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Surname, Initial(s). (2012) Title of the thesis or dissertation. PhD. (Chemistry)/ M.Sc. (Physics)/ M.A. (Philosophy)/M.Com. (Finance) etc. [Unpublished]: University of Johannesburg. Retrieved from: https://ujdigispace.uj.ac.za (Accessed: Date).

A COMPONENT ANALYSIS OF COGNITIVE

BEHAVIOURAL THERAPY IN THE TREATMENT OF BORDERLINE PERSONALITY

OI��OROER

by

MELANIE SETTERFIELD

DOCTOHAL THESIS

submilted in fulfilment of the requiren1ents for t.h�

DEGREE OF DOCTOR OF PHILOSOPHY (CLINICAL PSYCHOLOGY)

in the

FACULTY OF ARTS

at the

RAND AFRIKAANS UNIVERSITY

SUPERVISOR: PROF E WOLFF

JULY 1996

RANDSE AFRIKAANSE UNIVERSITEIT

UNIVERSITEITSBIBLIOTEEK II

Tel. 489-2165 K A U

Sul

VERVALDATUM

11111 BIB

A COMPONENT ANALYSIS OF COGNITIVE

BEHAVIOURAL THERAPY IN THE TREATMENT OF BORDERLINE PERSONALITY

DISORDER

by

MELANIE SETTERFIELD

DOCTORAL THESIS

submitted in fulfilment of the requirements for the

DEGREE OF DOCTOR OF PHILOSOPHY (CLINICAL PSYCHOLOGY)

in the

FACULTY OF ARTS

at the

RAND AFRIKAANS UNIVERSITY

SUPERVISOR: PROF E WOLFF

JULY 1996

ET1

A IIJMFUNENT OF ANLYS IS OF COGNI TI VE BEHV I OUFL

THERFT' IN THE TREATMENT OF BORDERLINE FERSONLITy DISORDER

"THE LIFE OF THE BORDERLINE IS LIKE A MERRY-GO-ROUND OF

GETTING INTO FREDICMENTS AND DISCORD, AND THEN SPENDING TIME

EXTRICATING ONESELF FROM THEM

(MILLON, 1781)

ABSTRACT

d1c�V1:.: 1 opm<·?rit coqn it i ·vf:.·

··,;;;;1r· i ClUS,;. ..

psyched og i cal conditions, hc:-1s

c: l i. ,-, i c i 2<.n�; anl3 inv0stiqate the effects of t.h? ':5

therapeutic modaljty on Borderline Personality Disorder.

t.he comp1£·?>:i tv the disorder has 1. E·ad to ff:uc.h

'=·P (?.Cul'"' ti ,:;n E·tioJ.oqy conceptualis�tian of

Of the various treatments proposed for

disorder that oFten presents as chronically suicidal or as major

b i:2 :T1C) ':, t in this modality

emphasise co�Jni t.ive .f2-1c:to,-·s 1.J.ke cor,t.er,t-.. specJ.t1c cogn1tjors

and earlv maladapti�e schemas.

The hyr:cthe=-,:i. s sL=,ted �;r·o21dl y

cognitive behavioural approaches would result 1n equal treatment

t?fficiency, C:Of"I t.er:t

i n t e�-v<?.n t 1 cw, s. This hypothesjs was investigated in a stud� with

sixteen selected subjects.

Apart from me21sut-es f cw depre-:,si cm ar:d cognitive processes

associ c.,ted 1,.-1 it h Disorder, a depth-of·

processing task and a schema questionnaire were utilised in

i nveeti ciat i no the hyF:JtI - ee 0,

These ireeur'ee toether withL the rrentic:ned c:oqr'itivc: hehv].oL1I - eI

itenver- tior- e were ai:pi ici to a eai 1 group of coe+ui. 1

eel. Octed Borde Irline Personality Di. eec rice ed pet. 1 oct o

ihr:+ iodine oc.::oLr:ci the hypothesis of the otcid, end

iierrcjre:cet.ed that c:ooni, ti. '.0 behavi creel eprciechco e±ei thor

content of oeocoeo t.vi:cer are OOjL.iOi 1. v e+ + 101 end i n the L.ceedment

of Bordt1 ijic Feconi. ito Ul000cier.

OF'SOMMING

-1ini·1ii;_I£� \/ClD

t: e: .. , Z:t\' l c.1·_1_r- j. ·::: t. i e: .. ':::;£.: ·:· tcit. f, 1 e 1 !,: u·-· d 1 9 c·

c1 ,. e c_,c,

!:: i::: �· l !:?i'::·I DUI. cJ j f.::

l·. " ..

l:tE=·ht:tr·,d�:·· ;. :. ng':=,"'

On l i:· ,·, c1 �,. F·

,� -· I .;., ·- ·•- --

T .=.. r: ,_ t..J r ;;;·

·-) E_, ��. t. t'? :t !":et

behavia�rist1ese

c,.f fjit Ciri ir:hOL1.d CJf

Di t� 1-,

Duiten metLngs van

met Persoonlikheidsversteuring, lS n CJiepte-van-

verw�rkings taak en skema vraelys gebruik om navorsing op n

q;� ope van sest. i r2n gecJ i ar.,:ino<.:=.f.0et"de Gn.s•nsqeval

iEr ;cor i hez d,vEI - tE•?u cle i nt e,.

Die bevindints het die hipoteee van die etLkdie ondertEun

i.nqetoc -', d.t irhoud an ::Ee .::c)cn.LtjevJe iediq. tErpE:.ieeE-:

Lerder i eq EE cic.e1 LrE: fend i. n ii.e behende? i nqian ri

Ye - EteL - 1rc in.

TD f�UMH , MY

E:NCOUF:P,GEMENT .:

ACKNOWLEDGEMENTS

HUSBAND, FOR /OUR UNBEL1EVA8LE ..-;.,..

TO PROF. EDDIE WOLrF FDR YUUR CONSrANT PAlJENCE, WISDOM AND MINO

BLOWING KNOWLEDGE THAT YOU SHARED WITH ME. ALSO FOP YDUP

GUIDANCE AND COMMlTMENl.

CENTRE FOR SCIENCE DEVELOPMENT.

TD ·r H[:: f3Tf�T I �;TI Ci�[_ DEP{;F:::"rt1Ei'·H Ljl. f�t:U ANL• h�f-n I Cl!Ui!:;:L. '{. F'F:DF

L..OMBAF:D Ar,H)

STUDY.

MRS MARTIE BES!ER

T' i,-· . r11: •. STATISTICAL DATA OF THib

Tu MY COLLEAGUES. MAF( IL YN SHL.JU·1,C:1N' P,N I TP, i:.lf'.'1DENHOFi:ST Arm EL SADE

TO EDNA - FOR ALL YOUR HELP

l ::i"7

I N D E X

.,..

CHAPTER ONE - LITERATURE REVIEW

1 • J .. J.l\iTi::Df)UCT I DN ''?

] ":�. ;)ctil'H-; TO!) {;ND crn,JCFP""T'I.JP:l_I':::';; .. !1TlClN DF

BORD�kLINE PERSONALITY DISORDER

l. 3. E!IOLnGY OF BORDERL!NE PERSDNALilY DJSORDEP

I c: 4• .. .... } ..

• •-; .. <

!. � · ... ) • I ,.

-:• .• ;. " .• .. ... "

J • s. --�·.

� (� ! J . .. ·t .. .,J. "

.. 4 .. :: .

1. 4. ,:j_

.I. 4. b. 1

,, ;1 � .. 7 ..

F(�M I LV DYN(..'\M I CS f�!\lD 1�=:XF"Ll� I EnCES

SOCIO-CULTURAL TRENDS

CH l LDHOtJD ·mr,LJMA

THE NEURD -BIOLOGICAL 1·HFDRY

COGNITIVE SPEC[FICITV fHEORV

PSYCHODYNAMiC THEORY

F'SYCl·H{YrFdC Il'-. .F'?'tTIE::.!'JT "i HEPhf'Y

VIAGNOSIS AS lHERAPV

t: T O····C(X:;N IT I \/E m:::i-1;1\! I ount,L -r I- iEDF<Y

DIALECTICAL BEHAVIOURAL 1HERAPY

F-'Ht�F:MACDTHEF::P1P\

COGNITIVE BEHAVIOURAL THERAPY

�RDBLEM STATEMENT

CHAPTER TWO - METHOD OF RESEARCH

�- 1. lNTRODUCTION

2.2. DESCRIPl fON OF SUBJECTS

(:'1C3f:: DF m.:B,JE:C.::Ts

�;Ex DF �:iUBJECTE1

2.3. DESCRIPTION OF APPARATUS

2. 3. 1.

2. �.:'; .. 2.

2. 3. ·.: ..

2. �5 .. 4.

:2. 3 .. 5.

THE BECK DEPRESSION INVENTORY

THE DEPTH DF F'F'.:CJCEf�:;�3 I NG T {.�::?:i!<

THE AUTOMATIC THOUGHTS QUESTIONNAIRE

THE SCHEMA QUESTIONNAIRE

THE SC:ID-II

.� r: ... ..... ,

. .

., .

�.:8

:'., j

r ··, ,·-, ,::;. -,1

:1,. I·-·'

2.4. F::: flfll.:1 5

2.4.1.1. _1!JF'F:.r'.i L;i I r- i1.Fi...)ii-i [ T. 1Ji'-iE. 10 :ç:ij5Tc::: 3[!-I[I'I•) !Tr:I: IL-

ill -

V j ••.

.-•. S . I :S V S' CC '-r - c-I. I-: ::.It--iI ...:.I.LL,.I -- iL

CHAPTER THREE RESULTS

3.1. 3.2.

I: . 5.iFF:: --:,j[ ....

T.L-IFEIII- Ill,. .i::r--. AND -', ".'Sr

STI11I1'rILI--IL Il - Il -I

I. Di.HERE 1;JLEI f:PcJ1:H::L.1 LI ... ... ift- *1 IILI:1...I.NE 11J. MULTIVARIATE 2'F- ITi1..i '.........I -- 1I 1... .

ECi. OF LUi11F C 1NDI V IDUAL INTERVENTIONS 1 1

1 NTEFLIENLr I 1111 1 11 3.2.0.2. EFFECTS LI (PT

iNTERVENTIONS

11 OF PROCESS FOLLOWING I.I)1'-1'[EFI'1 'h

$Ni4L..2].2

ANALYSIS OF Il!,... THEPAPEUTIC EFFEnTo TIIEL [JFI!TLF. INTERVENTION IIIFFE1I ..... OF 1 5 LI .1 V II LUlL. IP•.1TEl'1EL1.LL

is h:L:I:fl'I:. OF tJiII5I .-ii"1i [101'

!NTERVENTIQN1 -_; EI000L.TL. III FFII[iT 1 '-.....JL: h LBI

1.1.2.3.LIF'F'E[ITL OF PROCESS FOLLOWINE CONTENi 122

EFFECTS OF lIT_tIC I _, S FIiiTF [1:-I .21

2.4. sIx IEEE: FIILJ uN--UP 1.24

CHAPTER FOUR - DISCUSSION

4, 1. iN] RUDULST iON SI.

4.2. EFFELTS OF ... ij T DUlL I FTrFFhiF!.tT I INS

I

FFF'ETc UF: [FONTEN[ 621 I NTERVLFNT I 061 1 2 1 Li21 1'1E;Fy[F1 IL]IS

EF:F:EF:I.1

ION 1. [f: :: ijLjIF\Ii i1'Lr

LI ii i I I 'I J 1 L141 1. 2,, L6NOLUO [:fl.

BIBLIOGRAPHY 1.1

-r t-1L)L_ J

I Cr

FIGURES

H i FILFURE F ill U Fl F FIIIUJFFE 4 111111

F1 i1!JF1[1 1:

F 1. -ijF 1 F I FLURET F FIILFIJFIEI c;

F IFFFJRE I F F. fl, C: i .L

F I FFI_JFIE. 12 F. 2.IFL

CHAPTER ONE

LITERATURE REVIEW

, ..

1. 1. INTRODUCTION

The psychiatric population which 1s at h1ghesl risk in

its morbidity and mortality �s well as d;.·:=+ic:ult.y J n tr-(:0 ,:1tme1·,t,

is the Borderline Personality Disorder (8F'[J). It

\Jr. i ffldi··· i l V i:iS

anxiety related disorders 'Taylor & Zaparniuk,

prevalence rates of BPD

tu 4i:,

from statistics that the

in the general population arc high - 1�

E,nd ou.tp ,:1.t i er-. t

settings <Gunderson & Zanar1n�, 1987).

l_.i_ nehan (1987) suqgests that

incorrectly diagnosed and this cauld possibl\ be respansjble 1o!

the pc:;c:,r· t.hF.�r ::�py. I t. ::;t:.,1?111::,, t.hc�t

personality disorders in general, 8PD individu�ls hav� proven to

be r· ather- c:li.·H

thc1t ther-·£?

. 1 lC\.L t

seerr,s

to �;tudy

to be a

�iri d ·t !·- E-? i::C. t (JLtZ £� ( 1 c•7<=; \ . 1 . �' tTlt::"1 ... ,t i. c,t-,s

tend£.;ncv c.1mon g me·ntal heal ·ti:

professionals to label almos� all affectively intense, jmpulsive

and interpersonally difficult patients as having BPD. This mav

be due to the fact that, despite various research done on BPD, t

ln cic)E?s not seem to be crisoncLic on vhst 8PD cct.cisl 1.'' :.

rEsult]. nci in 1:.. ho c:iE!vEii opmsnt of rsrv coritrovsrci ES surroundi. nc

Lhodiscj - sis and cicr± ini tion of this diriordsc and hruc:1 sr::

ck:scri ç.:ti co has been scjmnechot el urci vs Ni. di c:]r k iihes. • 91

ihis has resriltod in ;Lierrt.1onrc I:irrino ssksd c:c:flCErninc th::

'si:i.(:t:Lt\' of ErE as :; disorder in its cccjn nicht ((]4-j•• ]•

Spitzer, ic::c::.: h L;iLbor •

:5: with tb:: :r]i_ ; sr. voncc.s C: f clEciin:t. ic: n And •lisoiu.:cis, tncccrc

has neen 0001: r.ps:: oticin ccnc:c.nrinc the c:ccnccct trrcot:ircnt ful

Lr ;:irc. :iir:c:cicro. Of .icn p :: t arc:e rc:c:js::i]nc tti: S lc:c.LC, is i:hc fact

that the inOrir.iJ its and rrrc)rbidjtv n000ss]. L a L es the c.:Lth

ofEr.ci.c:sis to i-uI] co-rite an Ir!c)u:.rICSE cnc;urt of time or:]

J1-:Mij resources to the icnsc]smEr1: of this ccrrdit:icrn an

0] 15.5. procerits as c:hr uric: rruic:ids] and ri-shun

I:; - ::. : our

(;lthciucih thi c rundition has been )is.rrcclEd 10 li-ho cost in tsr-i: o f

oscdri str - rc: tr- cl.:m:::L of is '::rv lr'ts':nrs notice, c-: li-h electro-

shock •SPc- prc\ c::ho her op-v and icennnsnont incsroer- st].on 11

iic-c-rttis) znstitt.i.onrs, the costs of t.r:curinenL are hlhh

riecEssi ti-ti nd the mer- t.sJ hc:sl th pro-foc-isi or - c to seek s.l ternoti Vs

misc of nnsnsgi nil and t.reati op li-hi:: c:cndi ti on (Ehel lock & Horson

1990) Fychcrdyriisrni c therspEcuti C: 1 c-tErn venti DOS have sppE2St Sri to

be somemhrst ci sappoi. n t: 10 ( hiec: P 1980) and other f 01- 055 of

t:rsatiTieflt have not been too impressive either.

maintains that IL.:. u_y::'.:L :;j_:1 treatment

L.ii.) has thijud diEma!O because I

the

and not for

L:.•Lc::..v:I approachen will L.

in the treatment Do BPD.

two 5 oad c.t.Ecc : c::c::- CT approach

Li approach. The schema focused LI ---' r:.

adaPtion of the TIc:J:j (1979) short 1; E:riit CT. which

i.riit .]. I'' dEVE:lopEd for the Ir rt.mricit of depression

'i'LLt!U pvnponEE four Lf(YCt.iCkj c:c:)truEE: in rJrr Lc

RM

utilise the ocLi iia-c:cucad a.ppri:a.ch vi : aor y 'nal odoI:cI:ivnn

a:,haiaa ac:hairo rrint..ErorL:a, acheiria ovoldonic:a and sccnrno

compensation. Yourici ( 1hCZ)) r'iotern; • hocavar that thavo ova

specuiRtive and have not I.:caj'i t.t.ici ariipir iv all

• the contonLLvpa L;hf in naEed or the:

assumption that n:cnnt.nnct. apac:] 41 ci to has been found to arhonc:v:

the LhcnroncuLic,: rn f+e:t:ivmnncnnn:. 10 CI.I4T in U- a L':ocmv:L mU

::n.nmvrmi..nn - cn; ringram & I;arii:iaII.] Furtherwore, in a

in'nl].ns i.P) it was ]:oncI that thava is co;at*va

specificity for L- 1 'Ti • vo;nmt.n. op that thra are Certain

copriI;.:oi - n: ape::: +:L:: to HF:L. that may be in..::] '00 in tOo

rnni tanarc:a of ii rn: P.r . arm

p1 iL at..ivpar+rrrncj by L.:i.ic:ici: 1991) indicatnind that Lct

c.haaa two mpproach; av:rom mncu.oI. I V a-F f: vi ant. in the r - vt ilirinriL v-F

iFFi 4f;.t iv., hoNevEr, not cla:mnr is what are Ua :rrnt oral and

feLtive compupents that :n'F ].renca li'+ {..]

Thu non.:' throat of the t.rcIv ar 1], be than in U'i'j ca wh a t

fuiii:t.:onal and af+active conincur - irita are that ir:+liaarca the

a-f -fact: -anoaa of [IErT i rt:ar yrirli any. in the tvaotrnant at

i

1.2. DEFINITION AND CONCEPTUALISATION OF BORDERLINE PERSONALITY

DISORDER

An i.ro:ortont i ouo in this ot.LkcI' 1s the c:nE0+ the d+irH t ion

and conceptualisation of upu, 0100 of 1.0)0±0.000 is thc

distinctiveness oft. the HFi1) in rolati. on to c:tor closely rd oe-o

cii ccor err. h11ici- ±. F4rrror (1990) notri that tho cnror1:.

conceptuaKEation E.-Fi) has arisen f rcrm a no] at i vol v I. orc:

histcry of olin 1. :.ai Ui aJ. and oor - or and ampiricol

I nroot i .Ot 1 o no.

I] ..n:. L:cr+c:rc: ?.c1c:iEc::0Lr;c] the .:&r:;.n!'tv of c:: otori drti.nit:.ai:a and

c:jr:ctLlo1 i.Oat].cnO for L]Ft], it rppa.nc 000EiEOry to dincuss

c:!e+:rott:cc.rcrpt of c:rc: (.:ra1:t v' cii::cnclnr . E:ollrcit

( Ic() menti on th.cl.: the notion of r po - cinal it0; disordei

rrqurcro the ac.ccuci:t::t.i on tl;0t.1 mdi vidro]. ::onavi000 cia±.terncc

(i.ncJLo].rI: jattr:rns of r:liLr c:0cir:1 I a-c OcrCclrdO or:]

p!c'roiolCcL::al ocac:. on ooperacc' are roaronahi c:cnrintrrv co- cao

both time and

From a bohavi.00roi herccpEc:t.1ve, :cr:mccjn.al 1 Ly may beet be rociardeci

as a cot of boho......mjrol cmoobi 1 it.iee *i01 lace lib)

personality di corder would thos be do-f inec:i in terme of de+ininci

el eavan 1: bob a...i oura I. and asceoc. i at I ye et I. co 1 uc contort: dome.

and chooci rtq hohavi ourr: thouqht to be repr ecrentat 1 e camp 1 cc cc

domaars of interEet. (Fiel l.ac: & Her- ser , TurLt 0 L.eviri

(in (dtmo & Sutter, 198) do+ino pornonal 1 Ly disorders as

deoc:vir:t.ve labobs of various C5OLLO of beha'iour

iIiY.EM--I I. --F (f;P, 1987 ) dOT moo a personal i1; disorc1sr in

tecmy of rritrr- i a vjhi ch niT-f or LCT bepavi ours or t.r.ai s that orn

char :teristic of a person roc:ent (j.::osl: vOOr ) and I orc -- t.cnir

-functi rni. Li oensral 1. 'since adol eocec:o or oar I T adol thoc:r.:

ame trait-c or the constelition of beaiionr crjoes either-

significant J.rrr:aa nc rt i n s ocial or occupational fLuL:ticrirc.j

Ti.kbTa::I.icn oistreo-i or :!isccr:r'fort.. The Leha-.icunu

uuuci as iur ic; :: rETu,.L ru

in the lILt--i I--k, t.viu-::-:Iv'c ç:rnrcrouiui. i tv cimsorders are icci_nci

a-ac La-cite L:an:r.c.. mt,- dmsu::ncirrruc are jividori i.fITi thur-ic--

:1 ucu-tcno. CL. ucr:er i c:oIcuri she of the €cc:certri cir cup cc - f -

unicorn- i. itt uiiecrujers v1:-: pt:r- oi.d personality di corder

ructmcc::uci CErconahity di condor -cirud schi.uot.vpab rcr5Enai it-:

cil sorrier L ucter Li c:r- sisto of cnt.i.sc:ci ni por-cronuri Itt

cii sorrIer, :nnder]. ne perrcoria.i] t.y d:icordor • hi -et.ni.c::rii.0

personality disorder and n-ann islet ii: pesorui1 it.ic- di cc:r don

LI uniter IL corel she of avc::i.dant penruoncuci tv disorder, dependent

personal it: dz-s:_.rder, ohenurusi vE ---- c:oiTpui -ucive personality diconic-a

and narici. va--apor ccc-; i vs personal it. y cii corder Li -fur then C ate 0!'-

viz not oLhervuise specified c-ihmch is ut.il isd when Lone

m cued pi ctLtre of symptoms and hohavi ours • chi ch do not meet the

-fob I c:ni.teni-m for any one of the disorders Cncithor two

proposed cLt.EcorI.n!. the •E1L .f {:(• . i_ . L1 . 1 personality dincrder - id

the sadisti c :&rnon.1ti. Lv disorder are also 1 ntEci , but are oti 11

I::ni ic s tudied.

he Muster F$ 1:,erncriIIiJ. I tv' di I•ECjEVEdd i rdi YJ 3L.1 0 tnnc: to

oqoc::ontric, ei:tt1oFieo'ek:Lnq. rinipu] •ol:ioo: and eIpIoCtive.

dldE.pJ0'.. ].1L0reI-0OFL0T c:t). - f - ]I:oi.t1ooerd C:Cmflhf .r0r

!ability CLivesky & •::::hrc:ecoi' )

diaunnsis, based dJr Lrd: It:1I.L••• 11

stipulates the fc:J.1cicni niiteria foot.1 - rr irric:rrio of RPQ

j'•dY ''E Pattern of instabilitVof ricod • :IrLoccrr core

re].o.t:.i.on -'ipo and colt :iiTiec:dr, bownning in E?0i I.' .OdLO.tI000 ancl

prerrc:rt in •ovoricto of cor i tE.tr as indicated by at io0dOI ti :0

of tc: -- c I ]nvi:i n

.0 pattern c:fr.ret.rr.b1• and i.iILr.rrro i.rtErherrrc.Ire , .

roiet.i.c:nshlpn chc - ec:Lci.ced by cltorr:otlnd boL

oct. orro:o. of :'•' J.d0dt. . oct. or and devaluat i om

1mpLIlIcI.vorecr; in at I cc-.tI two cooes that one

potentially self damag ing, eg. 0 i IOj] Ci

cL.Ii:)r1Lcrc:E o:)CIde? cLc:Ii:I 1. :rttinc • OIC:d:i:1EECIO dr:.;Irc

bince eati rcj (dc: not inulude ouicidE or salt

mLlt 1 1 at : nq bob cvi our

affective instahi 1 ito'. marI.ad shi-f-td- from baseline

icood to deprossi on , I or i taLl]. 1 i t v or 00;: :i et V

uoua.L i. V 1 Ont. 1 n1 1-k few hours and on I v carol y more

than a + ej

1 nap p opr I at.n i. nterse anqer or 1 ark of c: onkr o 1 oi

op requnnt: displays of temper, c:onntont

recurrent phyni call. f

recurrent suicide at.teml::ts , threats psLu.ro-a or

onov I cur or cc El 4 out 1 1. atm 1 bc:hav OL:r

uncLeS and persistent. i.deritity disturbances

manifested bvLkric: octal ntv ad out at I. nast to of thu

- ccli ccui no nut -1 ima.oci secuol on. onttc on 1 onp term

quals or c:arnlor c:hci. ccc, type of +rc Rr1: dr:ui r ccl

:cc?r-ccrcrcl vol.

c: - F rcel. I non of urrpt. i nosic or hoc eciom . and

5. -f- u on t I c n1- f Or.... cc to ccvoi S root or I inapt ccci

cc L: on ci orimon

The Uc::rciui1 .nu prcrcrorni it.v disorder has remncF:.nbl-i Oroad oppecci

to clincuinns and t!- er:ret.ici.nr -- s in s:it.o of its bcpu.ili.fnci

'..-icpciEnenE h cccncen, Liar- kin. Llijinorci Hc.irt S cirorn. 10511)

Gunderson it: 131 OC) or ( 1575) trace the otccadv no pans Dfl of FiLL as -

distinct category, despite rather ignoblebeginnings. According

to Ecin]. Iacc S Hi-crccuri ( 1C15() • it was an early as 1700 that

psuchoanol \ti call'r ur. ontated cI ciii ci ann were 1 vinci crtteriti on

to a group of p at :L onto Nho app earei:i to -f 0.1 1 1 n .s c ont 1 0000

hnt.oeen puv'chosi s and nnuron

The j€1 of bordori me oc:ndi. c:ne can be tIrocEld bocH-::.ns -for as

Kr- epl in, who rE -fErrEd to otyp].col or borden lEE? C0E?2C of

ii ii.a (Tarnopolsky & Berelowitz,1984). /Stern(1938)

was actually the firstci :inicier to use the tErm boo dcu line to

c:iE::nitDi- i:Ior:o who did not noor to :00 -f]. L + 001 'ic:i?oor?ni

and who ooesertrvd vii th the nrer-iriLet i. on of di. r:cdern thot

I. nd LICIECI narcissism, Lelr -no of ::E?V - on ni in-I - eLi O 1 ., i - i

tvrrcrini iI:- - f:'/DErE-.fliii ti. -i. f.-, to ircu.i.t.s. • and a deeiy ruoted

-nrnr-iiin of anxiety. t.]r-?u_u.r;c:h 1 referrpa to t..t1]

per-non-il i L--- :i.ndi-.j..d..e].n vihc:se -OLpEr -iic.:i.n.] Social

nl::[r:pri e.Lenens ne-i irenI-:ed to iiicIh 1- disturbeO PEnsonal

cI. i ui]:: -en and author, Kr:. ott. - ; o;

argued that b::rderl lee p.nLi.ent.e u;Li+±.Dnii-:ci from neverely yEDk000C.i

coo functions, as ii rE - suit. of underlying dove] oprontni -fe.i boon.

He nI:pi ioU the te-nirn borden re to ostients who c:cj:..id n-nt. Ne

c]. aii-:.-ei tied in one othE-:- one or category, ru:ndorinrl the hE]) in

eftioL no tsr - codes v. oent.eLasl-:eL. di .ecIn:siin, From eLi.-:- it

that + nor: the oer I cuit c:onc -p1:. L.-n 1 not. on:: of SPO, if has Leon

IELE-Id as a term eic:ciiripnssi r - ci the mis-fits or the i-c']

psochopotho]. oc'n. Jr eddi tion to the ocr -f os.i. on in

con: çtuei set]. on OT ):up:.F) her nbero ( 1967) empi c:veo the

Lordc-inl ire ::er sore] ito orr- ri s-el:]. on v,hi. c- h r-:i;r . hod

sooc + ic. -tbi. LJathoiocIjdni. per5000l :LtvEL.rLIOtL.ILE WhicM

order I i. nes van i cci 500pi DIII c:o note]. I nt:. on-s. He desco i bed ii I. cool.

of personality Organisation nether than a disorder, .rqii.n thol

border]. inc personality oncerisoti.on was dr -ferentiDt.Ed from the

1 8

ectiotir or po.chotic on the b.cy:1 c of t:hDoo c:::ritorio Duf-ficion

for the ciiccnc:ois This nritor:i os: :icrleiitit'c df+uoicn

yrrnov and Di 1i1itico ciofruce iriccchonioinu (ord horo he ro-feio to

IsplittinqN. and — theif.rrrc:o of I 1; v tEot 1 DCI except 0

their :iC•c ::c:Jt I ci of self and otherE. it ---j- however.

•oi-rboo 1ici not rcJ•:(I•: the lnLoupurucnI•:tf and e:ncirc:rjmonta].

C:ntr1rDiLic:rc 1:c: the etiology of this disorder. Kullgren i.

validity of her riber cr i Lou i

fl io fOlD I ono tIll tLO.f

:Ic.rjt::. -C:r:cc :r:.C:c:ird:.ncI In irjulL:i•rcE. JLccric:Crt:.c: c::r.jterio., the :..:::i -

11. criteria curl the lI.:cc000.tic: irrLc•C;1rcccr Po-di.iruc

II.. :inl .L.irl -•' r.rclt cillIcjrc:ic;L.1c. uL.c:tJl I.

L.jE: nordetlire oersonality cicc:ri cdi on was j.Cjl-1 with Only 10,1

uEtcc].u]n:.i their rIcC::r: on Th'c also ±urIr:cJ

interrater rnlinjility to be cold : , This study also join1:o to

theI dcc that the concept of fir- do ri I. nu pccr cccn ci it'-' oroan,rc.of Jon

is :r:H-i.:i-lj. ccr:at:cbo :i,cr t..i:re and too ic Di.: o:ivo to 00

uo'i:ccudeci -c-icc cc rui] 1 .obJ. C:

here±ouu tI cc bc:cdcci-i i. nc-: poiuor:cc]. ::. dc oc - o:crji sciLi on turneci c.: to

be a c'ii.dc-c c:.c c:ucc::L including patients cci.t.fc a vlide c-cct-ietv o+L)ld

111 di-cici [and if dcccordccr.

