data were administered to the participants. There was no significant difference in terms of total IQ among the participants with BPD with and without a history of suicide attempts, suggesting that the heterogeneity of patients with this diagnosis, as well as the large number of comorbidities in this population, may have been important factors to explain this result. However, we found that patients with a history of suicide attempts have higher index of impulsivity, especially patients younger than 30 years, leading to the conclusion that individuals of this age group with BPD may be more vulnerable to both suicide and suicide attempts. Although there was no significant difference between the groups, the means on the Wechsler Scale (cognitive functions) in terms of total IQ were within the mean level of cognitive functioning with an IQ of 92 for the group of patients with a history of suicide attempt and 96 for the group without suicide attempts. Levels of impulsivity were higher in patients with a history of suicide attempts; in addition, the degree of adaptation measured by the FAST Scale was lower in the same group. These results explain aspects of BPD and provide the opportunity of developing appropriate therapeutic methods. The need for further studies on this topic was also evidenced by the lack of neuropsychological research or studies on cognitive functions in patients diagnosed with BPD in Brazil.