Two other - ci in] ciano who c:hai lenoeci the toruT border 1 ire were

Hoch d c;ettel. ( 1. 59 ) They regeorleci the tOOT PFD as a

of echo. zophroni a and ccircjUEd in ±avour- of replacing E:FD rci th the

term eued one on ot i c cc: h :1 c:p hr en i. i nc: e t.h e'i p or c. e i ved the

eimerv cltncc:ei c'U'fnpt.onis of EFi) to be Echi.zc.prenic--]. ike

di cLcubcrcec of thoubht and

However, it appears that Oin I r c: el y , the c:cnc.ept of ilk 11 as

c.b -- c]c cup of e.:!izo:Jhrn•r1 0 • or the propocod hcuro.rDr v betceen L;Vb

has bc-Den rc.futod (f- n .cn_:.ee... Clarkin, Siir:orc.

-'t--brcvn, kPD has been cic-ecL•z dcctir:ccicbed

schivonhFvnia in i nI.Deti Olt ccLti r:cp:cuc:} c:Le ::cLi cut. cotci cue

dccci cc a bk-s.c I cc . I PbtI

by E:ce.DDtD:1 Et.0 (19) in -r]e.:r area tcc..:cccIc:c:

inmEated <5 near cc-co c.oEe-rbcd:Lte rato v:c.h ccc:hicc.r:hreni-cU

Family ccc ccc::id'...cc:Lc-:-:cl by Ic:] c:-t-t & Millward 4VOW, .:--jreUJ no

significant I. c- e-cc In pre.-si.cDnce of -EDcbvi.cOfsr5rDj0 5.corc

t Ci

Another p-:c].rt of -I:<-cJ to t.h:icc. is t.k.et of b:. :cr (<Jorbic: I Dryce

i.PbF_ cj:::,'i.ee 1FD as -cc (3'U<clroTe, By using <c c:I v - c<Lccr technique

t. cc I - ct c:-: 1± 0 oh cv cure] (IDEDcDSELtr ccc: of t: h nice cli eon occod as LIFLI. • t he':

- found that tiFf) cccui::i be cherccrtcr:i. -cod be fout nrnr<< of

pet I entee

cc most ic-everce]. di. ecticrt:eci c:iroop bc: - der i rp

on poychoti. c:

o core borderline proop displayinc

chccotic.inteerporsonc.i. relations, acti.nci

out behaviour nr ci en 1. r erie

co:Tipi i ant group lacking

Ii I. EE.0 OOVOI 01 V Cli et LAr b e:d

op on the neurotic:

iJtrt__tI L.iIii.

i on oil coo

in I dent ltv: and

cir c:o.p

and on

Endicott & biLLc:n i/$) regarded bFi) an c:Cio:L

too I ndopercierL di. monsi unu ei thin ohat they termel the

"borderline cc[:e: ruT • .:;hic:h ohf:ro::iuic:itco the ccc:I.:tz.c:t...n1 and

no the oc:hincjtv:_o,]. c:orsc:ro. I to. roforruod to

L:at1e:Itn WnD OS C oc:c: a]. Iv •arr:i. c:oe and preoaatcccl aith

:ii C1:'n,r:.o:i c.i+ :c:ith o::c:rc:h and Ido:ui iii: on v0i. I as recurrent.

II br. jcacc. Inp necond dinccno:i. on in ref rrec:I to as the irEctnt1cI

perc; ona]. I ti and referred to i mpub ni. vu and unprodi ctcch]. e pat]. onto

who c:i pccr e rc_ CCI prc:: I. e:ncLic: and unstable and lntEflE.E

interpersonal rcLat].::ncLicEc,

hoc h op Ecu I at i. on has f ci 1 c: nuid on r'1et her to c-op or ate L hr t rn:

entities or ohether a. unI+:L cut concept oho.1d be maintai.nrii

hpit:er, , Lndc cott. & Gibbon, it/b. But c:lccccp:. he iIctnV sticti 00

:ic:no by authors. I I to hi dicper -ccTtncE?c hccrner t: bi UJfl (tbti:)

Leorpo & bcjl off (1986) t.lotind 3. COtO E;< tOnCOL vO over lap 0 f 4 :cu

hotocen the di ocin!:J005 or LPL: a rd schi tnotvpia]. personality

d corder • stud cc have i ncii cated distincti ic features of the two

di soriero 'Leoroe & Sob off • 198) In fact • Scot - sin t Sd o-f

18 -1-ounci that ehi be c:ommonei i ties of perceptual symptoms and

micro — psychotic episodes c- I ot od b ot.vjoon 9F1) and SF5 , SEE was

dl ccLi. r.:t. f ron PFL) Vjl th 'oqi"c:I to f ecLcrocc li. :cc. ccoc: 1. .ci. i. ao1 ot.i

:iIL.(d1BCi t 1n.:it'ici and •:.n:H ot.-y. in cdd].ti::r oot.hc:oo ]. l:o

F ccc: oF oF c cc --1c,;ruicc :c ;•:-. Barrash cc F:: cc c'cr'c:: eo(1986) ccc]. cc-cc onnfirmerl

that SFF was di.cctinc:t from SEE) in t.c-rcncc of cc-cc co] LccinLincc od:

r:0mniui' LccL I or :t dccccc cc of reference and I r ococ .it cc:: cc -ccc pccc I

that cS.ccroccto: -- i aLl ccc of EE 't.jcccc'cc features of cc CIlDU]. -cci. ccc

c:::c:c-ccict:.]c Icc- and c:hr- unlc: bcrccdc:i. F.J:c:L:.ccscc lSdc:) c:ccr -)ic:'c-:cc

ccjccd occ-c:ccJl.Lccl .....:c:ccccL:L -c

i.c.c tl':i.:c.rc idocccc. of :- of ....orca. r ecarnun

I.1. cc ccc. crc-c and C.: 'crc cci:) iciccct.icc:c : more 0cc 'H - F - j---- c 1- I .... Apo

C--CL...ccl interpersonal nymptoms. in dic:r]r.ncccLc.nci 5:ii..

Gunderson I-: loiS c i.Th isolated c discrete I cccl: of identifiable

')r ccc: t..cc-:c....dc : ccc-- of c:cc'p -ccc o..a .: that DFD could 5cc: cc co-cc:]. dccc

Ci -ciL] :cc'_t: antitV c-cc ES characteristics -ccf,coc:i - cc to

H features leadinq I o the diagnosis of L5f ----- -4- C

cchich c-coo Men incorporated in a ccic"l] -f]ed -form, Int.cc

III (f'S 1785) .....ci the DE]L'l---I[ F 1 F (5Fd 1587) The cc ii: cc:cccL cc

id2ntified •-'--'-'-•---" cc dac-ccccr':ccLi --ccc bcahc:-;icLcc :cf

conceptualisation of 5ff')

The DE:h--I I I--F ((-lEE, 17) 1 'iota the --fri i.ocinc:i eight

cc-f cchi oh +1 'ccc have to be prE000t'. for the di ocinool a of ff1-U

Et. a. p at tern of cccrcctcccb 1 cc and ]. fl ton ao c. oter per - ocr ccl

cccl ati orish i pa

b. ±ontic: o+-crto to avoi ci roo.l or imooined cbotndonmont

C. I:: ci oh 41:0. in b oo:I. i LIe irocci t. o ci en coo on

d. inopprocrote, inter or• onqor or S[oc:L of control of oncer

F. cc: vonccoc• iri oticoot to :trc•:no that are ootentiall , z

001 ± d 011: 0 0 TL n p

ci clai t.hnc:o'Lc ciec.turen or bc.•!hnci our

mutilatinq hekouour

marked p0cc -ito 11±. 1 ciEi'?ti. to cii c:r bnrc:

H. C:hi-cirLc •-•rccJ 1000 of emptiness or

ps y chutic +c:cL1_ncc ore rncr1incc1 as cc cc::cc cctoci ±ecoturccc nO

brood or the )SM- - I LI. (Phd, tbSP) cci to ric•i.

F-i •nccnucct. c: interview 4 on border 1 i no pot.. I onto (hIS) hoc

icicct ; used in rccceerch EtLIIiSLEOII carlO +ouncl ret iablcc in

diocni irinatlrc:i opp -Fnc:jcr othor di.-oordercc (Gundoroc.n P (nih

1981 [Icc:el-cor, 1993) <nib S cdorccioc•rcn L'SiI:

indic:-nte t(?cct. tho Slid cc].uotE.c + i -cc carecco of

p-o.thc:I.00ic: featuresl c-coc.i ccl •ecicapt..icn iii:pLllSO n.c.tt.ennc-: affectn

o-cychrct i.c a-yllotocoonui 1 ltErpercIor'Icll. rE] atinnchipc hoib

LiLnderoon 198I)) )Ln].o+ - f (joIst) and bro] 1 Sinecc Montin Liri

( / 10 t Zoncircv ( 198] ) oupport that the volidity of the dc.oc?nccctc c

category of the USM-- I I --id 00 el obcrat:tcd in the Sill?, has been

suppor ted for i npati erlt ccaimpl cc. Su+-fi ci ent rccteo.t reli ebi ii tv

±orthc2 use of the 518 was -found by Lonnel 1, 8]. IF L_udlph P

Lohr (1987), orovided the intervie-cers were trained. it appear c

thor, that the 'ial. iditv of the L)IC c:ontrih'atoa to the conat.ruct.

vol di ty o+t. he ciacr]4:ctivo behavioural COflC:E.tL1ci 1 a.tior of E-cFD

U.r\1:tEr - 13]rcrIiri the Ei-M[-I J S--C c:rit.eri.a.

Criticism has, hoLe'er, Lcrerid i. r ec: ted at the cor1cot. of HFD in

c::-teoori.coi trm-. dcii Ia the t.i.:crotr: and rtr0EOrChE?rs bohr nil

the Dti1---- II I---F. (ciFcii. 1887) cii bard a occtrcor ira]. rret.hcc.] n -i

cia-f i r:i rc paroc:nal i to di-swdar and at the -a.vrria time rarocin] cci

that -iifilii(1-1• jrc''icI1.ciilii c;c - cIrrc. criLcir:ia for 111110 than one

di •11C]fldJO] 0 111 11-1 I:: Q. c:it.rlicr cc r c-c_icc:'.ed th.i cc framework, '.,

dimensional :crcL;rocc:h i:Irc iii. :rclr'c:cd].ricl )-1riic 101 itv disorders 10

-Y:!Lccdcd L-- SOME nlo - 0 than the raterior cab -cc:r - c.rc: h a

appr- cach notes ] nc. \-idu.a].0. along Ii coriird)uo to cnclic:.cctce the

eat art I: a aic i. rh they cicen i + eat: each of t he-rio: i + I a p or ocr: a 1 1 Lv

cic. our ci2u- ccc Frau: CI 00 18801 hoc av (1988) dccea not u-a iec:t the

::liteclor 1 c: iethoi ,, bc..ct ca - pi..rc-cc L.Lc1.: if -10 1111 fluid. net

cii acff)u-cc.tj .]:i içfl OhOL.I1d -c - u] 11110 :11 huEEiarcOdd c-cl 0rdlarczscticn

el tid e;cc:l ucci cu-ar - ' c:u-i tori a do - ti ii ncj the di aClflOcct:L C: C;itcCci - i dii:

that or a auujrcrordi naL:-:-c to ot.harcc,

It -appears that the major c.hl I on:cec; of the DFFi----I TI --F-:

1987 1'- dear ri p t I on of EF:I1) • at. cia f ron a orccrcr n srso or ci the

dist:r - iminai- l -ycn pcaar o+8:PD criteria with raciard to 11cc-c, II

disorders. The e+'fect I aciners and desc:ri ptive vol i u-h. ty of 8:81)

has been questioned in coinpar loon hotjacrin 111Ff) and other e>c 1 0 11

personal it a di sordera, and accord lu - ct to Zonari c:i & 6undersori

24

(1990) , par 1: i no 1 an]. y the Ciii. Leter B sub --- cm ocp It 1 5 argued thai-

].

in the ii cht. of the -ds:'ciree of di acinosLi. c overlap, the oc:c.urrencci

of pure Lcr:i.s. I]. c:ondi.tvions may be riative1i rare

Bomc - -ct ud I as have + OL.0 rid that fiLl) cool d not be di eti, nqL i shad -Er or

other hr icc iii di. 'sordars on various cii menicci oncc LopE: at a!

I +oLknd that E:F-'L' could not be dietiniciuishcrd from the

histnionc: and anti--social pccrc-ronalit.v dicorrdars or the rasir 0

oh anaTo ...cii or's family hi cit or i. cra and +oi 1 oc- - ' - L4: cii aprosaca H-i oh 1

fit snip I'd iii rcc'e'man (1984) r_Crr.i an art croci i ye over 1 so c ci t. ha

drarrrcti.c ccrc"st.ic: c:]u':-ctccr (B) with two 'i:hid'ii of thoscci who were

cl pr'r.rr as BPD ui. so mart.iric the cr'itorx a for si:nioni.c:

c:c•:rsonaii 'Lv d -a.rdr,r [base cctrtciiccu t .... Us. LinclarmlrI2 tin.

discriminative i:oule" of the DBN1-'-I lI--k fF4, i'i'fi'L) criteria in

respect to other hrs Ii ciiccc:rdersanci par.... ',i.c:ularly the L:lu'cccter

B typa.

fiEcerc" cit .....i =. 1 j ke those dora by Zenar ri

f-c - rc - Lanhcar cc K I v'Hcm ) have made advances i. n isolating

cii ann cci native 'features of lIPID in respect to other hr is I. I

di,'aordor'ci +indinci that quasi-psychotic ttrorccht de+nad as

trerici ant and ci. r cumscribed, and consi sti ncc of at"/P Cal

del usc oncc and ha! I uc:inat.icins.. was si. pni i cart! y more common

actions those with lIPID than other hyis II di senders. The stc.td'

also revealed that of -1-i'ftv of the patients with BFD IOCh'

reported disturbed but non-psychotic thoupht 407 reported

cusi. --thouch1: and nono r ep orted trun p nvc:hot. in thottciht

Lundntuon- & Frankenburg 1790) v;qont that c.tinui

pn'cIiotc. :hoc - 1:; may be a mnn:er - for EPD. This unuid c:on+iY- i:

ti101i the findinq i:± [- c:rn nt.. A.,185) t.hnt. under 01:nv::v:, LID

Dn 1:1 eritn can dnv:ompennai:n and suffer rhorl: ]. 1 von c:n,cL - o±i

vvrJinrJc:}en, Znnnnj,r:i Lv.nc:hniiv.or , vcr:I::L:i:Ovv 1 r

c:nrvfir - mnd that in 1ddit.loir to Lncli:ltivvv features jiLt li1ciJi

LED from otrer non nonc. I i to disorders t h:-r eo E vo 1 :r:L:j 0 00

].flt.I3E1rsr,.I fonvoi..:; that cicinvI v this cj.nii - i - Hinr. Din;

found the f Ol 1 ow ncl i - eaturps to Do hoth vnc:i1c cvii

cii noijini rv?.Li;v3 of DPD

cognitive font rron. v: c:h as ocin -vvj. 'r n' criot :i. otfoirohin:

::ipu] rv:v-e 1 onl:.L:oer; rijoch as nolt cruti lotion

Ii<:FL1 JLJ. tJ. V LiLi Li do

vtnr:ooi:c;r;nj cr...

:tboncicirf /ejc:_ii f non!; orni hiln!j or

vi orion cli rc /nnt. 1:]. error - i:

trontrieni reer E00:i. One and

c:r;i_rt:nn ti - i; in:erc=nc- p D:i±i:cl!::],

Li noD en (10117)

of the in -fl Llenc:n

1 nO]. hts into the

the JU]rtiRpOoltlon

0. Chyoiologicodlv

dinDloc:t.ice.I :iorivoc:i ni. thnoiy, 10 :1 Irvitroti cc

of i eLi losophico 1 onient.otion providi ni

con000tLuviloE;tir -)n of ErEf) and deoc:nibes clF_ as

of an erot 1 onol 1 c- i nveJ i dot I nc environ mont end

predi opened vol nor ti ]. 1 ty to omot ono]

C)

or tr cr00 cii. t.h tb e core of the di aorder c:on ceptea). i sod aethe

physiOlOC10Ei predieposi.t1Oli Lj.ne -ta.fl b Wagner 1990) go or to

describE: the fol I oei np behavl ouriii patternS, orool sd a? orp

t hr ei I rU oct 1 c:al hol o'and our anped or cond a - b I c--soc I al It-: i ci

emotional vulnerability, or the inability to reqLil0.te eroti.eratL

the Lr100lidEktiflY 0Tidr0iEe re+err1rg to

th(,-. invalidation of a -F -I ec:tivo c:-:1i0ri.eriCS OCtiVE p0.001 -ut

referrOiflg to a 000,Sj.Ve helple:E.a approach to prcLlE"mS vecuo tLa

.ap.::00nuil,cO1iPi0t 00000n decepti'/0 in apps.E.00000E and

cool an. rD or :1 ci. -a-. or the cr:pE'r :i. erceo+ be i n p 1 n

, iiuinh1h1tcri orii-ino referring to the

tendency to: i.r:piit e::-:ner....lerce and erprE05].Or of

emo tional c eccon ire

It a0pe000 that 898 is not cirl',' idirntil].2,ble interms of

dictiro:ti3O hi cr-aoc:i al oha-octer...Ieticc Lnehcn 1837) but aloe

I n tarms o f a di ci: ........ct disorder when compared to S chl a oDOrefli a

(berieriron cl -bIb , 1978) ancisch.oOti901 Faoo.onal Ity Li aordce

(Geor pe I. t:c:l c::+ + • 1986). Turner 1989) r esponds to t h o

hypcthesis that 9911 or per i cnc:e thel r en', I r onment as emot I onal 1 a

I rival I iatirp and tond to inhibit pOi fl+Lii emotional rE'SPOriSEc

(Lin, ehan I Wagner, c;cn) adi:! i np to tb i a: that theso OitOt I onI

responseS may marl leek: themselves I. n the dramatic shi +ts in mood

I nvol vi i - p deprcassi on ,, an:: I ot.v • irritability, anqer outhLlrsts and

impulsive acts

An oddi t.iono]. +octor that pioyo o oicjni+i.cnnnt role in HI:D is

t:ha'i: of of -fc 1: , o]thouch thorn are moo',' di++crer - cns in

I. itoiotumo noncom r].nci the c:oricoptLtoi 'i. nation of the mn1o:i.onnhi:

botonn a-f-i-ect3Ve diccc::rcien cc and E?FD L:?kt c:Ionpite tJicc, tt;o

FL ioti(::roh:L2 is well established (;Lcok ci

1981).

The crc:nt nommor: a-f-f icoL dnccc:r I hod of the Lcc:cft:r 11. 1 rn n-'rcc.jr c:r:cc • i cc

dnDmnF:oiccr ( --'dn' - , hccadi FILLo & dco::c1:.o to: 1982)

1 J )r agree ic Ii ot. while t:.h a ci eon -oc of overlap 0 et eon-n

depression and BPD 10 c UliortEnt as on i rci c:otor of the saverity

of tcothnlL on: in RPD, the n:: oc::L rcoLc.rcc: of the cinpr n:occ.nni Onod

FD rccma.i. no cc question ehi oh has I po'L.nL implications tOr Li-n

EnistE?r':c:e of E:FD as o djcct.j:c:. cicc.c:d0: OF-cE eni 1. 00 0

cOciriti\E? n.pcccc -ii

F rr0 [.0:[i . E?iI 0000ErF:i nc:, tk

relationship bolT EJEEE2O BPD and ci cnr:r eon c oc 0000iF' . 21 ; ) 00002

that thorn has been a rrovccrriont t.c:?eordcc Wscribing dEL in

of a cctnonor ccnccccicct:ioJn with affective ,-i-F-E ,- :I- ,

nchizophmenic: disordenca

Inivontigotinci +anii] y hintccry stncdi.occ :crtu].oatncc- Lhc-ni_ the: E is

ci one asooc:i at ion of bED to of-f enti ,e di n.cndons stud

per-formed by Li ehoei tz & Li en (1981) reported that -f Om]. I

hi story data general J. y sugqestnd a 20--35/. rate of a-f +cti oB

ciiocjrdE'r'a 0ffioric f .LrOt degree roio'Livoo of those indiiciuo1c

c:IiocrIcJcoL by 888. 2inc:thc:r otod',' by Lororicjcr, Oldhorr & 1u1 Ic.

1982) suggests familial tronomi on i on of 888,, And 'iot or othor

study be So] cii + S Hi.) I ar ci (1983) al no f onn ci that 181 of t h onc:

di ocnoccocJ as 888 had inpr enni vc• f i rot. degree relatives.

Fr on the more c:nLccnni. c:ci point of view , the Dbhi- I I I-Fl

1987: :Lnc.L!_oiecc the a-iecti Ye dinorcftirc; on (2<1cc 1 and personalitn

c!:inc:rcec; on •),nn 1.[ This moc.t]d im(::].n that affective and

personality disorders .riYIt irrde(:End0ni:.. Farmer (: Ei00ri

[1r 'i 1991) hcccYccver • rhal I nrrpd this propoccition with rei<ic1 to

pervanalitj Cii ac:rinrn in cene - e:i. where prvJtnce

personality di <ccc Porn i n cio(:recccceci cicero 1 ec.c are c: j tc;ci as hoi nrc

and an ir_ch as

hi ei. cc (1975) and Akisk

symptamatology 10 1 <<<pale

niani+rc'cctcctior of inrimor'

c:cncEfntcal i octi or: of 8F8

cc sychopathol oo ,' accccoc:i ai:ed

i to. cceoar - ate existence.

accso:i ti on bet.-ieen SF-i) a

(-):cc I doordeicc,

1 (1981) • have propocced that 8:88

secondary or cc:nourcccnt

cci 1 en t i. en cii nor dccc cc. P1 thoco h thiii

1 ndc. caSes the ccnvccr it'; of Axis

with 8:88, it ci no c.eecrcc 5cc uridevmi no

here hocccecver • 00000 to be a st.rccnoccr

id cc-ffnctj en di <corder cc, more than other

Ni Sb rec]ard to 8:F'L in parti. ccl or • the studi en pnr+ormed by

8unernon S Eli loSt (1985), soqqost that roucihly 25--e5% of those

MM

ci I acinocced as LFI) experience concurrent. •a - -t OL.t i a U I ordar and

1065- of parccc:ns with nor -----p-c.yc!otic: urn polar depraoccit-'e c.)rdc:-., r - cc

riot the c:riteri. a. for HF-li). But ac:c:ordi ni to F-rch' 1984)

figures ncv ho aorronhat. In-fl cci: rad in that ttercr mccv be an UVRF

ccro-ccontati.cin of -f-I) in di-cprrcccsc. vo via-a injatircnLa

settings.

-vccccn t.hcs t.c:Icic: is c.c:nccir-tcrt. with the

pcc-chcana-..io-a-.1 t!cccc:r:-ctxc:al {-r-ai-rvrcrh as n1win

tha chroncoity of dv-aphc:v a svcc:torrn in HF:I as -cctprio-at. arc cc

car.cc:tEroc1i.Ca1 origin and vi.cca -a the rEccc:t 100 dE rccrrrcci an iIiccocrc

of HPD an pci ma'c affective cii -c.rc-cL:J. ut.c. rca - i . Lharanterological z

+n.t.corc cc'cpc:in-ccibln for de-foru.-o manocc!c-va ccv by POt.ltcnta to

dcccl ci th _4:.f0ç-f •-E di c-t.ur::artoecs

ii-::i.cciai ccv. -a] ., iih) arcii.cccs ichcct r t -f-fca.ci:.c.-cn disorders -can the

::rir-cr ---' problems in catic-Iic -ccith bach F3-II' and .a-Ffccct. ar--

dc.ac:rcler. (;iri.cck-cl (1985) cc-f ora to thi-:c HF-li as cc rnuh---a++ec:i -crc

ci I acrr ci or ch :i. a h may i: cc sup Er ± uicp ucccccccd an t no lifelonq C 00.0 SE

dccth-'rcicc or r:yc:1ot.hvnc;La He at.crtccccc that HFEi -ari a.+--cccal.;i-.icc-:

disorder can €ca;st concurronti' • hamad on hi a c;oncEptucl i nation

of the reciati on-cchip bet.ceon E)FD and cc++ecti ccccdisordaracTjr

4:1 nd npcc of his cctLrdy vhc. oh c.ucipoatad a I arpe deqrcc-e of ccat

comorbidity betjecrn HFD and cc++aci:ive disorder. 1 e. depression.

dysthyrnia, cyci othymi a and bipolar. Thi a study 0150 indicated

that on + oil ow--up • HF-U had a graatccr 01 sL for a-f + act var di aordai -

i:I - an t.haa a who h mci been di ago oEa?(i as hay 1 flC at her per mona]. i ti

cli sorrier a

( iTTi.) I cnc•r of thinhir'ci that c'a1i.hv(ric patients were

mi cdi •agr:isc-i as PITh and may usc: pond to ii tin rim tr.atmert'.. is

+o]. lac4ad by ccvi LL Jo±±E:e. :flr;ia, Mac Donali ci & KutcnEr

who ic.L;c.l that c- yr I otb'"m], .5 and no c:thsr tvpei of cimoc'srca i. en

oc::cr:rr sri more + r'ac:es:rt V ] ci IT.ii"i.) t.cmj' other crr.:'aonal ± t'y

ci 1 SC I'd ECS

[II. I iot 1985i ororcicced that tor E:FD. t.hs: chautii

1. i'fcc'aLc•].m Irds 1:a c - .a'iid 'fi.,..tct:_ial.,i.c:ns in iriarid ai":sr'cras for

c::vcloLhvnie the aralonged mood disturbances r'erilt.s in dca+] ci La

in csr'sorml 1t. L.avt.t_ ot. a],, 199h) tiUS atatma that it

cecil ci he .rgcic'ri that .mri, icti ri::t.:i. on bsh.aamn We two di. ac'rdccr a.

den en cia on ahethar....ha bob mci our ml or send di star bar; cm a crcm cc

+ i ccci:, This thor sf or's aucciec;t.cc and i cdi c:cctacc the di -if '. ccii ti cii

d'i.'imti rign'i.: ring hat:..mcen the mmcii +ast.mtion of EiF'D and CvCIOL.hVTi. ii

vj'i c ' +artr;er rIic:'rc' c.rdic.ccitacc the sicc'v'e"'i'c.' of ricc,c:hoir.atJ'c':1 Dclv in

DPD.

in the ii oht of the above • Ma Lii ashen ( 17Th) and Fops at. ci

1983) areas that cab), Is TED and m+ +Ectj 'a di. mordars cried at

c.oncLrrent lv, thi a does not necassac ii. y negate the Si-i stones of

TED as a di sti. not entit. Fops et. ml . . ( 1783) conc].udes that

ml thoLtgh -f i ndi. cci a large number of those ai th EiFD di ag] myl ng

IN

major depreosi em di sor - ders there are ol. so otJ ore who display

FiLre EFLi mi th

little DY no EYid enc::e of nc: or depromom en

di sccieis :us i - di coti. nC4 that it is mi ccl r'adi nq to thi nt: of the

borden moo as

iy:i rq on the boi'u:e of un''thinci but that E:Pb

c: en be C: On CE. 1 U Or no boiri:: ci distinct 0 t :i. LV.

tic: Hi •ciehcin also ljijfi 51 (Cii I itYi ti no betvjer:.r: E:Pi.

0. • c :t•ie cCi.sc:ruiers but eciucci; that depi-esoion 10 not the or]

v;ipt:cJ(1i but el uo a ciymptom corn:]. (00 He c005l dorec] it poee

for CJe(O0 -EC1Ofl to occ3mpero the bordmr 1010 syndrome withow

validity as diagnostic

1;: c:nntj. nun, bundorson H H] I cei: I: ( ].tc3H) propc-cco -ci h pot:he-o.i CC

that both BFD and •-• -ec:t 'or: Cii cionder are d epnosed mi. tb ei or

U symptoms on :i ni no; + --- many sourcEs. For ni C hoc - a-f + ti.

disorders or BED, i r:li'iidc...aie may boo;] n with a bi.oph\'ciiolooico].

'L1.C1E0P0tJi.itV that if:crrc.ciccee their ri-OF: of boinci psvoholoci:cilI

i.moaire3 Cr: early development.

the answer to the over]. -op and the di. sec oil en 1:100 betmeen the

two di moo dens • may be a corist ml I. at. ion of 1 nnate mc; ternol -{ actor

epheerinci oloro: or in comh::ineti.on to creete or contribute to t;:e

depress]. Ofi 1 n BED. Roomer oh per -for ned i n thi e, err-st ECLECICOSt CC

that those mi tb BED mci,- be di. -f f erenti ated from Lhoso mi oh

affective disorders alonci the +oi lam -mci 1 memo those mi th BED.

compared mi th dopreseives have been found to display qreater

seuai proiriec:'._tit.v and deviation (Gunderson & F•..oib 1978)

]. ritenric: and unstable i nt erprsona1 ral at i onch i po Mc L-i cshar

1987 L3ri d rson 9 Fold 1987) iiipu1ivi ty substance abuse and

SuOp ]. ci C:)uiciEss and par anci a ( Eir- dersc:n & F. ol b , 1978 Snyder cit.

Mc Iii ashar • 1987) Zariarinl (1987) noted in c_icnerol

that those with PFD did not respond to tri.cvc:i in antidepeacant

iicdicaFion Finally, Parr ].+iJb) lOLind that iLh1ECti5 with 9FF

retrOSP2CtiVely reported havi op c::oer I encod a diiprerssi on

sometime in their ii von cihi, oh 1 acted for mo" in than two

irdic cti rn that those with PhD iiOy o:.:pcir-'joi-'ce more

deprossiun than thocir ijI th othr:r di epnoce'n

in addition to the dif+er'er"ic::c.ri botieen PFD and affective

hirdorc indic:at.cci across a viide rarpE of behavioural

cli meri'c],on'a and phcrmacolocp.ca]. reapon'nivenEiE.s , the t',pEi o f

den ro'a'rsi on ci: or eon ad by thorna vii. t.h PhD I. a different from Lhc ...

with cf-f cctl'ye di.ciordcrrs S r'iriF:er ci:.. ci. (1+98) dicti.npnished

betvioon the typo of depression cc per I erc:ed by each of their + our

cub--types of border ]. mE ondrome the + i r'st ctnb'-- t .....or

pat i onto e: pci - : enc:e a host i 1. a • anc ry doni- coci on the accor - d si.nb--'

type of Fat . erttn. a ]. COOl 'V , hopel ens der.r eaci on ci ternat 1 r - ci with

anper that Can acted out. the th i. ud oLd - type shovied an

affectless depression and the fourth were depressed with or ose

defects in sd ± esteem. Mack (1968), hoviever, cr1 tici SOS the

method of this research and considers it to be both ci ustercici

and inc1usva.

Sn'deC et. ai an well an Kernberg ( 1-t7) naive

c:leenni ve - manochi ofi C: troi to in some pernorro, vi t.h OFD, Snyder

nt ol 1582) oclde that a ]n:e'ise of reo'cti. on by an

amb I v a. 1 cot. 1 'v p or ce .i von ob cv: i: 1 c•:odn: t. 0 •nnanr end a.nigr enni on

vihich in t!...rnod inviard by the border]. ire individual r - enuii:inc_ in

a mooc:ichist:i.c: rather than a PLI1 it. riddori depression. The, -

o no and d enpa I r Or Ci ho 1. :1 noon non , in noun I nuier': tori by a. nerno ui -

injustice and prc:tn:.t as the keynote of c:Ieor ennui on I

brirdrnolino orn:;onai,: tv oh. nnordei, dn.r1er el: . al . . 1581.;

±cuncl that ni...Li_icc:t.n with 85k and .1.vt.hvnnir; dmnunr'der

;:lic not differ on der:oennor'u on def-inad by the staod.ar'd ratinci

irc.aie'o. Thesycar: • hovirnvnr, be c::riti cmnueii 'f rc'nr: the r.;cnir'rL

'iev that on [hone oc;aleo , roni:ii.opii: nticviiatn are of control

mportnnco. the more poycho] opicual conntruc.to used in the

ncnl.eo +il to prEoo r '':U the 'unpinit: of the de1jreooi.on of the

L:ordcur1 inn clinooder, in that adepriate donu::nipto - n of bor'dnrJ. inn

do: nosior notably el ienatior fu.ti.eopai.r and the 00000 of

0mg t i neon :r &: o I 1: h or nub sen h or n.mi: d nun eiTih 'man], nod i r most on a on

dLmnder000 & Singer - (1975) denonibe the cioprnnun.ion in pp

marked by a. senne of {uti ii to and ioiL ion and an overjhoirn1nu

sense of dengai r - . Zoner- i ni OtT. al ( t - yL) r'eoor'tecl that SFD

were sicn1+icarit1v' more 11 kE:i\' to enhibit e++ectioe ±oatrtreo oh

chroni c/molar depression , c:hroni c anger and 1 annul i neon boredom

and/or empti roes more than control n with other Axis 11

di sorders . Other a-f-f ei:t joe + eatmor - es of chron i cal 1. v + ee,l inn'

I

helpless, horjo.L ass • North]. easness and CIL(i ii: were cvi dent ir1 as

much as k• , 7 of those di acinosed as EIFD , conpare:d to 96 • 4) of

pat 1 onto w i th other Pit 1 a 11 di. sordars From these resu]. to • I t

Noul. Ci seer apparent that the ciepr essi on that i s caper i errs ad by

those ,ji.t.h 13FF) ch.+ far - s not only in terms of the chronicity but

also in irtensi tv as wellas in c::ontent from those with other

hue. Ii disorders.

From the above di sc:ussion, it seems that ahi 10 the rI(LILVCii.

i:eteaendepreeoi on and FtFD i a osteb 1 lobed by aenet. i and

+anri I ci Lransm sei on (Lor'rincier at ] F 1998. CJ

i. iaou - d 11381) the Precise concojt.ua.i isat.ion remains rilusi so

and Lrrcieer rFni<iskai 1781 L.an±t .. et, ci. , iso- P0 - 0 at. al,

1983 Mn:: Illashen Ih8:3: it does, honevor, seem evident that

taker; toor:t.her all these mentioned factors so ntt 0 the i doe

that there i a.........act. i vs component and caper i enc:e i n FF1)

Furthermore, it seems that the depressi. on eaperi enced in FF1)

di -f 'F Sri in net tine compared to other depo cooi vno di sordars. i n that

depression en-perienced by FF1) is marked by a sense n 4 ft1 1 ity,

i sri I at i on and dasp ci r bLinder son h Si. n oar • 11375 and Snyder at

ci 1982) chronic coDer, F 1 onci Incas, boredom • hi cii essne-rie.

hcJpti. esarress and guilt Fr i. n her at a 1 • 198 i--.errberc , 1967;

Li nehen t WagrieF , iPStIb Zaner 1 ni at. ci - , 1990 A.t so i nd Lrded

are gross defects in -sal + esteem (Gr:i. nker at. ci , 198) and

masochism Kernberg, 177).

55

1..3 ETIOLOGY OF THE bORDERLINE PERSONALITY DISORDER

(-ccordi.nci to (3underoor (, Kolb (:1778) it is only sinc:e 8PD has

beciun to be estabi :ieheci as a -id id c:IiacC nc:;'etic Ecnt.it'/tht

eiric.:ci vionl-.: reciardinci the etiolt ociy of 8-1) has been

unc1erta::er bei'ore thin • the ctoirrnicnt ctiolcciic:n,]

core lera(iio .....jorcn epccui.aticns from riryrrhoencr] ytic ejriter-e

cerived +I • C31i •r reconetrucL:iore from the app]. ic.et.ior: of

inn' choanci '.rtic: develoi:mental theories or from thorep-/ (flernberLc

I r 7CC , -- ... .

.. C i -...........1 . I. -

i7/J i1.-E LJr I?IC) ;I.O - r, I L!L.. IItI \

pnc'c:hodynairc theorice have been chic]. irnnc4eci in 1 iterature b'

an nun rcr I ter cc proposing neur obeh a-i i. our ci ( ....ay I or & 7 e: err i uP

1991) , etr',nct.circci facci].v theoriac (M nuohir • 1971) and +cmilc

d'namic theonice (Mi lion

In add i t i or- • rec ecnt receanch done by F-1eriran C Ferry I van dcc

Kol P. 1587 Zanarini. , Eccndeneor • Mcci no, Sc:hc-certe & Fcc ....

-- -H....-rlr .... ' ,L7I/) ,LiIl ,I 171)

theor ice have bequn to point to ther ole ol ccii idhood LraLAIna in

the et i 01 •i• of PEP. P1nothen noteorth-' theory and one torini rr

a core component of thi s st.udy i cc the thrcu ri en: of F unner 1997

Young (1987) and Freeman ( 1990) -jh ccl -- point, to the role of ec.r'].

mci adapti 'ic cocini tive schemas in PEP and nocini ti ye content in

P PD.

56

1.3.1. FAMILY DYNAMICS AND FAMILY EXPERIENCES THEORY

There h as h een var i nec r e?Cj oh and 1: henri. es r5LWr ound i rip the

+ cmi 1 y iç:er i ences Q4: those chi 1 dreri who 1 eter de'el op EiFD

Un -fortunately it appears in 1 iterature that there is no

c:oneersL'.s emonq c:iinicianc as to the Cpec].+ic cyedic

c:oncte] lations ebic:h produce a. borden Inc outcome with:i ii

-1 ami I ics. she :rodu.cn 898 s. The robber nt the borderline

patient is etrsn described as be:inc disturbed on borderline

hEimSeJ. . Her 1 nterect. ore with the eati cot are shsna.cteri sed by

control and c'ven --e rise]. yeini:•?nt or on the other prod • as rEiect.l've

and passive. Fathers of her drinl i nec 1 Ln8 the chc id •Ciey troT

the cmh i no: 1 c tic to i be mother or con ver sri 1 v • the -f ether I is

host.i 1e, •ecicinescni ye and relecti. .'e (So]. o f i.: Ii 11 srd • 1982)

Hol herq (9182) states that the most common paEt.enn i. - th.st of

reiect o no-f a son by the -f ether • or a daughter by her mcither.

F -- .sn: t:, Ho+ f man (1 982) stusi v corresponds ei th cli ri cal

observations that the BED for ccc I ntenee yet +rustratinol

relationships with their f-ethers and I citer other men in that

they ± ound th at border I I nec ciener ci I. y r ememberec) their + ather

as cii phI: 1 y more affectionate than their mothers but

c.1 pni fi cant.1 y more absent

P -F cmi 1' d','narrii c theory attr I butes border 1 ire devel opnient Lo

structure of rolES ccci pned to di-f -f eront family members viithi n

the fain ly group. Solo-f-f b Mi 1 1vatrd (1983) describe spi ittirig

EM

and projecti. ye j dent.. t j. cation as defenses of the + arri 1 y ciroup

h]. oh ccci Pr 'qood and had' object roles to +ami 1 y members,

They note that the 1- 581 1 1 50 of border- i 1 nor; act upon sharer;

orconcc: i eec assumpti on that independence or sOparat on - ron the

1 aml 1/ ret bets. reioct ens and hovel u.at.ior of the f 5811. i

sal eec. c:3 r that dependent demands represent an ovrrrihe1 mi np and

three.teninq bL.irdrrn on the i-ar1 lv, The parents in these feni. liSa.

thus re--once. 1-hci r ovr de,'ei c:pmentsl. conflicO tLO_

chi1dron

Mi nuc hi it 5 (1974) 1. hour y of at rue tur a 1 family

emph cci ccc concepts i. I K o :1. n t.erq moor at. i on a]. tjcund r i as nd

parental coal i ti on to conc:ei:::tuei icr: these di st.u.rbenc: cc i n the

fami lv structures and relationships. In erect ions in +acni 1. ice

are ru] ed by nature oft he bounder i es hct'jeen subsystems in the

-f ami 1'. Heal thy and flexible struc, Lures ci br'; for cdi ustment

over t i me • whereas r I ci i d bounder i cc. or enmeshed bounder i cc do

not:. This could result in the devel opine of patho]. oi Ca.I

behaviour rihi ch in i tad + is a ref I set: ion of ehat 1s heppani on

in the family system,

Researchers have noted the importance of the relationships

bet'een parents and the BF'D as ch i 1 dren 6underson , Kern 1

Enqiund, 1980), the role of over--nvolved or protectie mothers.

(8olo Nil 1jard, 1983) the role of t he + ethers rFrar1-: t

Raris 1981) and the +ormatiori of Fr - ustr'atinp relationships 0+

ci

thone with E'Ei with their + at:horn on well on nccj 1 or: t. of SF1) as

c:hi ldrcrrt (Frcrd: & Hoff mer • 198)

Sr i n her • 9t8) f ocind that 17 17. of his h or ci Ci line p nt i c:rt cc camt

+ roil 1- cmi 1 1 ccc that were chntrcc:tc:r i nod on not Pci. rip cc (nurLici. 1

protoc:tive uni t. He cccl led tieno the type 1 un it hic:h:

describen onrentcl relntti.on'cshlp as dinc:ordccnt. , with chroni

cJ'cc't 000+1 ict • Cc hr i.qht reioct; on or oonf Ii 1: over pn.r - rrnthoc.rl

The rrc:ther 'C cal oti oncchip with the pcahiert is ii.::.rLl or.

prableiiictic: v1!:I; rcIoinccnl:].v necrnti nc rci-+ec:t. [3nirker

ccl no denc:ri.hen cc ccac:crid or type 2 pattc:rn of cc ccmotheninc) , acer

protect.i 'cc and nt.oti c +cciiii lv vch;c:h roniol:.n the narecil pr or:ecn 00

dinintepretirn ;jit.h time. Mothern in thrine ty:o 2 ±rrmnliccn eon

denc:ri.hocl as over 1 c devoted • intr - L1s]. no and jr-n/ui cod ci third a'

type I ptterr in chccrectenined by denlici of probiemn.

801 1 Ml]. 1 cord (1981) emph ccci on ntrunp 1 ',•' the t Lhn

r athol api cc]. p ott eon of over - i 0 /01 ned mat. her cc. on ci urd Er .... 1 nv a] nod

1 atbero in the dRv=] opTion1: of SF'S They .connu.mo that the

rec4ati ye ccin+i 10. toe]. tore of the ml ot;. onnh pcc ren.Lt.I On from thc

fether 'C ceol.: I onci di otonco or •ichrcenc:o and the mother

ritruni ye and control 1. 1 op presor:c e Si ncc:cd and chicoc; 10 t.trv

Tori h] rd at.i onshi p as cci 1 as hi ph ±roquencv of neparet:i Cii and

di vor- ce all contri but.e cci pna -f I contly to the devel opment of SF1.)

(Soloff & Milicard, 1981).

3 p

1 eorv that cribstant i ates this is that of M]. I ion (1985) who

vi es the border], ins as havi nq three major cli ri cal

mori footati ons of parental over or LlndE:r i ovol •iement The three

meni -f ectati ono are the border ii ne-dependent • the border]. I re

hi. ctr ionic and the Oorderi 1 nepasci ve--aqqr OsSi vs var ati crc.

The borden i ne-dependent. ear i etl on of the EPE appears to be

mcci dod by parental over protect. ion which paves the path f or

laJ:er reiectic:n by those on vhom this individual has come to

rely OflS.

The bor dccl I ne-hi stni ciii c appears to be moul de!:i by inconsistent

ani.ahlnr sinfoncement problems chich iO-5VO the individual

con i nuc]. lv pe -- + cciii ncj 1 r: or dec to sec:L.ir e support , attert i on and

nuturarce. The jassi ve - apcir - essive earl ation appears to he

shaped throucih envi rcnmsntal as NEl I as parental i ncorsistsncy

Ihi s leads to M lion a arpumenI: that the BFD is self

perpetuated , by crears of the positi veil y rein+orclnp re] ease c -f-

inner tension in the -form of hostile cutb.irmts and the

utilisatior of sei+---de+eatiro copinq strateqios.

But not all cllriclans adopt this point of viem C3cnderscn

ferr t Encilund 1980) study of -fami i lee of BED chal lencies Eolo-i-

Millards 1983) theor. They looked particularly at

independently ohtai nod fami lv i ntervz evs of hospi tall sod

patients with BED and found that the parents of BED patient'S

were more af4ecti vol y ± nvol ied with each other than -i th the

child and the FF'U pati ent tended to be the scapepoat of the

+ ami lv. Their study thus ppses a hypothesi a reqard np negi eat

rather than over grotect.i veness,

A study done by Frank & Par is 181 of parental pr .octi ces i. n

childhood supports Gunderson Kerr & Englund a ( 198d) nosiest

theory, The study compared normal control a a group si th

neurosi s--personal i tv disorders and }3PD. Mothers ± n <a) I three

die nost.ic groups were not remembered to have

at gri + I cant]. V in the:L r responses of appr oval, hi S storest or

art t ± ci am. In c:ontrost -f ethers of PPD pat.i ents were ra:membcrr as

as ha<i no been si pr- i -ft cart I y lea-s .apprcivi nc and more

disinterested than fathers of the other two groups, The

±athsrs decreased approval and increased disinterest apol ied

more at uni -ft centl y to depsrdent rather than ± ndependent.

bcaha'vi our i n subjects. It SeEITS thus that the recci I ecti on oi

the -father a- i nape by the BED is one of neal oct. FraiL Ii

Hoffman ( 1986) did a similar study and found further suppor L -F or

the nepi eat hypothesis. They, hoaever, +oc.knd that both parents

were rememberer] as more neqi ect-fu]. . I r- eddi t icr- • patients cat th

BFD remembered their -fathers as more a-f-f-ecti onate than thai r

mothers and reported that thei r -f ethers were 51 gn i + i cani: ]. y more

absent. Frank t Hof+rnar (1986) +ind in addition to the idea

that the family experiences of BED may be cheracteri sad by

emotional neglect, that BED were siqni-Ficantly more sensitive to

non-verbal communication, c'jhich m - i be equated to the concept of

41

borderline ernnathv than non--' border Ii. nec

in 11 ciht of the above di scu.esi on, it seems that +actor a lie

-F ami 1 V structures , rd at i. o nob I 'o. and ad. 'aoe::- her- i orcec i n the

family may be eti ol. ocii call, in EFu a> pe r i cocos of extreme

emotional its and invalidation (Linehan 1987) as vel I as

contributory to t-aunderstandnc of the ( :,f ]L : Ilt, that hPL)

e'per'ier'\ce in interpersonal relatonehpe l

1.3.2. SOCIO—CULTURAL TRENDS

Mill or- 1987) :::ropcised the vi ox that the contemporary epi derni

of BED can beet be attributed to t.'..'io broad socio-cultu.r al trends

in Nest err I i -Fe • narnel v: the ecrerqenc:e n-fee c I al customs that

aorsen rather than improve early pia'ent.---chi id relationships and

aec:ond , the di ml ni shed pcver of -former].' separative social

customs incirdino crnsol idatino institutions and nJrtLrr1ro

sxtrropates. Nil ion (1987) poes on to des.c:rihe certoir" social

c:hanes as cor-idLIci -.-'a to the formati Ofl of psvch cdi +-f uc-:.i on and

division evidenced in BPD as mi rrc:red soci al di seer dance

sch i scat Ic -f arni ly structures the r c--cc erpe'rce of soc i al anomi e

ri h listi, c resol utions and the ]. 0cc of compel ii ic)

It could thus be conc:1 udod that the increase of the prc'ial C[iCd

of BF'D cool rJ be as a result of an inner resonance of those who

are vulnerable to BED, due to early experiences and b iol opi cal

WM

vuinErahi 1 it:ien , w ith broader socio:ult.ur'a]. tranda Mi ]. Ion,

i'287)

13.3. CHILDHOOD TRUM

I t appear a + r arc I it or a.t or a that i. at ar eat. 1 a ch. I dhood EE;< LOl.

abuon an an catjcc].oic:al factor in EcFD has aai arc an a cancer

I t:i.ci. ni. era. + i a an t that th a I one tar cr c: Or CEcjuE:t LEcCc of an 1 1 cftocci

olaua.labuana are i.dont.i.cal to the D8M-I1 1-H c:niter i.e for

t hat ch i 1 cit cod nea aol aI:i ucla cii ova a c: art r ni c a I a I a t ha at. i ol cm a

of JIcFC) (Z.ararini • Sundavtaon Marina tichn.mrc - 't:.m & Fran::ancierci

1989; bheorar , c:aLer . = cIt (Itc.civt.marc 1990) . Pcmrthncrore • imLuoc. CiC

that have b een done in reard to thi. a thaorv have o+ar ad

srcast i va cvi. dance that hi stories of ch 11 dhocmd atone may ha:

espec ial ly common i n SF0 pai:. 1 anta (Herman • hacraaa1 & Trocki ~

Har man Perry & van den Hal F • Shear , or Fat. Ot cc

L.ILcIRVi: man I 9ra ) Commona I i i En h et:cieen the c -f f ç..l: of ah I ] dhcoci

naicual ahune and arfl are noted by Harmon at. ..) . 1986a 10

ctudv of the I ann tenon of-f ec:ts of i. i ..costucca abase 1 fl

childhood, reportinq that these patients -frequent.]. 1 cOm[ilOifllld

ichniut chroni j a deressi on orhecion ia and I nicer deadness and may

be g iven, ocriodica]. ly, to soak relief in druen and alcohol

atone • ad + rrutc. lotion and aaic].de attemp Ls

In support of this a study performed by Shearer at. al. , 199))

reporto that those with 8F0 and pati ants Ni th hi atari as of

ci ldhood sexual ajr'cn both d:ispiayd impulsivity, nni.+

dostruc::tive behav] our , cubcta.nc:e ObuOE, identity diotorbancon

and chron i. c dysphoria. 'Iheco commonalities Lj'ni - i i:.honc with

PhD and t hone vho hayn been a I c:ti ns of oh i. 1 dhnod no:--. LIal acano

have ccntrloL.itE-?d totho :cr'itcnt in the :ocaibi I it.; of

being an etiolc:oic.al li.n-:.

Zarai- irii cc ci:. cl. 19E:7' eLud' to :naccc t1çat.c the pc-::n:bJ.n

I. inL: bntieccr PhD and chi 1d!socdc:o:-:c.ai. abc,rne nLrpper l.a t:a LLF:-cc'v

and r spur La -f :. ndinq that ao'.nrEc and r cIpcct.it.1OLLIO ab;:anti

reported in Lb usa cuort.er',c of tI-cc a.Lk:h EIPD. LJha.i: 051

oartic:itnrI',' ccacciucr was vcrb.al shuns, defined as dev.aisatia-a and

hi-acid no sctatcmccntn. hilt of the suciciplo resortod a c:hiidr- oud

iaL.c:ry of phv-ni cal ccL:iucce ncc:-:c.cal -ccbucccs; or both Zarcaciri a-I..

cccl - 1981) ncr - cl udc:j that the more acibti ccc form-a of ccmc:t: sinai

and phvni ccl neal nct_ are common but not

ci crimi.n.sincc fcsi:.u.rcc-cc of the h:ccctcrsoa. DL throna -i hi 99)1:.

L..imi.tnd ccupuoc-t. for the ro].c-c of 1 oncc proloncind ar-cp.ccc'ation -four:

c.cnotahsiric -acc coins ccccicmon LII: not necnacar'livdlaCaicniflStc '51

uggests I_Fiat many of thcccce ci th E.I9D have 2XPeriPnCed a.

comb i rat i sin of -cci:000 , non 1 001:. and I one at th abu.-cccc hot nt Most

diecr].iT:iriative of the PhD.

PEP was conpar ed sci tI-- ci onel v related di nordern- n.ch

schi zotvpat , anti --- son -cii and hi. polar affective di corder in a

ctudy by Herman Ferry h van der Kol k 1989) and stronci

4 Li.

•oocit.ior-i was found botNoon the diagnosis of EF1; and .o history

of obuoo in childhood. The resul to t.hr:y obtoi nod i ndi coto that

o I n i + I coot]. v more bondor 1 10 oubir:t.r, 00 much an 81

h:.otorieo of such'trauma, I nc::] udinci physical obuc id! • sexual

•obuce and ni tnoccsi. nc con ,i. OLIO doiiieti c: 11 o]. Enc:o

This onerro to OLt::port. +urt:Jc::r bother phyolcol and 00;U.0J

as being i.4t.L ::]. ::n:;i, c::oi in +4-ID.

Horma" el. :1] .. . TI) also ri. •oc an i ndination CT the

C epoc t.ccn::o of the d21.nl ;:. 4110; otoco in experience 0 -

.iLm:Or, 57i . of Licj . ... dr Ii. flElLC exrorienced abuse in early childhowd

of ••• Cj'.10 ri ED PhD ci no

(fl 1 i contl v uc:.te oLuor in I CItE: 1• • (:

other ......ccu;:rcc on -ol I. as ;rr u Evilor; of hoocuma bnci:L nni no

in .chi i.dhccd ret:rot.c:d over Io;c:nr periods.f: tinno, reculriro

in 1] c;Lcr t:oh.nJ t:r our.3. r;c:c:rclr. It oc:;:ccnrs t,htt. rhorn Ic

C Ci or cc ETC-I. t c:. whathur thy hist oriesh ad been exaggerated Cl I:

on the recr iLi 1. hoc:c:f thocco +;-ctiro ocuici 0.00_C _cnt

irtE?ritvci+ rr:c:t.ic:nol ]1'L r:.:[E.r ic:::c:c:ci by tLE (Herman et. 0].

h otu:iv by p....ye::r • Niel SC;ri 'H. It I or 0 4 - (1987) ott 111 ci

oovchi .ntini. c in --pot. j onto • 1 OLIOCi a. m.cc:h hi cihncr prc:pert.lon of PEE

di 01000TC1 &fl0flcl the sexually obusod group than O14OHCI the uNDo':

Axis nJ psychiatric -ji 1:c-) r - dclo- o In rj;- j j- -j- 000,0: oc ..I cJ. do].

cjmptomn; were evi dent i n the son no ii y abuced proup and there was

VJ

cc c:or C ccl cci: i on bet. jicer severity of cid rc 1. 1:: p cc. yc:h i ict ri c: ccvmpt 11cc ccrc Ci

c::Iti J. dhoccci phymical and ccECLal ccL:ucccc.

in c;ccccnt of t.hicc. [Jpata Si IL: Gc:odr:L oh • Lohc , Llcccctccrnthi

cc:cnir:cccc of aboco and rq}.ec:t cr

with pccach]aLr1:: i r--p.ccticcnt.cc from both sexes nbc:

as hcccci. rc EifI) and t.Lc:cccc as h ::Vi nc in 1 cc CiE: cccccci '-c-: EcF I

{cc:c:ic: wi th 8 PD reported significantly higher c.ccccccc cci

sexual cc (7 Si 7 than dccprccc.cccd jcct: ntcc(:7b7

•ccbuccccc ccOEc freQuant hn i::c:t.h n:cc ::cc:jc::cc. while .i:rCiC.cil r:ccc1cccc1:

cccicc :s-:Icc..tccccicc :Lrv cccc.cccrct. in potS cicc:L:pcc. Si:ci- ificccntH cc-i tHic

maxually •ct -cccc J::IF-i.) CaCiLip, ciccccc:rILccd baiccu abL.ccccc: Si

diffeFent pccc::jc1. c: ccoricc t I me in thcci r chi I dhood • repccr Li ill abuse

by S cci: m Towily me:iiIcer cc an Ci n c:n ccci at I vec cc Sbb of icc cc SF57 ci

e:-:uaic..ccccc also cccDoctcci IcLitipiEc dbLccCE!

75cr cc -cccccmc: 1:0 be a ccLronci J.rd:Lc:cc.tc or that c.ic: I C:

cc.:-: ::ca c ccncccc: of thocco who I .ccctccr dcc-ceci op EiPD occuc at -a

onicu ac:icc (1--5cci-- iccn at. M., i-?Sn) - Ncitcccb]. ccc too i. cc that the

is cccroet.rated by fami dcc icincFcecrc; , ccccurcc at cc, oroatar +rc'cjuenc:v

cc:n d is :cc:c:omp an I 'ccci mor ccc ni I: on by physical ccLc LiEO? or vi. cci cccl cs cc 1.: c ciii

ni th Lhocco who develop othccr piccro.orccl i. ty diccorderccc (Ecryccci ct

ccl. , i9S7

Li rehan 'cc (Li nehan 55 Waqner, , 1570) theory related to Oh]. 1. dhood

trauma , nh 1 ch is in support: of the above , is the f Offli 01 ct--

4 d

behavi our - al met:le 1 of IPD. Li c- oh an & Wagner (1990) note Lh a t:.

with EFI) thers is of ten a history of one or more losses at.

early aqe (cci sei-::ual abu.se death of a parent or sib]. ic- ri)

Being unable to fol crats thri r Err tr erile Eririot. rifle]. rirsponso tc

I ceo borden ineri, insteai: of Norkins throuph their cirotiora].

erper i cross t end to i. nhi. bit i:.r'e ci-ipro eel ro of any rimc:t.r. c;:nal

ion, resulting in erpericinc:inci IlLrmbnress, cmpirierre and

ti. miii. doper cone] I sat. ion.

is ic:ilciet.eci tJ€rc. ].1ii 2XPEr1 encess ole.rreileie

but esrio:il:ed with interpersonal ni]n. Nrit

5:552551 flO ii 00501 hive -fiTESJOrk bvchi oh to underr:ani

sE:rucl :i.tv. the ch:L id experienc:ei; somethinc her/ohs cannot

tol crete. In order to survi ye. the chi]. ci iSOlates these

reactions in his/her memory • so that er/she don; not:r cal 1 y have

to be 5v]0rB of it (Linehan b Wagner, 1990) Thee the child

c ann ot v.al I date that ch I ch he/she 5::; er i cnc:es and seer 05-11. t

hci nci sub iccted to c:onti noose inval i dot] OCI er:rperi ens cc the

c:h iii must di. chc:tomi cc h etecen t. h ci r roe per emcee and thee

i nt.ereersoneri cocir]. ti ens,

This leads. to 1 imitino. them, resuit.inq in pOSSiblE poor social.

interactions and ski lb (Li neha.n 198 7) . They necer learn to

communicate their true inner erperi er:ces nor 1 earn to trust

others. In this manner, childhood or early scrotal trauma

limits an ndavidu1 'c ability to adapt to stuatione, thus

,1

rredi sposi. nq an :L ndi vi dual. to devol opi. nc hPD and bei nd hi phi v

restricted in their obi li.ty to satisfy their needs in

i tierpel - sonal r el. oti. onshi ps.

It thor; appears a:parer'it. from ] i. teiature that chi 1. d aPe -SE

or - ersJ, and c:h:ild ;-:e::-:.u.aI abuse c:c)nstlt!.JtEs a crcai et.i.oi.ociz,:si

factor in 8Ff). As i.ndic.aed, empir].col studies support

Lian E (1987), n'r 198 7 .-5rçl Taylor & Zaj:trn;.i.i f: s K

hypotnesis t.KaL. EFEs, having been abLisEd at a :/OLtflC.] aCE

(..CrflrThr as :EdLLJtO ;.inIentinp ci.ves and are rr:itrsmsIv

sensitive to ELIOt c:ro. st.i. mel i iESO cruel ± cross al sc;

contribute to ear >..- çiJ r1j -ye schymata which could have an

narrie and sapni ficont. :Lmpac:t on the pFL that cornitlia

sE;a;;:r-rciKv ioc.iid co-sell.: (itaIl.ia., 1991)

1.3.4. THE NELIRO BIOLOGICAL HYPOTHESIS

From I rt.nraturn it .apor-:.ars that there is relative ISv

support for oroari c f so tar a asses i. abed with FED K K3:]. a ±

Mi 1] LJ.- ......j , I :F3:. I But deep 1. t a th i s , there have been recer S

dsvaIopiiIer!ts in the neuroblological hypol:heairr of v:hich than'cst

credible will be discussed.

HartocolIsb Murray (1978) view the borderline personslit

style as a possible davel opmental adapti on to any chi 1 dhoocl

brain dysfunction Vhich impairs the chi id s intecirative

4 0

i nh I hi tory c:aac:i ties TI-iey trace the or i i n of C: 1 as'ai.

bc:rderl me s''riTptorns of be frustration t0l0rar'ces; inn ].oi -c:i.tv.

iab:L be a±fect temper tantrums, de±ee:t.ive s ense of identity, lcne

oc1± esteem and manipulative bc•:haviouc to. the cliator tirc1

inf:Luenc:e of minimal brain dys-furiction on the chi id a perception

ri-f and interaction i-'jith its internal and ertnrnai enrldr; of

o;-;prmi-i.rmnce The LacJ:: of inhibitory c:ontroi and over attention

coqitition - .f:f4 and I rIc:ulnme pro-foc.indlv af±nicf the cli

reiatonahmpo with its iutothrnr and it-n-; inLerrier -aorai worlds-

resulting i. n border line ec:o develcmpmenL , drm+aram\-cm ccLr

and behevi cur ( Hartcco]. ii. -' burr-cay, 1979)

dridrulortis et. al., ( cp:-) ±ocir--id a hiscrv of brain trauma,

api iapov or encephcmi iti. in in I 17 of throne with PhD, and a tmicit;crv

of a; nima. brain dvccfurctic.n or leornmnq disabilitisa in 277

thoina cli aiinosed with 8Db> Sobo-ffh 911 leach ( I98.i) • hceoaei-

c: ci t i ci so thesri c puree and state that hL re I at i vel a hi oh

parcantapenc can he or; counted + or by the -í act that the soap I a va-c

draer from a pci -rote institution for neLcol on cal di nncrdnnrs.

To a c:ertai 0 e; -;tont • PD i akal (1991 ) apreao but states t.hna I. the

=-mptome of PhI) resemble non specific features- of mary ni. ] Ci

orcior 1: con -i i t i or- s ehi oh means that some pat i ants in? tIi ii 01 (nO 1

brain dysfunction and att.enti. on do-f i cit disorder may meet the

cr1 ten a for BED. As a result of this overlap then it has been

proposed that there is a relati onshi p beteeen impai rod central

49

nerv 002 EVOt Oil: f unot i oni nq :1 n c:h ii dhood and adul t FLP))

dEvol opmEnt.

Thrn i a hovea • indication : n Ii t.nratLra that the

nourobj.oJ.oica1 hvflot.h:ai a has been c1Lorstionnci. Solof-f

Mi I I oar ci ( 1 9I3 ), I r a nLu.ci y oheu a. a narrip 1 2 was cia aon f: CT a

fErinaa], hciaji1:.ai c:c:mpar lId BPD patients with achizcjljhron Ira and

c:!eproaaari pat. i. anta, and ropc:rtad that doap: tn iror

i rod donc:o of c:c:m:i j catncna in rilacnancv and a sraçoent:

prematurity or 1 oo birth oeiclht , BED natianta sh000c no incroanc:

in inc:icieroo of r:ac:rocd:./oIcTj022rtal deticito:.

i Cinc.t.1r ( 198t) o:an':Lrod the rc-:1at.iorni1p of BPD

to ntioc:taaI or panic ccridjt,iona by eoamininp the C1T rr:ani of

E.FJ) Out ±OL1Cj no obrc:rinollt.IEn in Ph BFD :at.iort.s.

Hi tharab Eodpeat I 'YE, it thun 22225 that orpan I c: ± octal a have not

been + ouno t. a be con a 1 st an 1: 1. a annoc: I at ad o I t h BFD.

Lomp 1 0:: p.ai - i 1 al 10]. ;: or on 02101? hooeoer, -f oLlfld to be 1k aci a- -br 1:

var i oh 1 e asnoci atad oi tb hi ator I on of oh 1 1 dhood sEsuo1 ab'..AaE:

(Shearer at. al, • 1990) Bhear- ei- of. al , ( . -/J) ncjten that

repotlt1vo trauma c:ould k].ndio Iimhic: system alteratic:n'O,

eventual 1. v moni + eat: 1 nci 1 0 Otdui thood 02 50112 comb i riot ion of

Comp 1 E;< part 101 sea. sure di sordorc: and chrori C post tr0Ltmati C

stress disorder. fi thOIJiTh not related direct 1 v to BFD, this

5

OtUdV 3. rid i c:al:eo an i n ter or ti. or bet*ien ch i I dhood 0E;• on. I t.r OLLII1CD

and organ . C: or neurol op i cal mani. f estat 1 ons • and roul ci have

app 1 i c:al: ion to EJFD q i von the c> 'Lenci. e research not i np so:: LOTJ.

abusE i fl the eti ci opy of EFD.

Li rie'ari & Wagner(1 990 ) propose ..,. t.heor ', of rh ici o] on : cci

vuinor'abii:i.tv in the otiology of HF-U and Ljii±'Ui.ff

of''Dya].oioc''i,cal L::asis of emotiot" r'cciuition , reporting that'

Lordcr'i, inns may have a low t.rLsloiri for activation of iruibic:.

stri.ic:turss which 15 the br"ai n syetnm associated othcr'otionni

requ.1 at i on

Feciardirio this, Furricr L' Zapar"nuik(1991) have proposed the

c:::Lster'Ice of hcciohterod 1. inhic activation in PEP, but erpiain

this i ncreased acti anti on i r terms of the pr'eonnce of coo,n'i ti an

schema mhi ch may create I oer i:hreshoi. dv. for ii. ml: i c acti vat ion

021 r conceptual i sat i on of the ot i ci. ocy of REP i rc I odes thus a

c:ompi cc:: interact i on of neLtrobiol og i cal and c:ogni Live 'factors

1.35. THE COGNITIVE SPECIFICITY THEORY

Those working w i th emot.i oral problems such as deprov.sD. or: and

an:< i et.y have over the years begun l:oqive more recogni ti on LCD

the role of emotional dys+unctior in c:oqr''i, t.ive processes. Some

clinicians like Rec:k (19) attribute a casual role to c:oqritivcc

variables in the onset of depression, yet others, like Ingram

daith 1h4) maintain that cognitive variriblari play an

i. nportant ccii E in perpetuati nci and exacerbating emotional

diat.r - er-ui once this amct;Lorial dia.Lrriss has been started,

Eeck (197) pos:ul.atca that in dereaaon ±ndividuriin urui

naciat: 1 '.ri coor i t. 1 ye tic i ada Nh ch .:.a'.sa 1.:hem to ace t.tamae]. cc

thai. r Erv. i - onmrirt. and their future r - epat. . 1/01 y Eec: :

(fl thi a conceW-

of thea opnitivc• trrid. dricri:: 1967) and hecJ: ric:c.000ta

toc: for c:opni Li.vri distor- ti,or in depressed ind:LaioL:ala in terms

r cirat.r uc: t. of a. ac: hrim. This schEorri r cpu crarir t a a

ct.uuc:tLY - rii c.c:naticlL ].ri.i.c:nu! n egative attitudes t.ciaacIs the ccli-

the cor I d and the future. it carves as a -fr - ameaior k ± cr the

Perception and evaivati.or -i of new inFor - mati.on.

Beck 167) atritcs that the individual ricqul IriS nepriti. -ac

scneaata dur flCj c:hc I dhood or ado]. Ericerce , thouc - the loss of a

parent or an unrel anti. nq aucceasi. on of trapedi. cc, throLiph -riL...c: 15±

reJectilon of peels or the c:riticirim of aicini-ficrint others.

Thriac neciat.ivri coqnitior - s ahi.c:h eare previously dormant -arc-

cu: ti arited b -a a at r casor aih C: h r cc &:J. I a pr cv 1 DLIII fl2 at.. a -:0

ri;-I pen encea , 1 hi a- can reaul ti. in an eutremel y naqative af -fcc::t

utoiTai:i c: thoughts ch 1 ct are refer - red to by BricI<:(196 7) as

uni qua or personal emoti onal responsas of the indiv dual Nhi cci

have been determi ned in the pci vata mean i np-s of the indiVidual

C:

and reveal. ed i n consci oue verbal and i ma.cery reports,

reqarded as spec if i-c, distinct , autonomous and occurr - 1 nq as 1 f

by re±lea or unsol icted by the individual E - ncri.erclnq them,,

These aut.oirati C: thoiJc]hts are al so thematic , are often shared by

persons with the eare omot i oral di corder and are i ni i cal: i ci F

the preser:cC of depre-asi Vs. pc-ychopat.ho]. oc FIend-si. ] t Ho]. 1 on

1990).

An approach Vji1 oh cor'it.ri butc:s to the c:ocni t i S.' a cnac:c F i a it -

hpothcsa is the information processing oporoach of fncioor:

0984). Ingram 1784) describes c:ugnitive constructs ca:c:h

the natsuad: theory and the deljtt-oT -- pr000scinq arj::r:s(:h.

I ngrarc - c ' 1 C)4 icteor 1< theory proposes that memor ic-a connected

via us :ciuut.ive ]. ::nkaqos, once act! \'al:eci beyond a certain

threshold antert he individual o. conscious -c*ierc-cnees in the

•-•a of coonitione. Ingram ( 1?84) epth--o-f-prc:oe-:c--ainci theor

a ate -f orar ci that i n-F ormat i on i s encoded at di + -f erent cognitivc-

levels. Ecicti bidl represents a. 0000i ti -id etrL)ctLOF_ that

c:omposed of i:csoci-ti ore or puuthi'uaye and elaborated ei t

ar,a flg darrees of coTpleai tu.

Rogers, Huiper & Lirker (i77> c:on-Firri this i:heor',- and e;-;tend it

c'i lii l:hei r -Fl nali ngs that in-formation processed on a sel -

re-f erent level is recal led more frequently than on other

cognitive levels • i.e. semantic or phonetic.

Derry S Lui.per (1981) used the depth--o+proc:essi.ncj padiqn- ,

moth + ed the tont.ert of adieL.i yes and +ound that the ad

scEma of at depressed individual consi sctecl of neost

ci:rosccior-- relevant. information, whereas, nondeç:;r'asssci

:cndi'i.d.uals had ac:hema c:or'aiotinp of positive in+ormai.:ion,

c:opnj+_i'y: speci .{: ic it.,, was indicat.c:i by the superior recall

self re+eront procss1no of depressive adjectives in cSn-aasai

sub iect.s and the race] 1 of nondepr eased ediec;t.ivecc na

nortdep' -'e'ay,s•d sub jest's

Incjr'aci'a. -tmi.th S Drehrc ( 19E,) con+ irm!d that even 11:1 dl,

depressed ].nd:L'ylijuoi 5 au-F+er from on endurincj nepotive self-'

scheme whic:h may defy act:i'atio" by posi tie erperlercEsI..

researchers; 'auoc4e'at that a. çjosai bl a reason why dops asses

indjv duals may strc.icturs' their sior Ida nepativel y, may not be a's

a. result of ar- over- enccitiv -jtv to nepative mel+-'rcc+src:nt

in+ormation bs; t. rather as a result. from a deficit in the

procemsirci of 'favour":ie'ir -vfcrmot: on This woul ci seem to

-further support the cognitive spool-fl city hypothee S

depress i or . Some c ocirt i t I ye t hoer i etc 1 i he -ia.mmen • Mar km

Mavol S Mycti(1985) srcjue that eel +---schematat are not

flBSdSSCr ii'v stable and liSt',' be both negative and pos.1 t I

determined by -factors such as the mood of the individual.

The cogril ti. ye speci -Ii city hypothesis was further supported by

Irram Kendal 1 Smith, Donnel 1 5 Ronan (1987) who found that

-i ro: I danl:al race 1. 1

oub j ecta demorst

i nf or mat i. on that

affect]. ye St3tC O -

hi4

data for purely

rated enhanced

was conpruent

the sub iects.

depressed and purely an:- 1005

prc:)c:essl nc:i C++ 1 ci erc:y 1-or

with the sal i ant i.iiternei

Not only have the depth-'--o-proceaair - q and incidental race]. I

paradigm been euc:ceccs+ul in el citinq c:ocinitive specificity in

arinietv and depression, but also in ppp Waiii.o. JM, • 1991)

Hal lie' a 1991) study where }IIFID mdlvi duals were c:::mparciyd to

dsre-uoive; and inclvduai a who had been ec:<cial abused in

chi ldhoc:d • mdi rated that I:her- e wee- eu) dcnc::a of schematic

orcc:aae-ino and c:r:ntent unique to 1391) to such an en tent that it.

wool ci seem that there ccii iota cognitive spec 1 +1 City for EF'13

Turner ( 1987) prolnosed that 811) may be the rasul t of earl y

1 earnt. mel adapt. ye schema Turner ( 1987) hypccthe-ei sad that 811)

coo]. ci be a. cii ciorder of pathol sri i c:ai actemeti C proce--Cei i]C! and

content I ccading to di sturbencu in the sense of temporal

continui liv • di sari antati on, dccreal i action and c.Oqni tl ye

con-f usi on, He a.l so ii 1 ustrated that the oesrnnti al cocini ti. vs

+ ecetures of 8Ft) were a severe i. notch 1 1 i ty of sal -f - i mage a

deficit I r sal + control ab I Ii ties and an i nabi ii tv to mci nt.ai r a

consi atant. perspective about sign i + m cant others

Young (1987) hypothesi sad that there was certei ri central

mel adaptive schema in BF'D with theme's 01 abandonment and loss,

55

or 1 ovab i 1 i Lv and dependence mi. strLLst

discipline. €ar of iosinc control, quilL

emotional deprivation In addition • Linehan

as mc]. udi nq pcttirrns of 1 rival m dati on • pace

suc:creci vs cc I see. This suqqrcLs and Is

proqosed under 1 yi nci coqni ti Va sc:hema of 8FE.

inadequate crlf

arid puni shrrerit and

1987) decribo iiru

vs help 1 eserecs and

re-i uvant for the

The many cLod]. as that .....ave been i:Iona Yegardinq 1 Liv

conceptual moat: c:r of 8Ff) have irdi rated thai:. BPD I

distinguishable from closely rd atad il sordors ......... 1 This suggpsKs

1:1 - aL coqntiore rouid evict, that rortld be cfleci+1c to

although cor: no coTmoral it.y em Lh other closely r' - cicLc:i

di sardero The c:ert.rcl 4 eat.ures that are behavi orirci 1.

charci:teristic: to E1FD eli 1 also manifest in c0qnt_ Hon's

surroLindi op re] ati onch i po views of 1 i + a and the 'future and

i.deni:itv concerns. fc:c:ordino to Linehari (1987), c:ocinitionc

ascoci. ated em th abLise and 1 cisc mncl udinp the themes

inva] i dation and passivity, ra:uid be roted by thoughts of

violated deopoi led • Invaded • uneant.ed aggrieved • a. ncju.i shed

di ot rE?soeci poeer less , hel p1 ccc , dcf onc: class devastated

rum nod • coonm cms"J • bitter and tormc:rited

5

1.4. TREATMENTS FOR BPD

As already di scuesed • it appears that there are many van ati one

in the conceptual. i sat i or of bEl) Tb -is. has 1 sad not on 1 y to a

mui. t tude of di anooti c approaches but ad cc to van Oti one in the

treat mert of EF'D,

1.4.1. PSYCHODYNAMIC THERAPY

From a 1 i terature ron ee i. t appc?arr that h]r.torirai)y the'

treatment mode of choice for 13FD ea s the psychodynamic or

peyr:hoana,iytic:al approach a field in ehi ch a ei rio ranoc of

techni puce have been odvoc:a.tecl Oi. ncr the + ecu-a of this stud ,..z

is not psychodynorrical iv on entated only two app r oachee ei 1 1 be

i 1 1 ustrated

he rnberci (1975) adopted or oh ects rd ati one approach----

c:OnceptLLai I rirci EF'f) as ,a patho]. ocjy of i ntvr - nal iced object

rd ati one, brouqht about by the i ncapaci t'/ to tol crate Pr iT? t.i yE

aqciressi or Kerrbeno (1975) emphoni see the reed to control

transference enactment, ehich in to be done ylO intens. Va

psyc:hoanm1ytco1 therapy onqanised around lntenpretatiOfl

mai ntenance of neutral i ty and the anal vein of transference.

Sear 1cr (1979, in So]. lack ct. ml . , 1990) hoeeven rai see the

questi on as to the requi recrent of strict neutral i ty, in terms of

ehethen the therapist can maintain this as Kernberg (1975)

Cr )

s:i puJ. at.ec ,, and vhet.he r - the hordei 1 100 pati ent. can actual 1. v

tolerate this, Kerrberq 's (1775) main +oc:us is on apclression

and may al. so be 1 ass-i-- + ec:t i vs boi nq seen as c:ol I usi or with the

put i eat. e harsh super epo. From thi. u it seems that more than

iuet. Tnterpretatior - is required (Pol lack, 1779 in Pel iac: et.

al. • 1990).

P di -if erent. therapeutic: upprc:ach is adopted by Pdi. or St Pu.j. e

abs, bused on the concept-a of :ir:toierablu aloneness and

tL€ - inabi. li tv to mairtain a hoidinp or soothinc4 memory u-f

aipni.+ic:uni:, utheu - -a atLii of -acaration or diotrsas see the

inabi 1 1kv to sustainiap hc:idi.nci memories as the cc:rs p-tho1oov

of BFD. The ti: of the therapist is thu.s to provide sc:tua

act. i. .e i. nter --p ersonal .i-: Llnct jor - o with emphasi s on empath I c

rderetanL:tno c+ the ei-::ist.er:t.ir?.1 pain of ic:neliress .jch so

many E:FD pet i erts rran i-foot

1-Jrnicott i-: 'lode] I (in ha-i lac:k, 1790) propose intecir-atec

dei1ojmenia1. - s-vchodvnumi.c: tbierapeutic: approach, which sarild

00+01 Ci V]. a three phases of hol di op • understandi. nip -acrid movi np on

Bei doe -fi ridi np lJs,rchodynami c i nt:.ervent ions as hei nq s-f ±ecti vu

in the ]. onq run in the treatment of P0, Psi lack fO Herser 1990)

note that i-f-ar; mode of psychotherapy does appear to pose

unanswered qucet.i one as to the et i 01 OV, adjuncti vs therapi so

e -f-ficiency and the bioloqi.cal interface.

58

14.1 PSYCHIATRIC INPATIENT THERAPY

in a cal. 1 ecti. ocr of ten studies done by '.1 cal or ( 1982) randomi v

assi cined sen ous poychi atr i c pati. enta i rid Lidi no the PF1i that

ecre sci ci dcl , to ci thor i np Sot. i cot on outi: at i ant treal:mon ii -a

none c.avc the i ndicat.i on for a super I at - i ti for I npat. ent.

treatiTent. It appears too from 1 : toraturo that there is no

emp i r i ccl data i rid i cat I op that hospitalisation 0+ cui ci dcl PFI)

actually reduces sui. aide r I aL:

be? 1 ack t. Hersor ( i.5'P(I)) propose that hoop i tal i sat i. on I

generally aol. a ree:c,mmended when a the apist bi lea--as th.rd: the

liii ri rnLUD I eVE?! of support essential to keep the pati cot r.i I vs

cannot be arc ancted or provi. dod Li nohan h Haseon (in hol. 1 cc k

at di 1990) add to thi a by noting that borderline pati. ants

often I n-si at or hospi tal i sati on, They cdvi so the t.her.sp i a-i to

lnstruct the pat i ant on hoop i tal I sat I on procedures, but not to

become act i 'id v i rival ved . instead a vice should be LaL en to

rd n-force the pat]. ent for any capacity to copy outsl do of the

hospital c:ortte;-:t Fol lack in hel lack at. al 1990h Proposes a

day—treatment proqramme as alternative to hospi tal i. eati on.

1.4.3. DIAGNOSIS AS THERAPY

Ohenne (1991) proposes a technique (rather than a treatment

9

nroach of di ac.inosti c 1 ntervent. ion +orte'Lroctmont. of 8FD.

Chorine 1991 ) notes that treatment. of HFD presents an unusual

opportun I ty to ut i Ii. so di aqnosi a as a di root. ci i n I cal tool

emphas i. a I np ho'jever, , t. hat. 1 + ml smart -aped or cii ausod COLI I Ci be

prob 1 ernst. i. c

Lhe.nr:e ( views }:pp 05 a avndr nine because the separate

elements of the pattern .t:Cl_nt Iv oc:o-nr topether He anti ritni. rn

that in the princess of the patient recognisincl this, the pa tiort

is drcrr- inevitably into a dif-foront lonel of discourse, a. lOvOl

at which he part i ci pates to some ertont in the ostahl 1 shed

'fact''. By virtue of the label itolf, an orpanis-ati.on behind

the pati ert a symptoms is aupposted and a search of c aLises L-h]. oh

seem i: in ercocoans that or ci.,r j anti on i a at i mu 1 at.ed , Lhonrie

1991) also post ul atee that the di scussi. on of di apncai. s promotes

n defensive use of irii:E].lefti._ta]jactjor - vhic:h is vico-'od as a

devel c'pmental n, d,nnncv for the ErFI).

Th i s t ochn I quo I a hoNe - ncr- not -op prop r i -ste + or ci 1 EiFL and ecu) ci

pose problems ei th regr eased L:'el oe aver ape into]. 1 I pent EtEli: a

Chenno, 1991)

1.4.4. BID—COGNITIVE BEHAVIOURAL TREATMENT

urner (1984. 1992) proposes an I ntepreted treatiTent plan Nhich

involves both hi. ol op i ccl. (ase of Aipronol am) and coqni t.i VO

0

behavioural interventi ons Fh a treatment approach is not ai mod

at restrLLctuririq the pE!rSOnal 1 ty of the mdi Vi dLtal or to cure

the personality disorder per se but rat her it is directed at

modi fi np the pati ant a behavi oural , a-f fsct.i vs and cocini ti ve-

di etcrt i ons and di erequl. at i ens P central focus 1 a p1 aced or/

reduci nq the I nci. dance of self damuqm riq behavi OLIr mm cro--

pS'/chot 1 c ep I sodas and el I cr1 nat i no the neceasi tv for

hospital] sation.

ciever, the study that Turner per-formed to illustrate the

s-f-f cuc:t i veress of such an ap proac:h i S viewed el th c-sut 1 on due to

sever Si limitations Of the study. Furthermore, 501 off Oeorqe,

Numthan Schulz & Ui r I ch (1986) cci t I cisc th i s f orm of treatment

and pci nt out that despite the p1 lot study pci riti nq to procni au----

saul ta • the issue of h id 001 cal treatment of choice for FPE

still a hicihl v controversial i ssue.

The outcome of the study di ci I rid I cats that the treatmant

c:orrel ated with reducti or in tarqet symptoms of depressi or

ari; 1 sty and q1 oha.1 psyc:hopathoi oqv as it appears that further

research in th a. approach is i ndi rated

1.4.5. DIALECTICAL BEHAVIOUR THERAPY

DT, a type of therapy developed and proposed by Linehan (1992)

in such 3.1 fcc coqni ties-behavioural therapy but its dialecti cal

61

-focuo and emjhosi s on oimU1t0fle0LS treatment of the thor - api. ste.

are two distinct di-f-ference.

Thio+cmofthErpymakesall 1 n t. en t I ona isol-f- ln:iLiriouo

hehavj our or porasul ci do, the hi pheot pri on ty +ocua ct

treatment. Treatment i. s carried out in pant hyteachi np the

pati ent other copinq skills to use in p1 ac:e of the porao.i ci do

hEaciour to requl ate or tolerate pn+J afferl - .

dial ecU cOi adjective in DEtT • hi qol i phte a key aE.000pt.1 On

10 tha.j that ouc:C:osstUl treatren: involves a EO/flth0E. a.

c:± oppositeo or dialec:tic::o, to achj.ee new behaviour patterns

and improve cop:inq Linehan 1992),, The most basic: dialectics

used by Li nehan (1992) 10 that of acceptance and chanqe.

Li.nehan (1992) also puts much ef4ort into reducing the

t1erapiste stress.

In a. stud'.' done by Li nehan & Chori on (1792) it was -found that

di al ecti cal techni qUES hal and nq acceptance and chanpo

more e-ffecti ye than pure chanc)e or acceptance techni qLkEis 0- 1

reduci nc eui c dal behavi our

1.4.6. PHRMACOTHERAPY

Drug treatment, like psychotherapy for DPD, is difficult to

conduct and of ten has a poor outcome and Should therefore not he

iror <ed on 1 i ciht.l y as

62

many pat :i onto may do well without dructcc

,while of ho be worsened by ifiE di L it ion Lr i r 1 992).

bot_Ition is rncic.icrcod when presc:ribnn for PF'D ouhioc;tn oit.h

00]. c::Ldal toriden::Lhcc and thus the lEthal. it' - of the CirL.lcl ].fl

over d occe shoc 1 d be an .i crip or t, on t -f or: t. or to con ei. d or vh or

-nol ec:ti no drucs (E3te1 n, 1992).

<1thouci.h rnucd'l reeoac:h has br-ron cic:ne in this area of t'.ratreit

the i 000001 biOlOCliCOl trarot.cer - t for hI-LI rcrmoir'cr

controvErs].al tine, with many c:1 inici. ens. cricirtainino that thE:rcr

is no one b 1 cii cc :r cril treatment for E$FI) i' - ULJ'l research has been

cionir in this area and nianv resoai-'- c:heroar;J ci iniciano- advocate

-for I OLcO phrrr moco I cc 1 cci. i nIer vent I or;s. Lhc] i 00 Of dc' Liil seem-c to

be related to ho theoretical link postulated between BPD and

other more b cii OO i c:.ci I.' I. I ri krrrd di corder cc (PcI 1 cc, L. in book

Freemar • 1990) 1) me_ion cii eclric:sti c issue in choc 00 of drL.;CI Für

treatment of FIPI) oculd be., ohi oh border -cc particular borderline

pa'Li, ent apprc:;rrches;-, 1 .rc. a-f-fec:ti. ye, po',-choti c , orcrori c

antisocial rrrrsonai. itv disorder, rcchico'I.:vhel tJersOiieJ, it,-

c:I I sor ci or neurc:tj. c ( Eluvoso • 3Nam I • Nat her l Sd 0+ + • 1990).

Med. cati. Oii -Ei that have been OL;ciclested for treot Tent Of SPLI

1 001 LICIE

* 1 o—overdcse anti psychotics,

* heteroccl ic and "new wave"anti --depressants,

monoamine oxidase inhibitors,

55

* 1 1 th i urn and

* c:1 or(az epatrn.

(;napor oac.h it: o admi ri stor 1 nc:i and consi ci sri no the flOC es.s I t V and

dcc roe of pharrnacoJ.opical intervention is that of dLt"/SS&? St..

a 1 ri hec k & Freeman , 1990) who CL.tCIcleSt 5 that an 0i tended

asasasmert per 1 on , dr--'f rue c:bssrvat i on per i od possi b 1

iciSD]..l :ieatic)r struc nEed dj.aqnostic inst.rumerLsard multipna

informants,a are factors to be c:onsiderad. d+t.erthi.i:n osoduro.

and if a pt&rrrc:c:J.opjc:a.I -ç----'•• is to be L.ks.Ed the ci. inic:i ar must

then c:onsidsr the dosaps for mhic:h saptcms:is the sent: tiara

aj:pi i sd. when is the apsit to be olsen, the duration c_i:

treatment, and ad uthea or not p evohother epa 1 a I n di sated

Buysse ± ri }iec: i. & F reenan 1990) c I. tea the + 01 1 omi nc

oh eurvat. i ors + LW research doriW in th i a area v1 z

-irst.c V ioN dose neurol Epti Ce C0C5E to be

af+ecti vat for a. wi dc rariqcn of symptoms in BED

I nc: 1 ud I rio cash I. otypal I apLi]. Si vs and depressi vs

hoat I ]. 1 ty • aricior, , 5050151 onenEss

anxiety, delucci one and behavioural dvscontrol

(Stein • 1992). Thiothi acne, 1--leloperidol and

Tn -fit uoperaz ins have cshoNn super 1 on ty to

placebo, while Ferphenax ins and Thiorida ins

have ernerpod + avourably in open studi us

£4

(Stein, 1992)

8 -i. de ct- ± ecte UC) h0eE?\er, of ten

0 c cc r

The use of tn co/cl. i c:m is ci mc rec:ommunded • hovjever, theme

to a-f-foct a-. much ririr r - over opec 1: rum of o','mp tocno, than do the

neon ol opt i. cm. 1 mpr overcont. seems. DI 1 y to occur lntIErdEpr omsi. -.-o

mvirptomo. -flOLhEir niol< 115 that ¶Olqfll 1c.0nt IJehaV1OLr0;-.J.C1t.'

in the -form o1-o-/500ntroi -- may c:ccur el th some pa.t.i entco

Thou 00 of "lor:.lieoo idame I rhihiLorm (MPh I) has -ml mc beer

but careful scclect.ic:n of acpropniaLe oat i onto 10

MPO1 0 can produce serious SIdE m-I+ectc inclu.di.rci

orthomtt.i c: hvoesrtensi on and hvpertenmi cm cr1 oem 1+ a prtl cot

is not cocripl lent in terms Of diet • it could 1.ed toenioum

odors-- me ml do-c++ oct-ri. Cormi. lien:: np the 1 E-Ui 15.1 venooc: and

sorest I mum reperated sulc: I del qeetures of SF-P riots ent 15 it

that MPuJ are not a eLcitabie choice for mary pati onto who are

d:c.acln000d as SF-S. MdOi. 'm do hceevcr, representvc:.thcptiiclmt.ic

charactri sties in that there is I mprovemert of mood ccl + i mae

and i mpul ci vi to dun no MPd) 1 m treatment: • am eel 1 as the deere-roe

in eel-f deetructi or: behaviour (Sell ac. et al

An e+ -f oct i cc drucl in the treatment of the rood component of SF-P

is Lithium C;arbonate (lfcuysse at at. in Sd 1 aoL et. ci

Perbamazapi ne drLes trials indicated a. modest but Si (:101 -f i cant

observer-rated effect, thouph no ci ni -Fl cart sub jecti ye mood

) S

effects were seen. (iprzciii trials have ShONfl n1>(E?d ruit.

1937. study with . this drug indi.c:at cd poitivc mocd

changes when used in c:omh 1 rt I on with a corronart: of ; 5 j 0 ---

L1c:)c1rj.t1ve-t:JcIa-.] jLi0i app - o ci. Liarc;lr'r.r & So'. dcv ( 17S5) on

ot.ior hard found in two cudiec that (:'1prnoi.ain can La

r!.c.c:].a.t.e?d with hehavioural (:i -yic:cr',trr -- 1 in cc:ttr,:Lr FFi) :i:iint,

'LU- CChOI:L cci -nt. 51cc mdi c:ccc a dccc n-a-ce in serotbnergic

--unct.jon in :atiert-nith isul Idal tEflCnci o-c aOCirE-:cc or

icu}r.vI- .; and obs-n;n-.icsnnj it.-.j .I-cc:cair at, ni

Si nc::c then.e cc an tcrn clusters are often present i. n HFL • aC2rtc

cit - inS inc-ease nar- oi:cjner-- jc- - ic.tiL:n in the contral nervc:)ucs.

c-vct.em -chould be c: -F- - ic:.iouc in the SF1) 1993.

Furthermore, 55 . LOSE of SR I a ad Jr o=n-: the a ccLi.Eo+ 13cc-ni 51 a

c:.vardocc on rsrac:c --j bc:-ci iuCd], c::-at :cn, St-can 1992) notec that two

drugs v -in inrtra! inc and Fiuocoti.rc both SRI. c- currenti'

ccci I able? in the Ut-iS, arn both ruin--I cut-tn) when teS-;on sc

cuvcrmjoscu. Stau r 1992i ci tees that tea-cc SRI n hava 1 a-nc acute

and ]. ono tori sal ci dc cu-It- cucL a than other tncvct-ot ropi c -asianS a

used in the ormstment. of SEP

Sec 1, 5 Fr EEaIar 19115) cEucu ph cril-anc: 1 oq a c:a I. t her coy + or the

treatment: of 51113 as an cd -iunc:t rcthcr tsar-, an ci torrat.ivo to

other treatments, it a-.eecia that sirrcrmacot.herapv 1 a siencurai. ly

di rected toaarduu state cyrptoms ejhj. 1 o psychotherapy addresses

the pata cot 'a under 1 yinq trait vol ncr abi lj. ty and mcI adaptive

66

c hat act er

1.4.7 COGNITIVE - BEHAVIO1JRL INTERVENTIONS

i rioLn ( i.87) , LkrnEr ( i.98'7) , Yourip 1990) and Linde

the most current thei arj i etc who h ave noted cue: ccc a of copn 1 1.: 1

behaviour inter•ent cia in the i:.reatrrcnt. of Lu'L

Turner 1 -?c/ p v opeaca t.h.c: t: ma. .1 edao + I a a sch emata ]. can pr rear .1 V

in life, rEeLltc in rapid and dir-:t.iLeic:ti\,e aPe ftc ic mental ed

errcitiortai vote, c:hanacteri caLl c. of EtFD This loin. to

ci: cetThanere in the ].ncilvidueei a erenne of +ema ceral Co:t.lflLte ta

P er - cal i ccl: i on ahcncver a + mcrot:i tnt.r caner Occurs. I1 :L C .i I

behave Our eel. c.eouenccc that + ol I oc thrice? prob I reeve I cc: 1 ode

ipttcrporecnal dIf-t icu.lti cc. ccc:cial ari:;,iEtv e:oc4nitivra

dyn-fuiic::t ion, deprrieeei.or and :impLeIe]''e hehavioe.'.rc

Li neh en (1987) on the other h cod protacoc a tpiocent eLi ch I a

rooted in a. dialect ic:al percpeac::tive of biocaociel t.Pccre This

In turn is !:eced on c:lIniceIi obeer- atiena o f - e:u. - ..na

boha .,i our-- envi ronnant:al patter nec: arrionp I. ndi vi PreCI S dl cpnoccCi as

IItFD P core component of beth the thoor 1 00 of L. noLan(1987)

and Turner 1987) • is the noti. on that bar Per I. Inc i ndl vi da]. c

have ceveral important bob avi aural de+ i ci ta. Turner +OCLI000 on

1 niterpersonal ski lie and ann i oty manaqement dc-f i ci ta. Li nehani

1987) also focusee on interpersonal skill a but expando an;-:i ety

07

iTOciE2ment. to oncomposo omc:i: i onal. c:on trol as ve1 1 as devo I. o i nc

distress-- toieranch sk:i I is. Poth Turnia-r 1987) and L..inehau--

1.987) offer lndivldual and group therapies.

ILi r - r er (1987) proposes a t r eatnient c: 005 :i. st. 1 rig 0± + our seqL'.erit i o

a as. v.L/i

a. pha rmacoth erapy,

U. -1 ioc.dii : prm:c:edros aimed at i roc:u] at.i.nq the pakienL

aga].rot cocinit:i 'i- and irioDil e:-:per icni:ra-aociateci

ci. U' tkoi r worst -oviriptom

Q. co--.--ort: iehaarsai. and in '-'.'a practise of c0:inq -sL:i I i-a

and o:-t.ategi es, and

d. intorpE-:r -sonal pi-oab].sir--- solving training.

Linohan ( 1987) -arranges treatment goal-a in a hi€ara-.rc:hial -F-cuchiori

05 i- oIiov;s.

a suicidal behaviours par.a -a.L.Lcc:Jcie, high risk: suicid

idat.ion)

b behavi Ours that interfere with the process of therapy

C. escape behavi ours that i ntor -fere mi th a roasonab], v

high quality of ii fe • eq. substance abuse, poor ,

ud c-mont

d. behavioural--cPul ac:quisition, eq. emotion-regulation,

interpersonal effectiveness, distress tolerance and

60

001 f ronaccmcnt

n. ot.hr goals that the poti nnt may want to +ocr.s on.

Therapy is circuinrir that the focL.1n rnvo1cio oc.nci time and

ottnnt.ion is chi-f ted bncJ: to earlier - pool cc it ion eci from thence

recur ace

i;c:;c doT:Lrati no c::!i.;c:ta:ri.s;'Li.c::cc of Li;.;ccar:c WON t.h000y.

arc.;: a poodle;.; - io1vinc +oc..;cc. • an ecihan:; coo JialccctccIi.

p L: cinonc-; an ci oh nor 'at. i. on and m.ar'ap eon.;; t of ci ho c.; on t. no or c

op air a Li no in the thccr apeut I ci rail act i cinch I Ii Di al oct i cal

t.ccr;avic:co - Lt!000py is do-fined by pI.;i locophicol underpinni.ncic

tciat;nrsnt oto a Lop i no and i ho tarcint hehavi ourn di pht baci. ci

strategy oroupi are uti 1 sed in c:ombinntlon to deal With

spoc:ific :;obionatic: situai:iorc, vi:'.: dlaJ.ai;:tic cci rjrcJbloT-

col vi r • ;.rrnaccrent, coriimL;n].c:art.ion corc;ult.ant ia? idation

rcroacitv cinharco;ner - t , oiahionhii:' and c:ont:ncioncy strateQi en.

dnother cocin: ti ve- --bohcivi ourni cijn; ci or; who recociOl cod the

chii. I enqa.; that po:'rcor':al I tv di sorderca • and parL. i c::]. aol c pc-and by

PHD is r'oUn (1 o'ti ) / poor: oced a v4:ec:i 1

Cociri ti cc -- john, i oem]. int.ervnnti on approach aimed at treat.]. op

PHD n. His approach is an e;<tenson of the Eec.ian 'l/cr

short--term cooni. t.ive therapy aimed at treat irq deprensi on

Younp 1980) re -fern to thi. c therapy as schema tocLtced therap'/

Fh i. s typo of CD therapy differs soTte'Jhcat to the Bock:. an nhort

9

term therapy in a number of ways ''ouno 1990) name I. 'y

there is 1 OsS pui dod di scovery and oreater confrontation

in therapy,

thers is cruc:h preater use of the therspeuti. c:

rd otis no hi p as a. veh i ole of c:har - ce

hbcre: I s more resi. otanc::e to clan pe resul t. i nc:! I n therapy

hei 00 1 OriCEr

the level of af+ect is much hiphor duri.nci osborne -F oc:uses

seesi or • ---the ther.spi. ot. is more soncerneS vri. tb i. donti "j no

and overcomino cocr - it:ive and behav'i. ours]. avo:t dance, and

gFC-F devol: or con si cier oh 1 ' more t. 1 mm to ch i 1 dhood sri 0.1 no of

schemas and to emotive techni pues surroundi rip these earl

105

Fiesides these cli +Fsrenc:ecc SFCT retains most of the more

I mpcv- tsnt el en onto di. f -Fer- entictinq Pool:: s approach -fro:i more

trodi ti onal psychoarsi 'tic or ci cent-centred theropi es. This

i rid odes the therapist be np more active syst.eTat]. C chsne

techniques, emphasis on sel f-- hel p homework .rssinments-.

therapeutic rel ationshi. p of col 1 aborat.ivo ompir diom and the

approach bei np more rapid and direct than con' enti one]

psychotherapy ( ' OUflC • 1990)

There are three chorac:teri sti so of BEDs that lead to

considerable di -f -ficulty in applyino short term cognitive therapy

OM

that 'r'jt.jnq 1990) jdnr- ti+ie. These are riqiditv &voidancn,

and I on--term ]. nterpersonel di -f+ culti &E,. 9hort-term cocini ti 'in

t:herapv assumes sorrewhat of a flexibility on the p-art of the

pat. i ont , nh 1 oh i s sornoth 1 rip not o-f ten encountorod 1 n EF-D s ci non

one of the hol imarke of i-$FD,r; is the;.r ir+ln>;ibii itv and

ripidity. To contirue, short--term copnit.i ''n therapy assumes

that the patient has Free access to his thouchts and +oel irips

but in mn' F-FL ths:ce are too painful and are rather b].ocke:ci

or avoided cl toonther

:c postul c.tes. that those three -f actors (ci i di ty

coictar:;-c and br- p tnrm interpersonal h1F - 1cL1ities) are haken

i ito account in tFLT. Younc 1550) proposes zfour thooreti cal

constr'cc:ts asan c;-; -sos on of the shock--term coqn I t I en model

proposed by E:ecr: and his coil naques (1976, 1579) These

sonntruc:to el ion for the more c:omplote c:onceptu.ai isatitn and

treatment of pat I ents ni th LFD s.

[hess construct-s arn

-- early mel adapt 1 en schemes,

-- scheme avoi dance,

schema maintenance, and

schema compensat]. on

'ounq (1990) points out that these constructs are not intended

71

as a c:omprehenoi Va theory of personal 1 t.y psychopathol ociy , but

rather -f arm part o-f a strai qht+oroard working theory oh:L oh is

comprehensible to patients as oe]. i as theraj:ist. This should

nab 1 en thorn to c:o -rrnuni cate about deep or--i OVEl nhenomsna not yet

inc:orpor - atend into most short--term c.oqni tivia--bohaviosral.

t i cc r op as

icairn (1090) dcnnn:.:ri,bccs schemas as est.romec1y endurinp and st1.:J c-:

pat.tens of thir4::incl that dovc-J op in c:hjic.lhood and are

si aLoroted on thi ouphc:iut. I i.ie, One vieo cc the vrcisicl throjt

cs::henacc i.nportoni: bi ia-f a thai.: are .ccc:coi::t;.eci 01 hou.t p;ssti.cnri

Or: c: or cii no to Your p (1 990 ) EdO have seVer a.1 do-f n n

c:haractor:Lst_ic:cc. Firat].v, they may be virnoed as uncondil:iona1

bi i. u-fcc anout c:nesoi -f -i n rel at). on to the envi ror:ment EceconPi.

ti-any are scnl--- pernet.uat:lncI and there-f ore resistant to char-cia.

Fhirdii, EMS are ds-furc::t.ionnni in a significant and recurring

rnarnsr - sod load to various forms of pncvchol Dpi c-al di stress (og

destruct) yE relationship, addi sti. ons , psych050:Tati c disorders)

Fourth 1 • EdO are + or ti-icr act i vat ad by events i n the er - "i rormant.

rd avant to that schema. i--i-f thl y LMS are usual lv quite Ci osel V

1:1 ad to hi 1gb levelS of a-f- +ac:t when act i va.ted • as opposed to lass

a-f-fact associ atari with underlying assurripti ors. Lastly, EMO sees

to be the result of dysfunctional rel ati. onshi pa vi th parents

siblings and peers dun rig the + i rot fev years of an i ridi\-i dual

I. i+e. What strenqthens the schemas, is the ongoing patterns 0-i-

72

evcr/dzty unpi easant exjtariencea ci th othera rather than i aol atevi

traumatic events.

'ounci ( 1990) has identified fifteenEMS a 1 hose usual I v occ:ur

in isolation but also appear in core cwoupa with sevorol

peed hi e vOl i at i ons. Young (1990) groups thEaT 1 FitS 4 our broad

eteocr I as,, c: err eepcnd no A I t. h -f our c ener ci or ec..-s of -: nec t I on i. ncj

viZ •aut0r1Lmy, Cc'nflaC:tedne]Sa, worthiness, 1 i.mita and etondards,

Young ic;.ci and hal I. is 1991) al_IcIcloat that t!c

±oLu- d in SF'S inc lucIa theciea of- : SL1ncic:nri:ent 2ho los-s

ui1:j'chi 111:' and dej:ieridence , cii. a.trLvzt , inaclecucte self-

discig] me, fear of losi no emotional control, gui it and

pun I sh mont: • sri d coot i OjO I depr vat: j on

Young en' ntr odor: or the four catc'gor i as :i n the +r° 1 oci r:g

mannei: OL:tonoiiy, the first c:ateqorv, coral eta of the Sf15 of

degendencc , sub iugati on/i act: of 1 ndi Vi duct]. Ofl, vulnerability to

harm or ii. incise, fear of loalnc] self-control. the eecoi - d

category, connrmct.edness • I nvol var:: the EMS of emoti anal

dapri vation ahandonmeni- /inas; , mi strr: at. sod ci

1 aol at i or -i/al i er- ct I on The th I rd cat rigor v , car tb i nose c:ontz

the EMS of do f oct. 1. veinesa/un 1 ovch 1 1 i ty ,, -soc: i ci. urdesi rob I :i- t

i ricompeterce/-fa lure, gui it/punishment and shame,'errbarrassment

The final c:ategorv, 1 imi ta and standards, encompasses the EMS of

unrelentino standards and E'fltitiement/insu+-fjcient limits.

br] c-f descri pti on of these categories is

OW

Functional dependence/Incompetence rcEre to blie'fs that one is

not capab].e of handling day to day reepor - si Li 1 i ties competent I 'i

Subjugation re-feretc: he]. i ef that one moot nnubmit to the control

of othEei in order to .avoi d 'oclati "/0 c:oncequencoe. F: Oar that

oni ece they nijb'rIt. otter-c ci 1.1 cet onqr"vc:r- re_)oc:t. then'.

Vulnerability to Harm/Illness r e+ ore to the bn:1 jo-f that one 10

always on the verne experiencing 0

Insufficient Self Control/Sel-f Discipline re+er'c to the

j.n.ebI I ICc to 'L:io'atE' fru'otr-ot.ic:n roachinci cnec goals as wall.

as irahi I. lt - to roct.r'air r-;-Jie!0eIC.fl of ore's Inpulsrno.

Feel nqe.

Emotional Deprivation refers to the bel :ie+ that one c pr'z

ETot i 0001 needs ml 11 never" be 'net b v others

Abandonment/Instability re-fore to the ecpect.etion that one -o. J. I

coon 1 ooce er"/ono ci th mhon' or eeoC i one]. attec:hment 1 0 + ormrnc:l

Mi strust/Abuse refers to the enpecto.ti on that others ci 1 1

1 ntenti oral 1 y tote advantage in some may. Eopect others to hor't

them or cheat them.

Social Alienation/Isolation refer-s to the belief that one 15

I

MW

isolted +r'on'j the world, di-±oroit from otIor people and not.

, or t. of any corlimur 1 ty

Defectiveness/Shame r o+•ro to the bol ief that 10 10j rtrrroI

{f.aoci and that it othۥs cct t.c:o c:]oo -:1l roolioo mad

the relationship.

Social Undesirability refers to the beliRT tL1•: LJV outwardiv-

tc ot:rL•, :E0 unaf

* rRCQVP thEfl0E. + as ulwtvraction.

::c:i•::1ro

Failure to Achieve refers LCj the L.o] j- : .r.l-ir (3±

performing as -o:1 1 00 c ' :ooro in areas ouc:h or :: o

schowl and sports

Underdeveloped Self rofcr. to the senor: that oro has LLJCJ littic

aderLit.v or innRr dirrrt I :0. f r-r- ore --ro

(1 t.inosr-; and ±1 or - borinci,

Emotional Inhibition refers to the bel j. of Mot you .:rt j.rhl b.

emot a one and I Tn(. 1 SOS O0 oc:: :i.a lit V anger, cc i ccc: e eror 0001 on 01

emrl:cos cco.rms others or lends to lose 0+1011 estSoin or resulto

1 n eTba.r r aemert or abandonment

UrirelentinQ/Unbalanced Standards refers to two related bol i of cc.

Either the foerson Lii i eves that rjhatever they no is not cfOod

/5

enouoh or LhcrE 15 O;<C5551 vs e1ph.Etsi.E on 'islues such 55 ststus.

veaj. th and pc:vsr it the E> pOnSE of V.5]. 005 such as soc: i.

i nt.eroc:t: i on • hi t.h or ha.pj: i. noes.

Entitlernent/Sel-f Centredness S0+ESi to the belief that coo

çiLO cj be aLl u to do say or have whateveryc you want 1 (ñfiiSd 1

's:jorc1 I. ccc of shot. er that tats others or seems rcccorah 1

-I- L.

also ccct.. . nuc/e in identimingt.hnc major schnms

schema ccci dance and

- schema c:c:c.:cnsat.i ci

AcEordiny to /cunS 1990) t.c:: prc)cs!zes are what Ei;Ci/RiIiE rico

the zcemas function sithin the individual, hoc they are

maintat ccci. avoided and a:tccpl:ed to vic, oveccomsoneation. Ihosu

processes can occur oIL h].ii the ccc.ir3. Li. vs realm, the tfEc:t]..!

sphere and in 1onc term cohcvicuro1 +ranct.ioninci. 9itcic.cJ. lv the

riechen i. cm of schema mel nter'encs is cc:p n t i VS 1 1 1 ter cc and ccl ±

clef eat i nq beh cvi ours-. oh i ch sec 'jo to per pet ust cr sch E0i/.kS and Tok: S

them i noreasi rip] V 1 nfl ox i 5]. e. Echecra +V01 canoe cord etc 0 4-

t.h-ee tpec; cie coqni ti. VS. of -fccct I vs and behctvi coral it

ci 1 ocs the 1 ndi 'li dual to escape from the pain associ ated ci th

his EMS' s. This ovoi dance hocover • results in the schema never

/

b I q br ouciht i nto the opcn and :i'.iet I ord I t I vc Shcfn.

to efforts that people may cit to thini-: about

upsetting events. These o±cjita may be ni. t.hoo 'i:jI u.ntar-..' or

OL..ktc)E,uL]c. Emotionil avoidance refers Lc: •oi..ctomOt.ic: or voluntary

l:i:ccfilLcc to h].c:L I.O].n--cIi. E:cLIL::ri r.'.ir.da.rc:c. i

whivh -:/r/-n.r EL -i. that a schema Efl. 1]. not Li::' Li IL cJDaiacl

L:rrn c:nuaricaLinn :rocaa-aan Mav be E.EhC'LL BE

.ntto'mn LI-:. by the individual to chalippoe

boOty thai Lndivtdual L;<k'c; 10 a. manner i.Lj. ott •iocc-..cr - i to La

Ltt:-'c::.c:'tc-:' i.', IL-',.ct::iEy:'cL-i: -Lc W Orman I

it :LJJi:tri. LLJI..

I on id most al t-'j:::r V -b IL fl\/C I. 'tiLl -Li failure t CL COO raft

underivinq V!i]vo'- .:it -lL i.:Lt:/ .. .!.oavinu the :tatic-:nt.

powerful f/baLi cual ::;iri:I ifac:hc-:rna oult iroitt.:f Cu -C.0iO

of I.JEtOEL Cr)':::Ci'tLLE-i.L- rd .ytOCCL, to Lit c-i

schewRs ::cmor-i. - ±runcl I i LF'D are di. sct..toctoci in L Etitcir

YOUnG LI--ID) - i-:: y- .: -i:.a - f - cca Lcd itta. -t.:c - nato' 1'iot: applying

t:rtat initialiv the EM5 cutLEt :':L:' -t.dan -L.i+r-'::i nh.

rtc:1'_.;dc-tc, ed!c:/at:Lc -,r., c::::r--c :Jrutci.:it:,ri and tr[t1t-i'tI.nC] of i.:iit-L c:iirE-:'

v-v herro for thc::' ah-rnoc.0 prci000c-L. The tno'rat::i.ot cdl l-cdr at iant to

- -:no-t a.bc:ut roac:ct'nt evorita or air oumatar':: rca in the c:. EnL a i. i -LEt

jhih have lead thou: to acme for hE'lL. The thi.napa 0+ will look

or oat L euro uh i. oh mav be r el. a Led to schemaa Hero the Lr'5E' 0+

the i]chema L!Lecotionna].r - Ec (Younci , 1990) can beaU I ised_

7"!

'T'OOflOI (1990) t.hcr pomt',ui tom ±001' iTmior t.vpem of I

when changind the tchemm. The ml n' In chanqi nci the mohernom. is

to rr•n the ccii']. 'i maladaptive cchemmm as much as poem'! h]. m , and

bui. I ci c:: the pun hEm1 tb,' ml hE t0LnCI 1991K interventions

that can be used in cmokeni rp thomo ochomam

umotiva,Eognitive. buhovi OL:'m.I. and intrn:'permc:ncl in not ur'o, to

more omunoblo to chonqo,, erc:'tli'u: tm'chnquom 7cm

usually . mmil c::vc:cj and 't.r"ac:mcd at the ben! nIl rq of- ttc'ric - '-.

Emotive tuchr'i.c .1mm mnc:omc.ccm the cli. ont to ia-'ooionc:o and

p comm the mmci I: nn.m]. cmpoc"Lm. of t hod r'pi- oh 1 mm,. I ntecpor con ill

t:mc:hr I poem ccc be omphccml med t,h'c'c:c.cihout. the Lher'opv

intenpersonal Omc.hn I quom. h : nih]. ph!: the cli. €-:-.'nt ' I nt.ei-"' oct.!

o i t ti ct hun p mop 1 e mo t.h cat t. he cc], ci of the mc: P ummm can be

or oconed Loon i t. .e too in i ou.um. are oiL. i i i med to mvmLomai: i. me the

oc"ucemm o+c: h-ccnpcn,, they ne' c' U - c- ce In oP,j. oh the oc.hemm--'r,ji - von

c-::onitivo- cii.'cntorti.onno are cimI J.enoed. As in mhcit-t term

cc:qr'l P1.00 i:heo.ov the :imc'tLnc:t],or'cp tho_phtm are identified and

the ccvi ciot'c::r:'*n'cr and coal. r"ct. ti - em WE c.onmi cier'eci hen noun

th.c_iu..:.pt'tc- m"d ho! lot m are moumtitutuch In thj.m tat,ients are

t. muoht. t. echo , ouam t1:: enable them to c:h 0,1 1 enqemomiemam whenwour

they .00 3. 50 out_mi dcc of the thor mpmcct I n: mmcml on Pot. I, mote an

ml so t mupht, and nihomun hoo cc:: hcnn'm cii, ot cot. I n-f or mat I. on and thom

ccci n'F orce he]..! cc-fm oh I. oh ooul ci ott- or - ui, em be moon as i. 11001 cml

The ± i no? , and usually the 1 c::nc1e:st stmoe in the therapy, is the

behoviour - mi chcanqe, mince it i000I.VeS ionp term stondinp eel ±"

de'featj. op het'av'j. mural patterns that have become deep 10

78

entvenched 'oung 1990)

Younci 1990, emrjhasi son. that all the obo'.'n mentioned tschni ques

be utilived 1 0 chillenging schemashc ii hc = triggered i n

SOS. 5 1 0 ii 5-

An oitsrntj'ie opiroac:h or -form of LBT in the!:, of th&: 0i"tE'flt."

tvpi L;HI, Lil I in ( 1991) idnnt:L+iod cor4rili.ve -npnc:i !-1c:'j,t,'\--

FiFE vjh i cL for ms oubstant i al bomi c, + oYt.he use of tf' 1 0 type 01'

!lOi - 0,'i :n' the ir'catnnnt of EPD.

op os.ed 0 5 oci n i t. 1 in modc'l + or emotional c 1 -nor Our's

ecJ]. all. '-•.-' depressi on This model i nd udod tern'e./concept.-e n-f

c oqn i t, i vets i ado • + or mat i on o-fc:o qn i t i ye sc:hemat. a and out neat 1 C

t.honqht.e. The necativn triad involves on indivdue.i hovirci

necioti vs thoupht.s or vi ejs about theinsel VS'S • the cnn-i ronmont and

the ±'LLre brsEr'hECC) t: Beck j:pc -- r---t' those cor'cspt'.e anQ

not.e that schieman -tOCITICCI in chi 1 dhood are ni so i epi 1 c:atec! I

Cnc)n], t',i -in di stersti on, They also rotco that neat1 vs Cofirl tiOIIC

are or can be act I voted by otressors vhi ch reca], I the repo'Li ye

childhood esper lOICO resul ti rci in neqoti yE-? ai- ±eCt

Fleck: (1987) describes automatic thoughts as coqni ti on -n that are

represerteati --ic of personal emot i onal moon i nqs Nhi ch the

i ndi vi duel attn butes to his envi roncrent. Putomatic thoucihts

are also themat.i c. This means that they are o±ten shared by

ndividuai.a with the SaflE? OiiiOtiOfl1i dioordevo and can also be

jrid cat:-•o of ciapracaivo paychopatholocy (Beck, 1987).

1rthmOrF,, automatic thOi.!Oh.a are rearded as apac:ifi.c:

cii ati. nc:t autonomou.cr and c:)c::cu.rni nq as reIf 1 a- I they arc

LJ -OC) ic:il:cci b-/i the mdi viiu.o]. eairienc:iri tam (LaocL: • 187)

hr"iothE:r aooroar- n t.h;;t ;:d cc cont.r 1 LLtI.:E-:O to the c::ocni. t

-apocl -ici:-/ hy:othaaio. 1 - b the -crjr:o.c.h of iran-arc tq-: h:r

cii - iir.C1L -:cOE5. c:;:ont r. -,-'o ::cj:atri.c:t:; a-uc:h as the rcci:ccrL a thEiic:;-

.rt- boor-., and acc_n-itc. for ?cJz -a Lid!:

t.hcor-; in term;; of or.crtive netro:s that are ccbnc::urr antIc

.act:i.-yc; I. ri thedotjnca -aed irdi vi aftsal The rlEtVJUrk theory proposed

be Inoram 19J cuci::ieatr; fOat momoni ma are c(:)nnE:c:tEci via.

at ye 1 si n P 0;] a -a • and on;: a thoce are act.; -- at. ad b ac or d -a

cent air Lhreohcild they ertor the individual's c:onocioun

ocarenes;; in the form of cocin;tiono.. Tha - ol:her approach

Ingram 1984) is idlE-s c:iepto -- o-f- - pcocesni np approach vshicc

- ropose-;-; that si nt oninati on i a ons:oded at di + erent CObIfl I t 1 vi

levels, each I e--o1 rerir - ceer - t no a c:oc]rit.ivc et.ructu.rm c;oirpo.d

by a.o-ocjc: i at. ion-:-; or p atksayrs and ic-i obora Lad to van viral drain 00/I:

of LLJHIJlE1 t'.'

In addition to tiie, koqers, Kuiper d. KinL:es(1d-77) +ourid that

]. 0+ ormot 1 on that : a processed on a eel + --- re -f erent 1 oval I C

recall ad more frequently than on other cooni ti ye levels, that

is semantic or phonami c son & Cr- ai c-ih ( 1977) • Ed so support

the c:ocr:i.t.:ivEJEc:i+te:itv hypothesis in that thEc'-/ not.e that

depressed in'dividials ccl aL: or at, cc nor cc extensively negative

i.t+oninati.on, and also rEca.,l flEc1.IktiVE: i.rv±C0r-nL..c)fl

ccccur ate 1 ' and I c' c-cc ten detcci I

Derry cc: -.vc..c-ccc ': in recccqcciccircc the .LIt:j:L.z '

of ad:cc:c::t:Lvcccc uc:-c, cc- thc-: Jr-cr:::tr ---of----

!..r _&'=ri;.c Caradian. Theydiscoverad

ccl I vi tic .0. c:. ccci. - -cccdcrcm-cc,tc'c cocci cc [cc-cc c::r"i cc-ri I cc" c-f

.[c-ccci c:c:::c:"c.'c.cS'

cnn-' cc Positive

fin-c' EuwErior recall, in ccrc:IL+r' c-:-'ccccc:crct rnc.cecccci ccci

depressive ccci 1ccc: ccc-co ccc:h:i bitted by ciectnecccced ccci iec:t-c,. and

ccci iccc::ti. 5-cc:; in nor" depressed i.ndt,vi.cli.,.cci'cc

U cctc:dv dnrc-c ic-, 3:;c4'cc::'f, Smith S Sr'e':cn (1981:) liven -fL

the cotta t:i. "'e ccpccc:i -f i c::i, tv hvqotheei cc i, a

i.ndivi.dLlccic.nncf also indic.atecc, i.i(r"t,r'• ncccicc:: inn' ccaccon'n mb

deqr'ecc-cccccd ind:ividcccci a -nctrcictur'ec their en"-ci.r'on:nccnts nccocc'ii,'-cel.y5

Tb ccv or op c:cce 1: h cci c t may not be t. he r cccccu 1 t. cc of over — sensitivity

to nnq-ccti ccc inl-or- i.cciion,, but rather as -cc reacci 4.: of de'fi.ci.onc:t in:

qr000acci rq of favourable i, of urmati on

W.iti 1 1 0 (17703) pr- opo-ccccd that the coqo I tivo opec 1 'f' 101 t v hypothe-'i a

81

orC:Y]CkOi a uni -f'vjiC construct In IUE study of PPD

I n 11: 0 E.tLldV the CLtEEt 1 or'iflo:t ro, o that vinE 0- L0&C , we re LtOE:Cl r1 1.0

the nUi to elic it C o g nitions th at -non spe&fic IC

nnnI..kr]flc and ai ding t h e t herap ist an& p atient in.th

:ir:•?it1 f ic.nt:i. ::rn ::U the c: oriiitin:.l. whico 1flt.0/Eflt1Ofl0iO..0 :1 Le

djnn ~ te d ,,

1.5. F'RUBLEM STATEMENT

OLO\'r .±i.:nc] or o.LrC]Lfldi :o tne c:cr CrtL.. I -rot ion

---h H-1 •r--0- :cr p erhaps Ii ho the 000r0:.TEr 0 BPO 1 t ncrE-

0-nr:: OrL:VOr to be 0 r-- nt.OE.ro d - i - TJ.n..L as :::nrcrnlr.t.n ciinrrOcr0

I co cont.oc:0ri of ::hE!1CJ(tOfl0 to ccci:? cL:: • dc-Cfl0 cro t.rcot

(Uth.:crch ttcrrcJ:uci.. n:n4c1E]flc 04 h as not been clr:i*rf

out. it :icrCco ccnrcnc - ±r0iIl Ir.tcorrt.LiEo t h at i t 10- .0 commOnK

D3l't III. -- P oconiurilrt.'- dicr0i ,T'i0c nt occ:crirfj

1990). I I.hPBI nntlmrctnd th e prn'-..-nIOlCL= boriC] at 10D-

:i.rpot].Eiflt. ncrnc: hictriC pnp010t.].C]!

But dosit.€c r:rLoir1r:0 nviEncEc of I to oreva l ence, tIC]EE1 10 oti t

niuch oec ul ni: I coon to ntret.000 BFU ohoul. ci no conc cci 'Oct 00

t di rcordnr Ak: i ohol subaf fecti ve l. n-f not 1 'co on pel'ncora?.L

185) To coup] I onto rn-nt. tern, BED ovor I apo. ci. th LoVer 01 0.1

other disorders, and oft,eri therE? is a tndency among flE-?flt1

82

hinti i:h workers and pro-Easel ona.l a to 1 abel a! most. a-f+ecti vel. a

1 ntense 1 IIiLl 51 yE - and i nterper - sona.I. 1 ',-' di + -f 1 Cu! t i r-id 1 VI dual s as

BFD (Guca • 1975) (iuthce-- s ii he Li nahan 1987) and Mi 1 Ion 1985

argue that ± 8EL) were marc: (Ii en.r 1 y de+ I ned , at i. ol mgi c:ai

t.haor i as and true : mart would I a a 1 ear er as well. L. I nehen ( 1987

cra:intninr: that E)PD has been great] y under diagnosed leading

most prob ab 1 a to poor - a E?Sp or' sin i ri thee spy b aced on the - fe-i: I:

that the 'ar - lance attributable to the chronic:it-i of a c:c:rc:iit.ior

by means of the bUt) • has not been ec:c:o;;nted For -Er! I v in

di eCJTF(:st]c: ;o;i-.:i_;p.

in - -- esticietian into the f actors that ray contribute to th

bevel moment of ElF-LI , I nd I cater: that thor a are sever a]. 1 nt er.act i -/u

-f art ore which -I or: i Ii tate da\/el c::Ip merit Elenet. I c -factors have been

widely ioest 1 get ad and ectrigastad . but these hose-icr • seem to be

so;rueshat hvoot.het I cal The negro--b! ml mgi cal modal is er it I. Ci sad

by io].o-F+ t Millsuourd 1932) as being not detinitela empiricalLy

val i dated. The tpec:,r iCS. suclgest.inc) the rol a of a hi stony of

phvsi. ce.l and/or aa;-<ual -abuse in chi 1 cffuood (Heaurien at. el

1989) separatior:--1rdividL1at1on problems related to re-a I or

i meg! red loss Li ncehari 1987) seam to be the more common of t h e

cli ni Cal studi as- rd rted to the etiol oqv of 8PD.

As indicated in the di scussion concerning the treatment of bUD

it seems that more emphesi s is placed on psychotherapeutic

interventions than on the pharmacological. Loncerning this,

C

En 11 cc: 1: A.,( 1990) -f oen ci t. he p'ccn: hod vn.ccm .i :.nnd C I i en ii

c:entr - cJ cchconc.hcs tO be i.nefi ci oct :i. n trnet:i.nb this di sor- dvr

and i. cdi c:oi:c-c that coclr -::i ti vec--hehrcc OLIrrRI •rchproachoe 'neon to have

more ';.:L.C'nEr i. cc the Lrccatc':crvL in

0 c:ociri icier-c- boL:c'.vi.or.rcI. rprr'orcc:h that has •r' :jcer'oci to he

cacti cccl •Li. c cc. ::ccrcrn fcc]. i. cc the COT approach of Yc:c'cn

proposes a -nccc'mn --- 'fcccu.nod cc,cni. ti. -ce rc.i:ci;:rcr,e: h r-.:hi. ;;:h fc::ercc'c; on

•cc:ic:rcr'::nc ic: and c:c.:q.ccc na.lce'ic:ci:ic-cr -chc.:cc : ar:; :c' He. I dhcod.

'c-:orc:ihon nc.hc-ria.n as filters nnyqwuh oh].

-con one -cc cr'nvi.'or - ccr:t anc:i experiences. This approach

eel v seemsto fc1 -rcc:e .:cj-N- on ti - crc c - oc'r-?cccr of coqnc ti on-n

the rcc:L c.:.rcj. c:c:ntcc,rt npoca-f::.c'jtv

To ir:::rr-cr'c-cLc-c this :(icflccflcn"H of Cor ci the ccrLonL -c

cit-.-- Df croci. Hr nec;, the ;.:c:nt.'ccnt.--O. -yr-ce .e:r'cnch cci - 'ohccceci b';

':rcncin] 1 (1936) on;; Hcc:-coc cr.,

liiorc-c; eL.. cr!.! .. i-if:)) TCJuflcl that ccrc!rctivec nec-.c:r.±;.c::Lt'--• ennanc:- en

therapeutic :nj:rEIcrz of c.oqrcLt;c'.-Ho -c.a'oc--';H tVonah'-i On

ciE:crecrn -i on arcci.ci -cr: i. etv, 0 crtuciv eec-f cc croci he ha] Ii 1991 cc:

i dccnti -f ted the prnnonc:o of c:ont,ent.--cchnc:i -f ic: cocjr:i ti. eec. in P9tH

' •rhr: £-.fJEiCi ±10 h'- ;r'cthr - ] cc, for 'E hi Er; ntuci'\' -Lo1Ioyjs are as

1 Pocdce - I lee Pati ents oi th POD oxpoocid to a process

94

based CE;T intervention ni ii shov t.horcpoLtt Is

3. mrro-iemer1t as assessed by the i ndi 595 of depressi on

automat i ci think i np and content spec 1 + i c coqn 1 t ions as

sensor ed by the 8cc: P Depr oes or I nvent or i • the

iLtc:m.nt: i C. [houciht e Puest I on nai. r e 1: ho Pd jar ii ye dm1 a

and the Scd'ema [)uesti onrai r a r cajnec:t. i vol v -

2. bc darJ. 150 cnt.icnt.s with 9k-i) c;<pc3aird Lu a erases a

schc:ma) ba-ned 981 inter './ent.i on vi. I i. show LIE 0EL.1Li C

i. mercivernent as assessed by the I nd i sra cc - ci apr cnn rn

aLtmnratic t.hinkir'q and content epec:i.+lc scheme-s an

neasur rid by the 8cc:-: Depression Inventorv. the

bLitCifl5.t c Ihoephtn hLrEat]. nraii - e the Pdject.i-nc bmv.le

and the I-3c:hemn Liunisti onnei ccc.

1. There will be no riluni ficant Ji++orennein

thor n:cet c of -f cclii vonniss botvjeer c. cortncrt v e rsus

process based 98T i nt.ncrvent i or -f or 9kb as :noanurccd b'

the 8cc P Depressi on I nvcnt.jn v ., the Automatic lhoccLt a

Duesti onnal re and the hdiec:t i ye Sc:al a and the Scheme.

Q.cest.i onnai re,

4. A combi nati on of content and process 981 n-n ii a-bonn a

qecater decirec of therapeutic improvement than when

exposed to a si nql e modal 3. tv of treatment.

05

There vjil}. he no siqniFjra.rt di+-fererce in the

therapeLi.ti C effect as measured by the peck Depressi on

I nvento cv the Automat i C Thoughts uuest i onnai re the

Adjecti yr. Dcal e, due to OrLier of cresdntati on in the

comb i nod pr es:at ion oc: ontent versus process based

CBT ntervertioris

B6

CHAPTER TWO

METHOD OF RESEARCH

,. .

..

2. 1. INTRODUCTION

To datE·, only Linehan (1987), (1989) and Young (1990>

have published their cognitive and behavioural approaches to the

treatment of 8PD. A pilot study conducted by Linde (1993) where

process and content components of CBT were contrasted 1n terms

o-f efficiency, indicated efficiency of both approaches. The

studv also suggested that when

separate treatments these two approaches would show even greater

efficiency 1n treatment of BPD.

( 1987) SL\gi;iested that maladaptive schemata learnt early

disjunctive shifts and

emotional sets characteristic o-f BPD. These shifts then lead to

the individual 's sense of temporal cc.ntinu1ty

and cognitive confusion. Linehan 's {1987) theory possesses a

dic�lectical biosocial theory based on clinical

observation of recurring behaviour-environmental patterns among

individuals diagnosed by BPD.

Young ( 1990) developed a cognitive therapy approach aimed

specifically at personality disorders. Young (1990) identifies

thr:o characteristics of EF[) that lood to considerable

difficulty in ojip1\'anc] short—term Lhor.np'viz

oyc:icnco and .Lonc -- torm jrtI: - flnI5cr -Inl dt+fic:uJ.t•:n.,

tr:-:.::.)tr ii:c:Jۥ-.1 of n.chorfo Tocused t.h: n. in on nnt.n:n: , cr

--Ln:ri 'I:i for cn nnn

c:1E:i.r:. L:. :,c..:Ii.rt; as extremeW :t:..L].c: arc rir:iiu:irci .i:i:.t.rrrn

thinkino t..i'inl.: dnrvci. ::cj durinD :::Lii.. I dno:n:1 and

t01..iOiLL1t. 1;i -n. Lion: V1.Y!OO cinris. ; cr through nciiEITon:

-..]nii are screpted cn.tfl:ct ci niLior

non :o. i:CO'JOYEI V , diffarencEs L:rni:L-Fncnr; L: hono I: C: 1 vcr-:rc

Lc -! c.H.Lncr in that with nLrrinc 1 ::c:i.r:nn.i :- crop;, tcncrn

c.:onfroit.:i. UI,, Vcna or use of L.hcv: • OJE:LII...1L_ rV-:Int.ioin.Ii.p

voIric::o for c:harco, the .nn : Lc:ncrco . ia icr/el. of affect 1s

highor and i.LiE!OF-. is To -on:' ti1c-: do \.rçr to the '::h? lcinoc€l c::r:i. no.

no rr.cheoan and hhrn emotive to Inniciorns cr? - 'c:rcilrci

An c.] tEn? rrrtvcn .nopnuoch of I1r is ti - cc o-i c:ontccnt t.:i:;o P

This cnin:irocrc.h lcaicic Arom the ih:rr.j of Iriointr

in-f occoLi on !nIc:cccrc,o nc ni[rc:och :'hi. oh pr - ci::ioc:no t.h.=:i

i n-cc mat 1 00 t.lr at i cc c roc: rnrnnrd on a ac-: 1. f --- - -f ccc ent. I. a'.ir I

renal lcd more frequently than or cithn:r coijiftive love] a) WE

well - = Roq ers, Kuiper Li 0 (1977) depth-of-processinci

approach ihi oh pr- opooeo that i. nfcrmnt: 10 Fl S encoded at di ±+DrE'flt

1 eve 1 rn each 1 cave]. r eprencin t i n ci a coqn i 1:1 'cc rot ruc: tur cc cornpoed

88

by assoc:i atior or path'ays and elaborated to vor - yl rq deprees of

coTp1eXity.

The hpot.hesis of this study are -forrrL'loted as +01 i5

1,. border]. i no oat i outs with f3PI) ox posed to a cont On 2

based LEiT i nterverti on Ni 11 shoN thE:rapE'ut.i C

1 mrovemant ee. sesocyd b''Lhe I ndi '::eso+ Deiressi on

eutcT.Ct.ic t.hinkinc and cc:ntent specific coonitions as

x0050red by the bock Deprossi on I nvoni:or' i the

hutomata c Thc:uqhLe. Quest]. enrol roe the Pd jecti so bcal

and the Schema Questionnaire.

border]. i no pat i crts with bFD exposed to a orocese

schema) based L8T I ntorvont I on NI 11 ShUN theraroul: 1 0

1 nrovenent. as assessed by the i ndi coc of depressi or,

eLitomati 0 Lhi nkinci and cortent spec:i + 10 achemas as

measured by the beck Depressi on Inventory, the

LItomat 10 ihoLiohts Quest i onnol roe • the Pd jeci:]. so Scale

and the Schema Quest 1 onnai re

There will be no si pr-i if i cant. di + ferenco in the

therapeutic effectiveness hetNeen a content versus a

process based CBT interventiot - as measured by the bock

Depressi or Inventory, the Automatic Thouphts

Questionnaire the Adjective Scale and the Schema

8 Si

Qucoti 001101 On.

4. P c:oTbirati 00 of c:ontont and prc:c:esc. CEll will sho'i

dr en. :cr denicn of tJe'rapeut i c I. mor - ovcctnenl:. than when

exoocceci to a single mcidal.ity of treatment..

J. There 'iii 1 be no OjnrIi+jOant Cjj.if00-ç---0 in the

t hor •00 IdOL 1 c:. E+ cc: too iflEd000Jt ddeI by t he 8c: k Ooor cool, or

Lr'i'vntorv. the Automatic ihcduOhl:.0 '.L1E'E.t1OflflOE. thcd

-d jec ±1. cc Coal c and the Cchccr.o L'ecccnLi orina:e re due to

t: he order of presentation i n I: he comb i. c' eel nt - esent 0.1: .i on

of c:ontcent ver'oue nt" oceccoed bocecid P.81" intcrvecnticinee.

To investigate t.h.arc hvpot.t"t'io, sit':tocn 'aubicct'cc dravtr' *r on

•.LI'jtahIc hOOpitIdl outpatient populatIon, from both oexeo, with a

cli at. n dill 0 Or LtFL) and depI' OddO 1 00 were 00 nosed to

inteivertiors.. Fonicdic: 0101 Lotion IJOS clone to O'Eddt:'CE'.E. ChEti'iOE

from a hanoi inc evaluation,

in order to a"c:.cj L.tnnE005'a.ar'', 0E:nsitictcotlon, iiiiniinal i.fl'fOriñciCr.

was given r'ecjarcli r'iq the purpose of the study.

2.2. DESCRIPTION OF SUBJECTS

The sample consi sted of sixteen subjects from both sexes vu t.h

an Avis I I pri ocro di aqnosi s of 8FD and a secondary di aqnosi of

IMM

On H:-; 1 a i o I OC non . c. ct- o op roan.: on n& u i. an ann nor a a -anon on

the Dth••-- I I {(c: 19E7) with additi anal diapr;oaicccivc-:n by a

team c:oncciatinci of a ci inical pay;:hoil.c:cii.-n-.t.. psychiatrist and a

medical t or - Selection of subjects was a I no dot or i ;. :d dv

the o;-:c.:luaor: c::;.t.cia no as to avoid any overlau bcct:c-near;

at: en c:r 1 an: I ho-a t a' a c: to hoop t. h an non 1 cc free of a: car:;;: I I a. a : I

diaorcicca-a natal: as ohtar c].;_;aI:or----H * - cc- ntL.;rcca E;-:ci_:aicr cc:.; ta-i a

irvr:i--o-c: cc'.,- c:.v-at:arn.;.c: dir-arcan. Oji,- -:iu-a ri.0.Ed d:.:a.:c-:c:: arc CI

any ::-r-a-ot:r;c

The na nc:I.a rarE bc:t a Enni cc-h .arc:l ;t.........i -Cocci-c --- c:-aca.rc-d.ra v;hitc:

Eojtht±r:can -a.-ccl c-care tiLt-al rod +1 c:;:, c 1 .avcJrc _cLj:J - L art.

oopulation;. ......a.po - c:::::....I. -aLt-; [ic:-yacrnmenta]. hc:np I tat 1

22..1. AGE OF SUBJECTS

The a-arc: one non of 1.F.;: nub ecta; was 28,1 yr-corn of -nor -:: a

aiccacic fcir:c:rcn c-cut: it-cct.:t-- was 25 aecarn and for IIiE?fl

2.2. 2 SEX OF SUBJECTS

a sample cons: steal of tart noma-cri and six men

2.3. DESCRIPTION OF APPARATUS

The -Eel 1 oni nc measures were admi ni stored to all the cacibjacto at

91

the beqi nni nq mi cidi c: and end of the six sessions.

2.3.1. THE BECK DEPRESSION INVENTORY

The HEck LEçJTE?001 On Inventory (HUI ) ]. 0 1T t.JEflt/ one 1 tern eel -f--

rei:ort measure of the a -f{ecti'4e , cocinitive, bcTh'-icjura

met. i vet i or a 1 and vecietat i ye asp ec to of N epr ossi or . Hoc:: ii I t cm

con cci etc of + our e-f:tceeontcci:hi at are scored or a r ana cc of C to

I rd i cat.occ, the hi. cihest dEccree of cover i t v ±.LjL' j cots or

then i. net.ruc:t.ed to compi cl:e each I torn -ccc:corcii.nci to hovj the ±eit:

i r the pr Evcedi nc cccek. I nd udi nq at the t. I me of test I no..

C Lotal acorrc, rorqinci .f: yccn or t.hinq Leteer C and 6I3 10

obtoi nod by addi riq a]. 1 the ]. teii1s. The greater the coors the

ceoter the sever I to of the dei:r000ion

When compared to ps -vchi atrj C rati nqs of severity of derccccsion

in :1 mi. cal penal ati. ore, the val. I di tv of thi cc measure 10

c:on+irmed (r = 0.79 N 226 and r = 0.7 and N = 183, Heck et

al i9i ) ) When compared v-n.tt' - the psyc:hetri: ratincis fOr

coil coo studerts qood concurrent vol 1 di ty for the HF]. i5

reported by ELtiTi Er' ., Ii]. iver & McClure (1978) - (r = C. /C N

5b.

('1 thouoh there has been criticism reqardi nq the item format of

the HDI , a survey article in the Clinica]. Pecholoqy RevieJ

r 'n 7.'-

(1988) states that of ci 1 the i nstrments assessi op depression

that were revieved ' the 81)1 1 s sti 11 the best pr&idi ctor of

clinical depression.

As + er as usape for South African condi ti 005 1s concerned this

measure has been extensively used and has been found to be both

reliable and val ± d for South A+ri can condi ti one by van E3redc'

(1981)

0 noteeorth " pSi nt. n'e..de by Sacco (1981) rhenedln]. ci st.er i. ru the

1)1)1 is that the 81)1 appear's to be a valid measure of deprose on

onl 'n' -f or the clay on rhi oh i t. 1 s. admi ni stored, Onothinc

consi. doe at ion is that assessmei"itsehoul d he made at a time

concurrent ei Lb other assessments to rhi oh ccavar anre is to be

oramined (Kendai I • Hoi ion Beck Hammen t Inprar'. 1987)

in an e'-f'fc:rt to increase the vlidit"

of results, Kendall oh. ci (1987) eu

a cut o-f-f point of 20 p01 r'ts cool d be

of "depression , ehe - eas scores of the

should be labelled "dvsphoric"

and accurate des.ce±pti on

qoets that scores heond

considered as indicat'i'ie

81)1 of brrteoen 10 and lit

The quest 1 onnairo was admi ni st.ered to detcnrmi no the levels e:f

depression in the SL1bieCt5

7

2.3.2. THE DEPTH OF PROCESSING TASK

Thi. a quest:i onnai ra corai sta of an Adjective Sti 001 us 1 i at 'Jhi oh

was adaptad +r am + i r.st.i y , lnqraiTi El; al (1987),who de'ii sEd a

1 1 at of ad act ivas to dEtOI mi no cocni t I ye spec: :1 + i I t' 1 n hot. h

anrie?tv and deprassic:n , and secondly from Darrv & Kuipar

1781 n::'i dant:a.i rscai I methodoiocy. Studies that have been

per-ormod usa op thi a methodol op'. have I ndi catcad that

].n+cmrrrat ion prc'c;eca:_;ed apec:i -f ical i'y wi. th regard to the aE].'f and

c:osi.stent with the individual s active aai-re-ferent coqr'iti -/0

is racial lad more frequently than :Lnconsi. stanl: sal f

referent ifl+0rffl/itiOfl or nor -- se] - ro -farant in±Ormat1On Snyder

cat si. ( 1982) and hJ:i. oI<ai (1982) both Tat ntai n that SUP and

clepressi on o-f ten present toqot her • and -F or t.h I a reason 1 t seemed

rei.eiant to thus use an -adaption of Inciram at. al

cad ,j cart i ye ii. at and Sorry h KLtI pet' -- ( 1981 ) methodology. inc)r aT

at. cal ( 1927) cad jac:ti va 1 tot corai stod of doprassa ye OflO 1005

and neutral carl loot I yes. Thi a cad lecti ye ii at was adapted for

thi a stud' by kcaapi nq 76 of those adiect yes and addi flP .

aiddi ti oral adiec:ti yea that are deacri. pti va of SF'S

Nol liss 1991) stud -v which identified cocinitive specificit)/ in

SF'S was uti 1 ised to select c:ocinitions and adectivoe

charactori ti c of SF'S. The adjectives chosen were descriptive

of the thouqhts and the emotions surroundt nq sexual abuse,

ax t,raii-ie einoti onal I ty and identity concerns distinctive o-f E4PD,

C? 1

adjectives which It 800 1 nd i. :.at'.ed to intrude on PtD 1 nd i vi dual

-. . I.- - ..;_.. .. 1.l ... i 1 . ....

UmIl.L LII.LfI.IIC 4cti.I.J..- 1 i17.L

... . . 1 Ii.iiL1IJ

.. ... . - JyL,L.icjp1c:::.

eo per i enc: oP i. [1 the diagnosis and treet:men -I: of El) were •oe:ed to

indicate vhic:L adject.ivc:s puneratd were most c--pti--o f

ens En sue of t. hose or! J or I: I '-'ec were ]. no I UCi oP i. n t. ho final

liziL. lJaIiic-:, 1991),

The ccrairirc: 76 oclie:;.tjves, as

c]st.rai ad i(:.t:i. •s.acc and 54 ci-::IEcce.]. 'is- or negative ?ca: ti

Dor 1 1.-: Kc.iper a (1981) dc:th-o+r , c..ceeainp rici.dontaJ

i soal I. ia:dccloov. cc'.jbioc:tr ...Co asE:ao to coca.l or MERV

they r;osn:i. lily c:cu].d three minutes after .I"v ' .

cr:op.et.ocl the PJjscti've 5l:.:iiiulucc I__iet This was drine to (I]]. loll:

nognitive c:.chrmas di et.irictive to each ircli viduI .. It

:io::[j008c that BPD irctii:ccivals all II rec:ol I orion - i. lv border] ire -

spec] +ic: .ad,joc:t.ive-cc,

This list was used to -as -rose the coorit.lve specificityr

to depression and borderline iO;-pJer I ences • as or] I as t- -

sell-referent i n-f oriiti on proresoirip. it was used

oulciEl inc in focusino on specific c:ont.ent c-jhon Liti hemp the

I Lrt0 t _Er lE - \ entjr I

This measure was found to be both reliable and vaim d for South

P+rican population ciroups; by Wall is (1991)

95

THE AUTOMATIC THOUGHTS QUESTIONNAIRE

Ho.L ton t F:.:endnl 1 1980) do -vel oped this qLtE2St: i onnaire to

the +reqLtsncv of depressi en thoucihts or nnqat.i de eel +---statoment-c-.

asooc i. at.od with dspi- ser; i. on Tb 1 s measure was ut i 1 end to

aecort.ai r cocri ti vs octi vi ty since it i c rearded to erhi nit:

qood speci+ic:itv (Hot Ion Lends]. 1 & LUriftV

quovtionrai cc is an instrume:nt of c:hoic:e, the TO i tecr-r.

ci or f i cartI v di. ocr i tnt note hel:ctoen depressed and non---depre-oeod

tndi yiduIe and it is re:reeent.at:ive of the tense of coc>n(tiore.

that intrude the (c hounhts of de:rn -c-sed i ndividuals.

he ccuest iortnai. ccc I icts 30 neqat i \'5 eel -f ---statements and requt rev-

sot iect.c; 0cc rats, on a 5 point. L.i tent. ScaI.e the +renL:ccncvciiLh

eh i ch each sell ± ---staterrent has occurred dcci on the east ecccf:

Total scores are obtained by add inn the rating. or the Li -cert

Scale of the TO 1 LBns Scot -- se- can r- ancitcc hetcjeccr TO and 150 1 ha

hi oher the score t:hec1reater the l - requ.encv of dtcpr -

coq ri t i on 0,

V-ali cii t; and ret I cclii. ii ty of the LTD have been sstccbl i shed crc

c:iinicai popuiatons as well as in sub--c:llnlcdci populations

Holion S Kendall • 1980)

Purne (1980) as se1 1 as Linde (1993) + ound this quseti onnai re to

he both reliable and valid for South L-Fnican conditions.

96

2.3.4. THE SCHEMA QUESTIONNAIRE

fh 1 0. qunot 1 onnai r- e was duvi ned by 'i'ouricj(1990) and i a a]. med at

i denti -fyi nc an i ndiv]. dual with personality di sorder ' s Ear].

hal adapt 1 yC Schema. The measure conn st's of 123 i tern's -h 1 oh ar a

prouped into fifteen c:ateporius

* dopendenc:y

subjugation/lack of i rd i vi duat i on

vinnrah1 i ltv to Liar ii or iilneun,

* fear of 1. csi p COi]ti ol

amoti oral deori '--ati on

0 abandonment / 1 os's

mi strust.

uc:ci a]. inn]. ati on/al i erati cs

rio-f act 'en en's/or - I ovab jil ty

ooc:ial u.ncie'sirabi liLY,

ncompetonco/fa.i. lure,

* ou:i. it /PL'.ri c,hrnert.

'shccncs I' iribarr acamant.

* onrel anti op otandar d's • and

* entiti emmni.:/ 1 ru -f -$- id art limit's.

Each of these cateqori en is indicative of an EMS fcccordl np to

YOLIrq (l7O) • these EMS are either maintained., SVO1 dud or

compensated for within the md lvi dual • and can occur vi thin the

97

coqrii ti ye ri cn , the affective sphere and in 1 onq ter

behavi oura]. +u.ncti Oni nci

9ub iec:ts are asked to comni t.

a si> point r- aLinci scaie in

bob octs a! e al so advi sod to

of emoti oneil ±esi 1 flCIO ratjior

c:Ltc1it. 1:0 be trL.!e

an d

ter rs

r Espol

t. h an

sc:or C each I terr acc:or di nc t

of ehal.: het descri he thor

d to the I tems on the b.esi

a rational bel 10+ about crh

cua].i Lat.ive ana].vsie was made, payinc epec:ial attention to the

highly rated items of b and 6 poin:s,as these points to t.fla

resence of EMS. Once i denti -fled , the theraç:i st and oati. rnt can

identify dai I v pattErns of behavi our which may be rel eted to the

scheme/s and interventions made to weaken the prominent EMS

Hovever, , 'T0_1flP (1990) 1 n cii c ates 1:.hst cc hemas are on ly

conctr ucte , and can he used to i cci 1 1 tate and pr emote c: I ear or

common I cat. ion ni th i n the t.herapeut Ic: re] at i erich i. p

98

2.3.5. THE STRUCTURED CLINICAL INTERVIEW FOR DSM-III--R

PERSONALITY DISORDERS (ThE? SL2it)11)

In contreal: tie the rr:ie traditionally nlayed by payrhoir:rhcel

raeaairent , pa'ychi. atr 1 C: di anneal a can now be madE? E?++ 1 C: 1 ant. 1/

thu ounh i n f ormet I on nether oh i n a mon a Or 1 ceo struc. Lured

ci i. n I cal I nter vi ev In that the cur runt. di acinoot. i c a uteri

j ncludes behe'r.ourai. markers with a ucieci+ic: time +i'aina the

data may tact he obtairr'nt in an :riLerviam and ec not 1:apeci in

taute that are a c:noau eec i:i onal sample of b mh mu i our (U]. dear

Studol hal iran Hvier I. Davis. 1972)

The ID i a a aerr i -etructur - ad i r terv:i ce r: cinduc ted bv thu

ci inician tir dieqnoue and eaceca ç?ereonciltY dicordere

This :iaaLiCC? was +ound to he va] I ci and r- ci]. iabia by Dldmarr

l):rdr], E:el] ner, Hvier & Davis (192)

The dUD-i I VJOC used to auci at in clear di acinocci a of E?FD

99

24. PROCEDURE

The TnubJects used for the study were askuci to compi etc the

above -mont I oned quest i onnal Th i a was done on 1 y .a+ ton

in-f oYiTed ccinsent was cbtai nod,

The P1)1 was preunented as the -f i rat quest ± onnai no and was used to

nscertnin the ] evels of depression of the atnbioohs. The

sL.(i::lTnc:ts were asked to road each seritencrr in the ciruop

statamerts be-f one mnJ;iru: a c:hoice. They were naked to rats non

'ci--oi-r Pt 0 3, thel r feelings over the oron-±ous eeok

i.ncladina the day of the inter-•--i.ew.

The Pd oct. i so Pt. i jiiu.l us Li st. was then admi ni stored to assess the-

ra-.tLcra of cc:pi t '-j n schema of each subject. The measure

c:on-cii cited of a 1.1st of adccd:i .'es ehi oh the subject had to rate

acccndi.ni to a nine point rnti.np scale ehere I indicated a ].cti

like rio and nine ind±cnt:.ed not al all like me? - After

comr.iletinq the puostionnairo, the sub cots were qi.ven P rninutorc

be-fore the 1001 dental recal. 1 part of the task took place. Here

the sub i cots were recjr. red to -r i to doen as mans of the

ad ect -i '.'ein from the questi onna. no that they could remember.

The -rLrtomat1 c ThoLrqhts Quest i onnai. re of Hol ion t Kendall 198)

was administered to assess- the -frequency of depressinq thouqhts.

Suhects were asked to • on a 5 points Li kert Scale., rate the

1 )()

frequency of bt c :o depreec 1 Ofl r ci etod coc4n ii.: I one during the

previ cue ceef:

To ci I cit EI'l% the ec:hema cucci I c:r nd. i - c was administared.

di: onto were a.cckcd to rate 123 x -1:emcon a 6 [JCi] nh OCdi 0.

the ouoti ailnal re had been compi etch the ntune of ti'E:oecccLci:

was d:i. c:-ceecj with the cub loot,, ravi no cocci. a I at 1:'l:rit:L or -

those turns that the sub cot c-coned the highBst- -

JOl. ntri

An introductory cocci. on nsc:cs:lod the :seL 505.01 One. Di: r I. :u

this cescion hior- .cjhjca;L in -Foi- rnatio -- was obtained, and c-i:..

acorn, one were oorttr'ac:trcd +or. As $:dr as in -f onrnino -cob onto.

the i i mc of the ctcd v and the type of t. her aeu t i c I n 1: en von t I on

to be Li-COd • ml n I mci I n-f c:jr met i on was di cc] ocir.d a ci as t 0d'C.ii Ci

un0000550.rv deconc;:, 1.1 cation. Final iv -i.Lih loots were aiaf::ed ta

ci orrip]. etc il ] 5 of the stat. oh priest i urn ci roe bef ore l eavinc

the end of 1: he I n : roduc: t c:rv cc-os i on The USE of h

priest I onnal. nice wa s no]- r aimed for the cob i oct cc i n tonics of thus

bei no ncircr - ccte nac- s to indicate any chrincpoe.

1 0 1

2.4.1. INTERVENTIONS

2.4.1.1. CONTENT TYPE CB INTERVENTIONS

Ei cht. of Lh3ou.Liucto were rundorn]. v assigned to rmn.cn..h v'o contont --

t v n. 15 i ri: cc unt. I on bn.cf ......e i uc.ui. vi riq n on.: eon.ctyc IF:

crier the o1:hor cii n.ht s'b_ectEr were

assioned n.oc cicoi vu the rocun. - type inti .....untic:nu L:ur::rc

::turL --vn- i nLcnc rflt1

..:uri c-f i.durL:i.yirci the o_ib:o::.to nicur-:

du1:n r::-ool:--rju and bor:leni iou nueci ic: copriLic:nu for the ncntn.nL

1::'/j:o- [IT.... ntu .......ontiuric:. ttio -foi I. ociinp two qn.otionnn.ircn.: cien.-

on :1:: the depth -o{ ....orf:oemn.siriq Lcd: vICli iliCiliLl

bcn.- do].inumn.puc:.i.k - ic: odn.c:-[i.yen., Eorrv I: :uic.iEmr, 1181) iii. ...i

C Munanks Westionnaire of -IcI Ion I Kurc.rci I

Id uccr:r WErE coed au n. n. to p r ov I do n. u I do 1 i nec: for ih ac

.1 nIna -n.Ecnt: ::n would ho nennocioura The 001: Cci: were then CL vu

expla5stirD cjfhn:n.t.hc:onteri+. of orac S t.hortnht.o duLern.ireo 10-n

ernc:0:i orn; that one + Oci In.

Therapi. ut: "If you real, 1 a thi nft about it our EliOt 1 DuE

is): OtJcin.IE from no..n.hern.n Sc: often we thi. nL: t.hn.i:

a c-il tuat[. n.. COL SOS no to +eel or reac:t in 5 spec 1 + I

iiSkfliiEir . But butviuen the ti. me that a si tout: 1 00 DC:CUr

and one -feels an eriot ion there is a oup vhi ch you + ill

ai. th your thouqhtu . All too often these thouqhtsCe

102

c otc:1T.t].: that we are not aware that we octLkL.1 1 v

L.hoL.cht something, all, that we are aware

uiTtc:ut. i on o 1 sensation. Nothing c: on change situations

and thi. non hoppnn:i nc to L.O. but what we do have

c:c:rto1 over, and what we can c:horoo In the v,ov no

fhinb. about the ni. Look: i. on • bun VJO r::nIc:E:i. ye i t.

toiic:k.Imnn t.hune Lho:.nihtn are rood lv quite Lintrue

and even irrational. out no be]. :i. coo: their to he Lron

oiLLorot: irorc:h eLd]rc:r: YC:i._r:Lo these next

we are not on]. v going to t.nnoc:h YOU to I certi +

oucht:n but niL cc: to d:L:iotn them orr err: ......::lc.

i=(I yc:[LL ttc....tt.r:. that are rrorri : o:. t. i cr:o i.

Subsequently the icotionlo can then c:i vi:: the therooint e:nniroir- -I

daily scenarios, 10] ci :. .: ci 1: her oo I cit. can eon i. nt. the rot: I or

ior:.:vircl ti:oqlot:: that jrec:edn emc:ti.onn. and

th::_cihti: that no irroi..i. ornil and c:reet.c: iriotior:oi discomfort

ihoieorL can be qoer- to the potient to purqcn.e -i.1yioc:-; tj:..

throne thouchts n. no e'/er'cio/ ni toot. 1 one and nubot i LLiCE thorn

Imm

Event Thought Emotion Substitute

My L L1Cb n Ci I m lazv and R2jeCted So what P-

rold re :h eL he Lh: rJ-:e I erd the :ruoer is

no coc:c: Hr:t. cc:i.ci I v:i I I.

C::] d ret herl::.

Doesn t

ther e.:rrd SPROTjonliv it the specific.

cc:rd:nnt in the identified rcinitionr lr--crm.rtion ett.ei.neri from

the ether qrreei:.ienreirE:e c:crrr: not uk:i C;Ed at this etion in

.:nrtilninh the contort of 1:nhnrticfln.

i :Lctrtnt. :: or inner

t:e+rrn rnit:.ei:::i or the [JrOEhrCE -- I:.ve GH i:ter.c:-:nie c:rsr

.iOECi1:0rC(i:h]. c:::tn 012 the + i ocr: rOt: one

q_.e ott 0Ofl.Oi roe-

104

2.4.1.2. SCHEMA (PROCESS) —TYPE CB INTERVENTIONS

For the process--type SEt i ntervent i one the Schema. Quest. 1 enna ]. 0

c;:omp]. 1. oh by YDLnQ (1990) carr i. oh the most hoi. pht. EMS were

identified here ehich provided the t.L'iorapist with ouide 1 men

for thor pout Ic inter eent.i on The other ciLEst. onnal (00 eeoc

used to Orovi do add i t I orl 1 nf ormet ion and to hi. phi i pht

The • .al:.er c:orro I. ct. j. on of the cuesLi. onuai ros were given

0 bio+ cco1orin:ion of ec:homas shch invoiced disc'._ccsinp the

nature cd -sc: UiO iiiO • joe they -ar o mel n t. -a i ned and hoe to C: hoop o

L ho

The :oj 1 of FFL:T 1 -a to t-eekon t. he EMS as much as possi. hI. cc and

build itj the individual's jr ]liiirc side.,

The assessor-cot of the client is alirod at firstly identi-yc.nci the

EMS: and this is shore the 'sc:hema ruestionrairc is icti I ised The

thor cci: 1 ot iii so needs to know about recent 000fits OF

circumstances that have dri von the peti ct- I: to therapy

pet]. out hi story needs to be discussed and the therapist noons

to make notes of hohavi ocred patterns that 01 dIht. be indicative

of EMS

The thorapi st can also make use of i maerv to assec-s schomos and

105

pattorric ro 1 eiteci to echomac Such 1 ifla.c10rv may 1 nvoi ye er

the peti rent. to c:lose their reyres and 1 macu ore therricel 'cc err

chi idron with their fairil ice or to icciaqi.nre there first intimate

pc:r 1 Enc::ce

To weaken the :rc borne • one -iir ci: I V needs to ecce icc eh i.

( 19(h çjroceoerec of eiamntcrence a ici canto c;

corr:E?rriCkt:L Co Err jet or Lhi n the individual. Hetcrr:: pr ::eerrrrc•r: verve

cc: aced 1. C: dttii. 0 1 Ci Lha.iJtcrr U

Tec:hni. C ice Lco.:i then t::.:recrak;eii t.hc:: identified ecrcrne C er cc

cooniti. 'e or behareorrel

t.Ecrhr:iCicte Ei'r:c0Lracio the :)tiEirt to career ].eric;e and to

the emticirre1 aerecte of their probl ccc. Iccaci.nar'• CL &JOqLXE eriLh

a preroor to ohcern cniiti ore. are d:L rec:tcci can her used or a i ott ri

can be written to the jEC eon

Interns nr::rcri trechnicin.tere i. rivo]. e t.iie p.et).ent. ri. lrterccti.onrr vJi tn

others bEtiruree in ttij cm the rechenarm ire cm a,ua]. 1

t.h err err I ret-- pat. I cent. r cl at I on oh 1 P can be + oc:tireed On as ore]. ]. 2 i_

c - el ationrehipre with riricuni i-icarnt other- c, ecu. :inciudcno the

patient ripource in therapy or respor:ore from the nipoucs crut.nnide

of therap'.'.

Locur:i ti \'e techn 1 DElCO CCC thoree 1 fl L-ihi oh the schema dr I von

coqni Live di retort ione are chal ]. erricueci Pvc-f uncti renal thoucuhtr3

IMM

are i dent i -f 1 ed and e"-' 1 denc o + or or OcIOI iiot thom is COnS]. her ad

New t.houcihts are SLkbSt]. t.utod .-itd al 'Lornt.i yes soupht

Eioha'vi oural t nterventi ons i nvol vs i denti +'ro, pattrno of

:etioviour which ind]c:ote oc:srros. Role ::lavr; ait.hir the

therapeutic -vit:u.at.icn can be used to c:h.oi:cr-ccu.ch patt.c - noi -

p ro i is al t or r at. i. ''eo; or a i '• i riq the p at. i en t. homesor -c to do which

i a so]. as not on I y bet c- ci ao-r-cr a of p-at 1.: or no that 0:-i par-ca

i oh::. cat.e [diii but r.rcci. no substitute hohovi. our

th.r-l: i- 01 JrLA'd 1flvr -JOel +CLT.U -ClrIO [OliflJJi1 I.e

and soc op arnutic:n.:.I inter::ersona1 , uts•kL.jL.kiel. and

LLCJi Li. eS tech ....i. u.ecr- to ch.arcar- or challenge their,

a odrrinis:.terinci of the ocnio.k: ior - nccj c- es was as for thac:ont:ent --

tops [iii 1 flierEitjCi,

P+r-Er the six -r-:-EEccioflE were c:omp1eta a follow up sesoccor

scheduled with the sc:h:ecto for the purpose of tonic n.nnenc

acquiring of arv other- cctuclv rol ated in-f ormat. ion,

1 1 was ocr sod up On that thoro soul d he a two and

cciii i'ieo4: follos up telephonically to c:on-fr-rm whether results of

the iii i ntervan Li er-cc. had been mal ritac nod

1.07

2.Z. EXPERIMENTAL AND STATISTICAL DESIGN

Tho Ejor i monl:.ai desi qn consi st.ed n-f' o comp<3.ri cci n -F tho tico [.0

1rtccn'E?nt1oris cr'ic].vsn•d Lv coans s-F -fir ccL1 -y in -ferErt.]c

cc-

Lat.iccticcl on-iclysic and secondly dnscnintive ccci: ticoi

he n-f erect ci Otctl ccc cc] cccii vsi,s uti. i i ccc:! t -test arc] one

ml -Li cni aLe cr-c1.vccis c-f 'vai-i.c-nce to test fcc ccc ann pcisL ccci:.

cc. 5c c:ant '5 ErE'flc.E-cc and the decc::ri pti -crc]. ccii cc i r' the -torn

bc.: ann] -•-J!if c:.c ri ots-.

3. 1.

'

.

108

CHAPTER THREE

RESULTS

INTRODUCTION AND PURPOSE

I.. i. t et·· at u1" l'? �suqg 1:,·�=-t ;:_, that th f21'" t'? is much controversy surroundino

the definition, etiology and treatment modes for BPD.

the dt��Vi?.1 Clpil'IE.�nt coq nit i ··./t:�--l"J f?f"t ,:av 1 our· E•. l

various psychological

today's clinicians and researchers in this field to investigate

the borderline personality disorder more closely and thurouohly.

Literature also suggests that among the various treatments

proposed for this PD, cognitive-behavioural therapies have been

most. succt:.!S'.:;ful (L.inehc?-n, 1.9F:l7; Tur·nt�I' .. , 1ci87; Yc,un9 l.9'�?0).

P1 pi lot study done by Linde (1993) ir1d1cc�ted that co��ni t 1 ve

behavi c,u,-- ,"'.l

was effective in the treatment of BPD.

was significant decrease in depression (as measured by the Bee�

Depression Inventory), there was also significant decrease in

the negative and borderline adjectives (as measured by the

Adjective Stimulus List <Ingram, 1987)), there was a significant

reduction in the amount of negative automatic thoughts (as

measured by the Automatic Thoughts Questionnaire (Hollon et.

109

al., 1986)), as vje1 I. as 'eiqni+ icr.nt: j •c:ieese in the iteme thet

represented n ec.t I vc-:• eel + -'-ee+ er en t c: oin I t I c:ne ancln.ch emee

cir-:eeur ed by the Schema Dueet I on ne I re Youncj 1990)).

rI rrr•:d to i ci er ]. ±' functional components that

cc:rLc ] !::trt.cr to the effectiveness of t:eee two typos of

interventions 00 well asorder n• • e:ct. of I ntorvcorr I one. i +

Thu :jOCJ.)LC hypothews for this etu.d.' are as ihni. ]crve

bcn cool. en nroi er:tcc with ore 000ec::c

booed hh1 intervention -1i 1.1 ohc:' therrrpoot:

improvoment as ri -cec-re-looci be the indices of depressi mi

outomcctic thlr:1rh nncicl c:cntorit specific c;ecenitionc; 00

rroeor mci hy the Er:c::: [.o:jrc?o.eicn Irivmrnt.orv the

-c.1tc1e':.1c: focccjht.c; L.L1crot:cor:ne].ro the fciJcrctivo :c:.0.i.e:

or: ci t. ho bc: h role C•tost I cr n I: I r c respectively.

Eordso II rIP nepti critvnth BPD e:-ipoe-crd to proEys-

(schema) ) h ocred [lET 1 nt err ent I c::n will 0 cnj therapeutic

I imp rev ener t. as crcm.cre000d by [.h ci i nd i ceo o f denreree i or:

outoTet Ic thi nki. nc and contort. open -Ii. c: echemere as

fli000:.rr Eel b v the idor: [: Deprooci on In crn too v the

Lktomet Ic: Thocccihto bluecti onnol re, the Adjective Soil er

and the Schecra Uueot 1 00001 re.

:1.

i?rr will be no significant difference thp

t. I'gr ccp ct i. c: ef 4 ect, :c vci"ccc b ct: ccr" .c content versus

occc:ccc bc.'cci LII:f : rtc:i""crt:L c::: for Un .iit'ic rrccLt,cecj bv-

the

iiC:l.: 1i)c::''c:•ccc c:n"' Iir':vc::i':t.c:i"".", the '.ccc'L'j.c: lhouqhtc

._.rici 1:.tc: 'cr::

[:!uec'L. 3. or'".:ci cc

:

greater dcci''cc of therapeutic imprnv.went

E.•':.::c:cct to a crCE

5. 'fhcco will b y no o::':r:I:':c::c': c'-1'cr'i',Iic

therapeutin ''4'c':'t" as '.,.:'c.Ic' tj',E Beck Lcc::"cc.'c cc

the f1t.omnot1 c I3cc.1L'tos ccc'!.::. ccnr cci cc , .

'dEc:'I:.i 'c: j'c:ci cc:. dccc to or'ciccc" of _o :"ccc:u"tccti "' I H LOE

c.c:;:'i:: 1 'cod presentation ':,'c r:t.cccit ccci ccc;

L:Li c ntci''cccrit 1 crc

I"h:ic c:hcc'iccr cc:.]. I dccci. +irctl 'v :'•cith the 1fl1i-cc!'ct1a.I ct.ct'i'c:'L

:crrc1'vc.cc and c;cc:ondlvco.'Lh the descriptive -cccl dcc of the

oh t .c i cod St ct :1 ot. . C:: ci. ICIOOE,L',r ccc ccc c ccc ci t cc t 'o'L ±

ci.nc+'iccnt di'ffcrercc:ec'o betcoon the c'-'c:cpc at Lcc.00l ircc, cttccc.!:c

of . •• intervccntic:ro and the thOrOOL!L1c c-i oct.c. Of

the orc:iccr of i rctervccn 1 i ons

111

3.2.. INFERENTIAL STATISTICAL ANALYSIS

0.2.1. DIFFERENCES BETWEEN GROUPS AT BASELINE

in order to c:c)i::)ccrEc the tcJcccIcc:cJrj:;. 04 bc:-.c?.L ccci

assess whether r c:rdr.ci:i. c:jr jic•ci. effective, a L. ---- t. cc-cit and

:i':ltcvcirc.ctcc cc1cir]ci of -.j.ccciuiirCci ccc•ce I:ecT::cic: -cu on

cc ci ccci :c cc

TABLE ONE

COMFARI8ON OF BASELINE VALUES

Two—Group t—tests

GROUP MEANS

t F

a b

PDI

dl. C.. d..:d

ASNEG CC 4 20.5

one way cicil t 1 yr I ccte are I ye j cc of yarc.c-krcccc and ci t - tEst tn

compare the two proups on basal lna 'IT.) LCCCTT rcivalec:1 tI -cat the two

eroups were corrpcirabl ci on bcicii i. ne ye) ues and that randomi. cicitl Cci

was ci -f+cictivci (P>0. 05g sea Tabie

•i 1. 2

3..2.2.. MULTIVARIATE ANALYSIS OF THE THERAFEUTIC EFFECTS OF

ORDER OF INTERVENTION

in order to analyse the therapeutic

two I tE.:IvEr 1: i c::I a onE ---- Ljo- multivariate analysis •-•

with 4j. IL::o L.-Eoc:L c:c: - o - i En•r'it. was performed.

TABLE TWO

COMPARISON OF ORDER OF INTERVENTION EFFECTS

GROUP A GROUP B

W I LI< S LAMDA P-VALUE

CO-EFFICIENT

4

:3

A3NEG

2- 2:12 1.813

A one v-a--/ fF0.1 1: i vr i eto analysis of variance to OE-CEE

therepeLktic e -f-fect.s of the DECIBE of the i ntervent i ons rOvEOl Ed

no significant order e-f-fct. tii. 8....'cduen . 8.15; eec

3.2.. EFFECTS OF INDIVIDUAL INTERVENTIONS

3.23.1. EFFECTS OF CONTENT—TYPE CDT INTERVENTIONS

In ordnn to EtE-'rm1 no tto o - OO1......onono too

E.. LOO. .... to.rvontic:rio

ij

TABLE THREE

EFFECT OF CONTENT

MEASURE BASELINE FOLLOW—UP t—VALUE P

ij

ASNELJ 4 22.4

1. S 5/

TABLE FOUR

MEASURE BASELINE FOLLOW—UP HOT TZ DF F—VALUE F

LI rerIEi. or- rE

c:f-I EC:t.I th mLv.uE of do:iooi c:jr I nci c:.t no on J.

diff eroonco LnI:i.o u!:-ooco.ortIy L-tcct.

on tic at.i:ocrot.:i. c cloj::r'000. t.ho:.c:ito covooio::i

LO tiL0OOE D0 - 0O(n0Ci 0 Inn

cd ccti 'vOO o.cc. mood ccl no ol c:ni + I cont. di 1+ ononcc in

border! inc cr - cl neotr.oI. .odinc ... 'coo IFtC:. Ott) but j i

mean n. tb nLJcLL on ad ccci inc. F:i) 05)

3.2.3.2. EFFECTS OF PROCESS-TYPE CBT INTERVENTIONS

[ri order to aeeeee t h e of fec i veness 0+ rocess--te LEt I

1 rite:rventi one on the meacuree of dc:r eeei cit ae neasured he tte

Eec: k Depre I on .[ nver- i:ory the Deprossi v 0 A'.t : omat c Thciuciht

rn000Ltr cci b,' the ALtt. cnit i. C. Ihoctcih±_ e Duciet 1 orraj. o and hoc der 1 1 nc

necat. 1 '10 and neutral ad oct i 'ios meaat_treci b v ho id .j 001: 1 c.

Sc ol c . a - eeL per 4 orned

TABLE FIVE

EFFECTS OF PROCESS

MEASURE BASELINE FOLLOW-UP t-VALUE P

AT 83.8 77.55 -2.97 PODS

ASEtI:R .s 8.s75

ASNEU 10.5 22.875 -1. PO.05

ASNEG 2.4 0.8.3 -2,57 FCD.Cl

1 1 ?

TABLE SIX

MEASURE BASELINE FOLLOW-UP HOT T 2 DF F-VALUE P

EDI 28.4 24.65

13,9009 F.tI:.

U 9 .6805 F::. C. 05

ASROR 9.5 8.375 16.6701 / 7.1443 P1001

CNEI.i 30.5 23. 875

55.1971 / 16.3625 F .::..:;

ASNEG 124 983 38U 1505 P

'L-tet pr-formEd to assess the of ocLi '...er'000 of the DC0000.0

type ............'ient. I ore on the levels of depr esr-:.i on depressive

outomati c thouohto and border]. lnrr • neutral adiectivee revealed

eini+ic.arrt. moane F.0U05) An i. nai ofli. f i.carit. mean was found on

the fl ç1J UUC ad jt1 p

117

32.4. EFFECTS OF PROCESS FOLLOWING CONTENT

In c:rder to access the a -f -f act i. veness of the jr ocess CF:1

oil cjj n Q content - tyne t:Ei i on macsLices - a-f cieprEss1 on

ciepressi VO cUtOmati a thouqht.o a n d border 1 1 n maclet. I IE end

neLktr-al thoucibta , a. i--teat v4as per+orrred

TABLE SEVEN

EFFECTS OF PROCESS FOLLOWING CONTENT

ME(SURE BASELINE FOLLOW—UP t—VALUE F

21

10. 8.5 281 F•-.::), Os

45N8I5 10.4 219 97 F-:0. uS

2,, 3 9.675 ---2-i

4 t---test cier±ormed toassess the e -- +COti veneEs a-F circiceas :'L

CET +ol 1o4ino content ---- types 88T reveal ad no 5101 i cant

di. -f-ference 1 n thE? measures 0+ depression P--0 05 . 5i ml -Ii c -ant:

means ere fourd for - the mecaLtres 0+ automatic depressi

thoughts and borderline, neqati ye and neutral thoucihts

118

3..2..5. EFFECTS OF CONTENT FOLLOWING PROCESS

In ordo - to assess that o-f+ ec:to, of cortnnt.---tvrn L;ET -oi1o, no

nr oc:.eoo--typn LET on the rnEasur E:o of dE:pr ec.c or ci Err nocci

.L1t.c'm5t1c thouohts and bordon1 irn, rnciotivE and r:tnol

0 t--tst was per+oomed.

TABLE EIGHT

EFFECTS OF PROCESS FOLLOWING CONTENT

MEASURE VASELINE FOLLOW—UP t—VALUE P

1381 284 199 5. 67

AT $3,8 73.55

88130R 95 825 276

AS'NEG 30.5 23.875 2.94 8. 85

ASNEU 12.4 16.64 --4. 24 P -ID. 45

A t---teot per+ ormod to assess the of +oct.i vonnee

813 F i-oil oving proceoo -- tvpee LET revooled ccicini -Fl cont. difference

1 ri the iTC00L0CS of depresc-;i on outomati o depressive thOUCht.0 and

border].ino neqative and neutral adcties.

119

33. DESCRIPTIVE ANALYSIS

3.3. 1. ANALYSIS - OF THE THERAPEUTIC EFFECTS OF ORDER OF

INTERVENTION

Efo;< and whisker p1 oto see F ciur 5 1 --5) of the thei'aseu:. i. c

c-f -forts of order of I ntervcnti. on indicate RD O. cn I -F i c ant or d o

c-f -f oct. FOrth or more • from this ana]. so I

it is aciparort 'Lt.s

tiese I os. cono otent rjatt.orn across al 1

sao.rres of a. do-f i. ri

treatmnnt n++ent,

120

3.3..2. EFFECTS OF INDIVIDUAL INTERVENTIONS

3.3.21. EFFECTS OF CONTENT TYPE CBT INTERVENTIONS

t. ---toot. p o- -F of- - onac to a coos CJbet.t00 t h o CE3T i n torvent I coo

v: +or Lhe measure o dpresi on I ndi c::.nted no ci cni -fic:ont

CII -f-f eoonce (I•.:--O. 01. However w, bc Lho data ic c.t.

and i 'r p 1 c) S, e E, h ciur e) • I t bE:omso np:

inLaroL:Ij v1?;iorce Ne;0 0± such a noL.;re acto ob'yit

siuni -f icant be can the pro--test. and cost--test.

vOl000, Li.eise. 0 bc;-: and e'hisJ:cr cio: the bordrl 100

ad i oct 1 VE5 ( c:'o Fl. cuie E and tne neutr al adiect.i -Es COO 0 F CILO

- 5

ih) inciicotac a dm1 lot - trend., The 5:-and jhioF::er clot-s

SOD cect. LhcL there -as ci cni. +1 cant. j-j •f 4- in thE (TEOCCCLIOEE

-

'F sr depr 005]. on • cc omat j c: t h i n ki nct and hordet 1 1 no nocot. 1 dO and

neutrJ. odJeCt] se-c, (see FiqL!rE /)

- 5011 I - i ciure 1 1 i t. oJTJ00055 t:hcl: l:her 0 0 dOs OJISO I 0 E1H-

121

3322. EFFECTS OF PROCESS TYPE CBT INTERVENTIONS

(t-test perforied to assess the e+fecti veness of pc oceas--tvpe

2[ interventions indic:ated no sini-t-icant di+ererc.e for the

iTieaSUres of necat j. vs ad j ect I '-isa (f (: ) I-loever, wh2n thr

in+ocmator is cast in a box and vihisLer plot it bsc:c'e

appar silt that I rtr agroup variance were of sLtc:h a n a LLr5 as . a

LJEJ Vi ate any si Ct I + i cent. di . : 5rE,ncc's betNeen the pmc-' - prf --

tEsj- values. The bo:c and whisker pi.tS saqoest that thercc was

s. on -F i c:ent: di. - Isr enc:ss I n the maccur Es. .....depi assion c-u toseb i.

tb I ok i nc ar- c_I Lu do 1 i ne • n eot 1 we and n eut- ci ad cc Ti

Fipure

From F i pure 12 it appears that there as a Decrease in EME

3..3.2.3. EFFECTS OF PROCESS FOLLOWINS CONTENT

}3or

and Jhj ski i ots -f or tho metsureo of dEproosi. on , u.tomt i C:

t.hinki.nci and artd nnt.ral ad ian'Li '.'ra

i rid i. rate a c o r i t e nt r- fr'n -41 -1 j 4: -J. --- di -f-f erenre

all neaEUrE- aE- roe r: e

f-' proc..nsn-- L'po CE3I inter ''enLi or +ol 1oinn c:ontont

-

t-oa

Li Liii - if i : 13

rchera c.Iuort i orinai rE • - h i ch nnent a dec:rr.aoe i ri the E!'1

eea n.t - - e i.

QX

(3) ci) :3

('3 25 >

l;?5Iq

ai

35

2C

1

A A

BASELINE CONTENT PROCESS PROCESS CONTENT

ic

A - GROUP A B - GROUP B

FIGURE ONE

AT

100

IiI

Elm

r: i (I) 0

Co > 6C

'I

A 11 o

BASELINE CONTENT PROCESS PROCESS CONTENT

A - GROUPA B - GROUP B

iL3

FIG(JRj TWO

I23C-

BORDERLINE

IFA

11

10

9

(I)

Co >

7

€

£

Il h Pt 13

BASELINE CONTENT EROCESS PROCESS CONTENT

A - GROUP A B - GROUP B

FIGURE THREE

NEGATIVE

I I I

+

45 - -

40 - -

35-

P + 30

cz

25-

20-

15-

10-

i) A eJ

BASELINE CONTENT PROCESS PROCESS CONTENT

A -GROUP A B - GROUP B

FXURE FOUR

i2-3E

NEUTRAL

I I

24

T

22

18

16

U) 0 3 Co >

14

12

ic

A A A

BASELINE CONTENT PROCESS PROCESS CONTENT

A -GROUP A B - GROUP B

FIGURE FIVE

12-3 F

BDI differences I' l l

10

5

iJ

CI) U) - :7 ('3 >

ic

Sig

-2(

)- +

GROUP GROUP B C - B p - B

GROUP A GROUP B P - C C - P

C - CONTENT INTERVENTION P - PROCESS INTERVENTION B - BASELINE

FIGURE SIX

2.3Gi

AT differences

11

-10

(I) U) :3

cu 20 >

-30

Eli

Mv

GROUP A GROUP B GROUP A C-B P - B P - C

GROUP B C - P

FIGURE SEVEN

Z3

BORDERLINE differences

1

0.5

0

-0.5

-1 C)) C)

Co >

-2

-L

I I

_ H

+

GROUP A GROUP B C-B P - B

GROUP A GROUP B P - C c - P

FIGURE EIGHT

tZj L

NEGATIVE differences

5

IN

-5

(1) Q)

2 -10 Co >

-15

I I

H -20

-25

GROUP A GROUP B GROUP A GROUP B C - B P - B P - C C - P

FIGURE NINE

If) ID

(13 >

ItS]

L i

23 J

NEUTRAL differences

11 1 1 1 +

5 - I

GROUP A GROUP B GROUP A. GROUP B C - B P - B P - C C - P

FIGUR1 TEN

w —j

dlr-

0 a

em

z z

w

L

a?

to ca z w

0 0 I) 0 (t 0 L) TM

0

nk

T

jZ3 l:

LU crm CI) U)

zuj 0(.)

H 0 o:

(/) LU!

Qz w

0 LijO

a Volf

2-3 L

uJ LL

z

U H Wj

w '1

NbKdOr

uj

0 01)

H

w H z U 0 (I)

w 0 0 cc 0

o 0 0 0 0 0 0 (0 to CJ

Frol

to

qT

z w

+

w -J

0

i w

Irm

123

3.32.4. EFFECTS OF CONTENT FOLLOWINS PROCESS

box

a n d wh i Sir p1 ots for t h ezi measures of depressi on automat j. C:

t.hi nl.::i nq , and borden I i. no, nec1ati \'E and neutral dject.i yes

i ndi cates a consi st.ont pattern of si cm1 -f i cant di f-tenor -ices across

all measures (see F 1cunEs. 1-5)

c:onten -- tvp 1 nt2r'ent1 on fal J. OWJ. iQ S proco-vpo

1 rter '/eV] Ofl 1 ndi cates a der e in the 5 arid scores of the

schema cues i 1 onna]. no • i. Sb SLpQOSt. S S decneasc 1 fl the EMS

(sec Foune 12)

124

SIX WEEK FOLLOW—UP

patients were contacted tel ephoni call yin order

to net +eedback on how they were copi. nq and i + reaLtI 'La ohtai. nod

after the si> sesaons were being maintained.

Of the ci Lean subjects . twa]. vO reported that they 'fel L they had

)mpr- Oved in and T&jnt1ainied their copina ski I Is. had not ±slt

depresaed and were appl yi. no: what they had learnt in therapy

Two sub acts reported ha": nu had api sodas of P'sres-c or' and

anx i t ti'' but had f ol t I ass he]. 1 ass than before the i:h or spy. Two

sub acts reported + are]. i no very depree sad and -F cit they wrer aunt

copnc4 efnotiona.lI,v,

4. 1.

, '

,.,

INTRODUCTION

1.25

CHAPTER FOUR

DISCUSSION

The psychiatric population which is at highest risk in terms of

its morbidity and mortality 1s the BPD (Barlow, 1987).

is this condition difficult ta treat but it has been found to be

linked with the now known high incidence of child

violence in homes (Linehan, 1990). Furthermore, contrary to

what has previously been thought, the BF'D

This has resulted, however, in more focus been

placed on the diagnosis and treatment of this disorder (Taylor &

Zaparnuik, 1990).

Various treatment approaches have been used to manage this

� • J... • conci1 .... 1on. E:-: 2'1ii1p l es o+ this is, psychodynamic appro,:i.c:hes

1975) , psychiatric: inpatient therapy (Bel l21ck

Hersen, 1990), dialectical behaviour tht=:.1 1··apy (Linehan, 1992) cc.'{nd

pharmacotherapy (Stein, 1992;

1990)

Buysse, c .::iwam1, Nathan t: Soloff,

According to Bellack & Hersen, (1990), psychodynamic approaches

have been disappointingly unsuccessful in the treatment of this

disorder- .

126

An approach that seems most promising is Li nehan 's (1990)

Dial ect ± cal }3ehavi our fherapy but has proven to be d -f + i cult as

a result of the i nt.ensl. vs persoral i oval vemont of the ther - api. at

1 n the cont.eu t of this a pr oc:o'ac (Li nehan

j , 92.

Dar 1 ow (1994) ma i nt al n-a that the r 00500 as to why t coot_sort.

have -F ai. I ed di ama? lv In t.reati no and monad nq th I a condition i a.

as a reaul t of the -F act that these approaches wor a

psc:hopathol Do :i cal I v dii. von The psychotherapy reed ad for this

condi tian should be cpeci+icalIv presc:ri.ptive (Earlow 19+4)

The approac:h that was ott 1 iced in Lhi a sLudv was c:OCini ti -

hehavi aural I y or I entated • mak:L no use Of and c:OITpariEq 10 tern's

of a-f-f I ci a- ncv two types of CET I ntar aen Lions vi cori:cvnt- L 7 pa

and schema/proc ass-type.

EPD is rooted i. n psychopa.thol Dci,' of earl :7 do 'e]. opner,L

abberat ions in attachment and inter - -re]. ati no wi Lh others. The

pervasive instability of emoti onal • per cone? ., I nterpec sonal and

neuropsycholoqical level a could be character iced in a do-f ic:i enc :

of 1 i4etyle (Linehan 1987) and in all probability centred in

unstable personal coqn it.i. vs schemata (Youno. 1990) and coon i tive

content (Turner, 1987). The CEIT interventions mentioned were

thus aimed specifically at identifying, challenging and changing

coqniitive content and Early maladaptive schemata characteristic

1.27

of BFD.

It ce?emo ci oni -F i cant to menti on that ± or th]. S type of therany to

be success+ ul , . t: 1 5 of utmost import ins a Lha L i:h E 0: be a VIE .1. 1

estabi i shed therapeut. i. c.. ret ati. onshi p.. 1 his .aPpeai o. to be a

chal 1 cop i nc Las:: as o+ t:ar SF1) patients p r sun t as i5i.i5p I 1 0LI

unt.( L0t 1 rig of the tha ac ci. and the therapeutic 01 tuat 1

Pnother (:hara(:terlctic: of the BED inPi i.d'. its rec:e:i.vrp thoap.i,i

is their sometimes irr:.tation--si. :153.tIHO Lohav1OLtr

mar1 r:iul a Li ye behayl. oui The therapist found ..chat to -pasc-

this, ci ETErt 0 of Kor .i an 1979) therapy can be utilised j

j - r (it , empathi and cono:ruence .. By ut. 1 1 1 01 rip i:h050 pr 1 ni: 1 p1

a earil and contai ri rg oaf e therapeutic an'..]. rorvuEiIL 10 C:reEit ECt

one cihich is conducivet 0 promotinc. moLivaLion 10 the patient

and ensur inc comiri teen L to the ther apeLit i c: c..c:Licss: O+L5E2:t.fliEI it

The croci. 4 i c hypothesis of this s body eer - e

i . That border], ire patients with 5Ff: e;':rosed to a

content--based LEil intervention ijüul d shca. thorapeLti 5.

i mprovement. as assessed by the indices of deipr ccci or

automatic thinkinq and content: spec:i-f 1 c copniti005 as

measured by the Eleck Depressi or Inventory., the

utomati c Thouqhts Quest ionnai r - e, the (djective Scale

and the Schema Questionnaire respectivel

128

11. Borderline patients with BPD exposed to a precess-

i \'.

v.

.,

based CBT intervention L"10L\J. d show therapeutic

improvement as assessed by the indices of depression,

autor:ifi\tic thinking c:1nd c.or1t.t:1nt. spE·c:i.+ic: scheme��;, as

Automatic Thoughts Questionnaire, the Adjective Scale

and the Schema Questionnaire respectively;

bf:: no significant difference in thE:

process-based CBT intervention for BPD as measured bv

the Beck Depress�cn Inventory, the Automatic Thoughts

Questionnaire, the Adjective Scale and the Schema

Du1;:st i onnai r1;?.

A combination of content and process CDT will show a

thet .. c1pE·ut i c improvement than when

exposed to a single modality cf treatment; and

There \-\Ii 11 be no the

therapeutic effect as measured by the Beck Depression

I 1;vento1·-y, the Automatic Thoughts Questionnaire, the

Adjective Scale and the Schema Questionnaire, due to

order of presentation in the combined presentation of

the content- versus process-based BT interventions.

129

In order to :1 rYE ;t1c?.t.e the .ctbove, sixteon adults. from coth

tcE <Es, wi Lb a diacinoss of BPD, were rariduuid. i di vidgW intoL

qroupo of uioht eac:h. Po+-c'.rc' any therapucuLi C: interventions.ail

subuc:tu were wukud to complete t:.f.C:l I owi rn pent:: c:nna:L

The P':cH: DE'renc;i c:n

The Automatic Thnughts [_uc'et nr:nc

The bc::hrcc. nent. I ennaa. rE

The Str- nc:I:.urnd dl rn.?::ai. 1Ini.eni ew For Dd[1-1

Personality ii. ::c::dc.u:

Un e group noc:c 1 ved a con ton: -t 'joe Ci:ET followed by 0 process-

type [FT intcrvr•:niion. In the sane manner, the olbaur oucLy:

I not recol. ed a. cr 0c05C5 --- LVF:0 CBT bef c:rs receiving a content -

tpe CH1 intEorvEritun.

The 4 i oe LUtEt onnni see were conioj. utud after th- ecos..o:or.oci

then apei n n-F Len the -F I ncol SOS-Si one

The results obti nod in th]. s etuuv were vi owed both

statistically and doscr i pt.ively and di sc:uscsd in the foil ow n

crianner firstly, which individual CFT intervention, if any, was

most effective in treatinq F3FD. 8ccondiy, it will be dicsd

as to whether or not there was an order effect of the two types

0j: C}3T I rter vent. i ens. rh i rd 1 v the e 41 -F ec:ts of one mod-si J. tv

+01 1 OJi nc the other.

131

4..2. EFFECTS OF INDIVIDUAL INTERVENTIONS

4.2.1.. EFFECTS OF CONTENT-TYPE CDT INTERVENTIONS

From a sta. :1 ct: i cal anal. v ti. cal vi evi pci i t.. I t was +o!...nc that the

e+ -f act a of c ort en t. FBI i n t.cr vent i or a, + or the to ee -LmonL c, f

deprasci on automat c thoLcibta., border ii no • nociat :i va and neuI:rel

ad iet I var: and ccernae. I nd I c:a'Led that thor a was no ci cxi I c:ets.

difference f or the measure c:fdep resEct. CEO [h ecr + 1 n di ncr c or a

similar to t.hoacE- in astudv pef-crrncch by Li. na{an et. a].

ore a p r 0:_.rc of F-tfD was _;t poccecl to fTP r and a. cop aced : ox gFoup

of FL 01 U coed 1 ü 1 r catcent as usc;4 I The - I ccii ruc indicated

that subjects art posreri to the CBT i ri:ev 'cErn Li OflE 1 )OV LJvEd 10 or

of beha'i cur and copi np ski ii • emotion room]. a.f.i or and control

- -. . ._ _.. - ._ -- .. i_ I._ . -. . . - ._ i 2.. ._. .t_l_. _.. . -- L.........- .L------------ - 1.. 4 -. - I.............. ()I.jr zr rrL) Lirti ._iLJr,'rj t;t_Ci,iti LI__I Lilt LJLIIr1 ifiLt_Ir v)...._if

on the eel 4 report depoessi on • thor a was no i. roi cation o

d :. f ference be bacon the C1r oul:: a]. LhoLcph thor a had tcramfl

a TiprOvoTEEnt. . Fur thor cuust.atnti ak ion can be-found In LEEcL

who states that 13FD is c:heractorieeci by affe:tive i.nsrrbiIH:.

and marked react ivtv of mood causinq api. sodi c ciepressi on The

implication hero LeinO that the baseline mood is not

parti cul cr1 y neqati ye or depressed and an episodic derressi c:n,

irritability of anxiety, usual 1 y not I asti nci more than a +e

dave • may present in I teal + - throLtqhout the therapeutic process..

However, from a descriptive analytical vieipoint, represented in

a box and whisker plot format, it appears evident that intro-

132

oroup var once were of such a nature as to obvi ate any

sin +i cant difference betijeen the pro- and post.- test. VOl uEd

From + 1 cLlre? 6 it appears that the majority of values are bel c:w

o • I r- d i cat. . no a ci pn i -i-i cant di -f + erenc.:e -f or the mcac'.re

depre-o.c;1 on The pr- oat variability due L o the ct e:t o- cer Lai r

c:;ui:lveccc r- esults in the iflS Lri], -- :i. c:.arit. P V0.LLt0. Vi

however, it i sc: 1 earl v ev.i clE-:nt. that content CF:iT interventions

had a 01 pri :. + I can L ef t oct on the dec eace i n dcpr eusi. on,

L_i1-::eI,'fl so- . for the si:at:ictccal results obtoinco for the adiective

coal c border]. inc a .. ..ci reutral adiect jvcs. whore an

:insipnifiosnt: moan was ohovr. Dcs.c:riotivs-'aiqnr+lc:.sncc 10

i ndi cated an figures 8 and 18 and sLronql v uuooectc that theu

was a ci. qn + c car -it: c:hancie from base]. i no vol ues cci. roe once aO1

most vol. ucs are bel ow 0 • and the i nsa cmi -1- i cant F value coLt]. ci be

due to the cco - *:ai n out. 1 yer cc

Furthermore, these recul ts have practi cal si cmi -ft canoe and are

descript:i ye of the e3-:trerne-s that BF'D eaperi enc:e As Linehan

1987; states that BEE pat 3. onto display antense and protroctad

emotional reac:t ions even to 1 ow levels of sti mul ati On.

Both descriptively and statistically there was siclnificarit

effect with the automatic depressive thouqhts.

It appears there-fore, that content-type CBT i nterventi onis are

1. :3

s:i qri f i c:nti v e-ff ecti ye :i n the treal:ment of rFr in that there

as a ci r1i -f i cant decrease in depressi on . autornati c depressi yr

thouqhts border 1 i ne and neat:L ye ad.j ecti yes and EMS and an

1 ncr ease i n the Cu L (a.i ad jest i yes

134

4.2.2. EFFECT OF PROCESS—TYPE CBT INTERVENTIONS

The i nsi cmi. T i cant F value i ndi eated for the of foct of rrocss-

lVOE' LFLH 1 nt.erventi 01 on the adective scsi e 'a negative

adiectives indicates descriptive sicinitic:ance c;incs all val usc

are below 0, the statistical ins'icini-fcnsnt F value beino as a

r ecu], t of i n tra --p I -' oup var i ance wh i ch obvi ated any ci on i f cant

di -f fsrencs:c betssn the pro and post lest 'V-cl usa Visually is

app ear a that t.her s was ci pn :i. -ft cant c:hsno s from b a l no

(FIpLU'- 2 9)

f'tati sti c-ally and descri pti vol y it apoecr a i:ha.t there was a

ci on + leant chanpe from basel ins values; for the level of

depression, aLtt omati c depressive thi. nFl. nq and borderline and

neutral adiocti see where the BF:D pat:i ents showed lose

depression, less automat,i. c depressive thinkinci and less

borderline ad,jec:tives.

it thus appears that process — type C';E'T interventions are

affective in the treatment of E1'D • since there was a ci. cmi 'ii cant

decrease in depression, automatic depressive thi nki nq and

borderline and recjati.ve adjectives and early mal adapti vs

schecnas.

A potential di-f'ficulty in the study was that of separatinp the

two different types of CBT interventions. Takinq this into

15

account the therapist • at a). 1 poesi bi e times • mci ntained etri ct

sopor ati or between the two typos of i nterventi or. To shed more

1 1 ciht on the two ty:os of therapeutic i ntorventi one the

oi 1 ovJ:L no transcript -i. on of erli ppots taF::er { rem cc: tLkal therapy

eessi one can be used to 11. 1 Ltetrato

LONTENT—TYPE I NTEF:VENT I ONS

ci peed b 1 enaririsr in wh i rh to j. ntr oduc:r: the c:cjncept Of aUtoMatiC

thoLchi:s (Peck , 1980)

F. n ow E • our emot i one don t 1 set p op out from no--

where, There is ci wave c t.hcuqht that precedes the

-- o -- I on Most of the t I no however, we are not aware

of how we -Feel These thoughtsa are e,1most: autc:mati c

II Fec a re-f 1 ei . We don t. even know that we are

thIn ki np them. cinother th I nq is that it is not the

events or eituatl one that upset ore but our thosphts

about them. You -Fl 1 1 1 n the q - p thc•)- occurs between

an event and the emotion that you -Feel --- and it seems

that YOU 'ye been -F i 1 ii na the qap with nepati ye

thouqhts • whi ch have been maki nq you + eel real 1 y bad.

Throuqhout SCSSiOns the content of the patient s coqnitions must

be challenged, neqative thouhts identi-Fied, and substituted

with more positive or rational thouqhts Of qreat importance

16

too is the reinforcinq of any attempts made by the pati sot to

chaliencje and substitute copnitions

Patient = P

"I just feel so horrih1e so corrfused 1 am 39

not married a total mess up Th I ncs p0 okay

comet I mes • only to end up pci op real. lv bad

Therapist = T

Pd most i i ks be:L no on a ro]. I. or c:.oast or

P ' \'eh • almost lie hei np on a roller cc:aster. I I eod so

lost - I am a nothi no I vs achieved nothi np Just

a total mess up I am

T "You're a not.hino? Why do you say trat'

P "Well - I am iust a nothi np you knovi a mess up

as I saicL"

T "Who says so?

P 'Everybody , me lots of poop]. e I thi riP

T 'Who specifically?'

P 'Well

T "Maybe Just you?"

P " Yes maybe Just me"

T "nd what you say is always true?"

P ''. No no

T How does sayi nci "I am a nothi r" make you feel ?"

P Shitty yes just plain shitty"

T "Looki no at what we discussed earlier about thouhts and

137

emotions • how can we chanpe this?"

P "What/the emoticins'?'

T "Yes."

P "Well I sLtppOSe by chanq inq the thoLtqht5Y'

T "Yes, preat • shall we do that'?'

P "Mmm Well 1 maybe have made tT1 stakes in 11 fe

that doesn 't dOESfl - t mean I am a moss up or a nothi rq.

T "Excel I ent you see how we]. 1 you di ci that all b

ou.reei -f'

SCHEW\/PROCESS INTERVENTIONS

1.1 1 ustrat 3. one of the schema processes of 'ounq (1990) that were

di. scussed in Chapter One are

Pati ent A has a main schema of defecti. veriess/shame

She believes that there is somethi nc basically v'ronci

with her and that i -f she all owe anyone to qet too

close to her • they will reject her. Thus her schema

is mai ntai ned in that she chooses partners who are

extremely critical of her to confirm her view of

herself. As far as schema compensati on is concerned

it appears that she, at times, has an excessive

de-ferisive reaction and counter-attacks when confronted

with mild criticism. She ensures that none of her

138

partners qet too close to her, so that she can avoid

them ccci nu her bel i eyed dE+ oct veness and thus not

reject her.

fanother schema common of SF1) is that of en'oti onal depri vati on.

Fati ent S has thi a contra]. sc:hemc.

She chooscs pai tnsrc. who are not c:.apab]. 5 of ui Vi nO 50

other pool:; 1 m and then she cc:tE; i n a manner that makes

it even harder for them to cive to hor. In this way

her ec:hema :1 a mci rita:L iid She ensures schema

avol dance throuph avoi dinq qetti. nq too 5.1 ose to men

yet she denies 1:hal: she has any problems in this vor'/

area. She compensates for her schema throuqh at

1: i mos act i nc, 1 n a vor - v demand :L nci , be]. ii qeren S manner

provok op a 4 i qht wi Sb her partner.

The manner in which an 1 nd i vi dual mci ntai ns , avoids and

compensates for her schema, can be pointed out to the i ndviduai.

throughout sessions equippinq them to do so outside of the

therapeutic context.

The therapist should use the fol lowinci techniques suqgested by

Young (1990) in challenging schemas when they are triggered in

sessions viz: emotive, interpersonal, cognitive and behavioural.

139

An example of those foil ows

Fati ont A had a SchEma of emoti. onal deprivation Smot I vs

techn i goes encouraged her to exper i enc:e and e> rose aspects

of this grab]. em. She was asked to i magi no a dialogue

between her and her mother i n wh i oh she then cx pressed her

anger and her hur : that she -f ci t. her mother had I n-f 1 i ctod

on her. 1 hr ough th s process she was able 1:0 di. ndrc:e

hersol f { rain the oshema • more and nor a i' homawor k

assi. gnmcnt that was ci von her was to sr :i. to a letter to her

mol:hsr i. n shi oh she cx pressed her aneer and hurt It was

Ci so iflIj cateci to her how • on the one hand,, she -chooses

partners who are not capable of giving her much and then

acting in such a manner that ]. t was Even harder for them to

do so and then, on the other hand • she could be demandi no.

and bell i cierent provoking others and eliciting rejection.

Sooni ti VOl y her di storted thoughts were challenged and

substituted with alternative views and bel i c-f s

Behavi oural techniques involved identifying these long standing

behavioural patterns that were deeply entrenched and then

actively trying to charge thern

The above techniques can be used throughout the therapeutic

process, which will assist the patient in learning to qeneralie.e

i ni ciht.s obtai. ned in therapy.

140

141

4..3. ANALYSIS OF THE THERAPEUTIC EFFECTS OF THE ORDER OF

INTERvENTrON

Ur:E of the hvpothEse o+ this stuc:I that there 0LI ci be no

therapeutic: o-F-F ec:t of the order a-F the i ntervent ion. From a

otati st i cal anal \'Ol 0 it. appe.r n evi dent that. tbere ac nc:

01 Diii -f i cani: order- effect. Thi cc suqoecta that. c.ontant ha-cod JJT

-F ol I on nq or oceoa-4:aaed ET c-a I I hv e ml ]. an and an a+ fec:ti

of-foci: ao proce':;cc--bacccod LF3T fol J.oi nc cori:enL baaod CE:i in Lhe

treatment o-f F3Fi).

142

4.4. EFFECTS OF PROCESS FOLLOWING CONTENT CBT INTERVENTION

A stat istic:al analysis of the c-f-F ects of proc:ess----type C:ET

i ntorventi on foil owi nci content-typo CE'T I nterveriti on Tabl c 7)

reveals an insicini -ficant ''S]LtE (F::.ne -Fc- r- the n- eE.urs' Of

depressi on However, , when ana]. ysed deecr 1 pt.i vol V (F-i ure 1), 1 'I:

bec:omes apparent that there was a si cjri -Fi c:ant: c-F -F ec:t -F or the

measure of depression when process -f ci 1 owed a content----L vpO LI

intervcnticn Once acia.tri , the urcat variabi ]. it.v , de to certain

out? yore creates the stati aLl cal insignificant F •'s}

The c-f -f cc: La of oro:csa + ci 1 awl op content ror intervention c1 avs

ci cmi -f cent F- values for the measures of automata a depreesve

thoughts and borderline, neqat 1 ye and neutral adjectives From

the qu.al it-at:. ye analysi a of the schema questionnaire, it appear

that there was a ci qni - i cent: declice in the 5 and 6 s-cores and a

ci cmi -f i cant increase in the 1 and 2 sc:ores Thi a supqes-ts- a

decline in EMS's (see Ficure 11 and 12)

143

4.5. EFFECTS OF CONTENT FOLLOWING PROCESS

statistical analysis reveals eiqnafcant di+{erences for the

measures of depressi on automatic depressive thinking and

border]. i no neqati. vs and neutral adjectives (Table 8) This is

substanti ated by the Fi ciures 1 to 5 • which indicate siqni + i cant

chanqes in depress on automat 1 ct houqhts • borderline noqat. vs

and neut. al adoc'Li 'iso. A quali tat.i vs analysis of the rE3sui ts

of the schema quest i orina:i re :L ndi catee a si qn :i. + i. can't: dcc]. z no i n

the S and 6 scor ec. and increase in 1 and 2 scores, sLCq5sti nq a

decline in EMS 'S.

It thus appears that whether procsss'-type C.ST i nterventi on 15

fol ioed by a ccrttent-'type LBT intervention or a content-type

CBT i ntervent i. on i s foil owed by a process--type C}3T inter vent or

there -i 11 be a siqni - i cant dccii no in depressi on • automatic

depressi vs thouohts • borcjer], ins and neoative adiectives and

EMS s.

The results obtained from this study are clearly substantl ats-d

by other research per+c:'rmed on the c++ i ci ency of coqni ti vs

behavi oural therapy.

F'revious research (Li nehan Tutek • Heard & Armstronq, 1994) has

indicated that even with potentially effective pharmacological

therapy, some -form of commitment psychosocial intervention is

144

general ly requj red. In addi ti on, some pat i ents with BED cannot

use recommended mcdi cati ens, 1 eavi nq psychosocial i nterventi eric

as the only practloal a:lternati ve L.i nehan s corn rehensive

copri ti ye hehavi oural intervention • dial ecU cal behavi our

therapy -f or BED has a very specific: treatment tarqet and -foc:uses

on reduci nq the I. i + e- threaterii no. and SLtl cidal beh-avi ours.

redLtc: i nq parasLt]. ci de epi codes • reduc i nq hehavi ours that

inter-f crc with treatment part ± cuJ as? y non-compi i anc:e and

premature dropouts, reduc I no pattern-s that have a. sevai e c--±ect

on quality of life • I nd ucti nq those which necessi tate ± np.eti ent

psvchi atr i c care and i ncreasi nq copi no. ski ils randomi sed one

year control led clinical trial of th al ect i cal behavi our therapy

found that this type of therapy was more c-f fecti ye than

community "treatment as usual in reduci no the frequency and

mcdi cal severity of parasui ci de episodes, therapy attrition and

number of psychiatric inpatient days. Generally a stud',' on

L:Lnehan 's (1990) dialectical behavioural therapy (Linehan

TLttek, Heard & Armstrong, 1994) suqqested that dialectical

behavioural therapy is a promi sinq treatment for a broad array

of behavi. our a]. and emotional dys-functi ons in pati ents with BED

However • an article wri tten by Taylor & Zaparnui k (1991) whi oh

gave a on ti cal appraisal of Li nehan 's Di osoci al theory and mode

of treatment for E3PD stated that althouqh the biosocial theory

is innovative, its parsi rnoriy may be questioned Li nehan 'S

theory (Linehan, Tutek, Heard & Armstrong, 1994) draws

145

extensively -from dial ecti ccl psvc:hol oqy whi oh proposes that

con-fl id: and charqo ire the -fundamental principles of 1 i-fe

E,or -v thosi a is cci C to have an antithesis. Di. alec Li c:ci

orocessec can consist of the vacillati on between the thesi a and

anti t-.hee:i. a or thE-> I nL&>qr>it i on of those opposi tea. Li nehar;

(Li rehar taoner • 1790) poetu). ates that three pai rs

I: oh cvi cur ci avo dr omes ar e c h aracter ist ic of f3PD and each psi of

those a. ndr orcs -forms a dialectic. The ECyndrdflioE. area Enot I era I.

\-Lrinercbi! tv versus invclidston nct.io passi. -.itv •eeUa Lhs

app-arerti/ E)eCSOn and enrol ontinq arises aereus inhibited

C1&>viii. The 5Ff) pationl: is ujuable to syr'Lhea-ieo the

dial ect.i cal ooposi tea and so exper i cocoa con-fl i ct and confusicTr

over the my i stenc.cc of these anti theti c:al states iayi or

LaparnL?1 P (1991) arpue that most of the 'a'ncir'omos are I acki nq i. r>

em> - ---i cal support xi th ii t.tl ci> evidence that each pan. r of

syndromes forms -a. dial ecti a. However • lack of evidence does- not

i.ndi c-ate a. woakn:sa specific to the thoory. Tayl or t ZaparnL;.L P

1991) state that a promi sinq alternative to L..inehan s theory i a-

that of 5ec a ( 1990) coqni t i ye model whi ch has some advantaca

over the hi osoci. ci model. beck a (1990) model is seen to

encompass a broad spe(:trum of psychopathol oqy. Secondly, it is

more parsimonious and uses only three mai r concepts to account

for BF'D vizz basic assumptions of personal inadequacy in a

dangerous world, second, dichotomous thinkinq and third, an

unstable sense of identity. Components of both Eeck's (1990)

146

and Lineh&tn 's (1991) therapy were incorporated into this study

and modal i ty of therapy used.

It thus appears that in the 1 i pht of previ cue research done on

the coqni tive behavioural model of therapy -for the treatment of

BFD there appears to be stronpindi cati on of the e-f-f i ci rnc:y of

CBT in the treatment of BFD

1.47

4.6. CONCLUSION

From the above discussion • it appears that the hypotheses for

this study are all supported by the data Subitanti al cvi denc:e

Was -F ourd to indicate that both process-tvpe CEEj 1 r'iterventj or as

well as content--type 081 intervention are equally effective in

the treatment of 8-PD 1 and that ox posure to either of the

treatment modal i t - es resul ted in si qni -f i cant dccl inc

depression, I ower ±requency of borderline and neqatz vs

adectives • lower -Freque roe of automatic depressi 'io 1:houqhts ,, as

well as a decrease in the EMS's-.

It appears thus that if the what (content) of BFD related

coqni ti ons is chanqed • the the how (process) of DFD related

coqni ti ons chanqe,, and vice versa. This soul d possibly be

explained by the fact that when L(5i nq a content focus the

schema s qivinq rise to these coqnitions are assessed and are

thus subsequently chal lenqed and chanqed as the cocinitions are

challenqed and chanqed. Likewise, in ut.ilsinq the SFCT the

therapist needs to utilise content. Thus as the schemas are

challenged so are the cognitians associated with them.

This would seem to support the findinq of EraSJLIS (1987) who

found in a dismantling study of the effect of CD interventions

with impulsive children, that cognitive mode changes overt

behaviour to the same extent that overt behaviour would

148

influence coçjni t.i ye changes.

Lang s (1971) approach of sstemic converiti ons in psychotherapy,

substantiates this further. Lang 1971 ) mdi cited that charge

in one system focuses on by a spoci + i c therapeutic modal i t.v

would correl ate very highly with changes in rd atad systems i f

addressed by the same therapeutic modality.

it coLt? ci thus he sunoested that sInce •Lhese two CET modal i ti er

are both equally efficient in treating EPD, a combination of the

to would be as • if not more • effect.i ye in the treatment of EFD

Furthermore • it seems that this type of therapy 15 not only

ecoriomi cal • but to some degree ci : m:i. nat.es that intense personal

m nvol vement of the therapist, in that the pati ent. is ver

actively involved in hi s/her own change and improvement and the

therapist is provided with definite structure for therapy

promoti. nq self --help homework assignments for the ciati ent.

It should be noted • however • that this study had certain

limitations. One possible limitation could be that the

relatively small number of subjects could have skewed the

results of this study in a direction not recognised within the-

confines of this study. EPD, although prevalent among in and

out psychiatric patients, is a. disorder where patients are found

to not only try therapy as a last resort but also where patients

are found to be noncommittal to the therapeutic

149

process and change. 1 eavi nq therapy prernatLire]. y.

However, the resLtl te obtai ned in th S study, are promi Si no and

may possibly provide a means of managi no this di ff i cult

cordi ti on, thus dscreasinq the hi qh risk of rnorbi. di ty and

mortality associated with the disorder,

150

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