TFP: MID- AND LATE-PHASE; EMPIRICAL STATUS

borderlinedisorders.com

Session 4: John F. Clarkin, Ph.D.

EVOLUTION OF TFP

Typical evolution of therapy I

• The patient tests/challenges the contract• Early emphasis on nonverbal and counter-transference channels of communication

• Decrease in acting out: life settles down while dynamics get focused in the therapy

• Increasing awareness of the importance of the therapist for the patient, and defenses against this (attachment themes); increase in affect intensity in sessions

Typical evolution of therapy IIAs therapy advances to the midphase:• Interpretation of defenses against integration• A cycle where the problematic dynamics reappear, but in a more contained and limited way

• There is evidence of integration, initially tentative and subject to frequent regressions to splitting

• Practical problems arise stemming from earlier life choices that no longer “fit” well

Termination • Every separation (end of session, vacation, etc.) can bring up the dynamics of termination• For borderline patients, separation is always an

issue• Narcissistic patients may have difficulty getting

involved before separation becomes an issue• The dynamics of separation and termination should be addressed throughout the therapy

• Successful termination involves successful internalization and integration

• Termination involves the dynamics of healthy vs. pathological mourning

In-Session Indications of Integration and Structural Change• The patient’s comments indicate reflection on and

exploration of the therapist’s interventions• The patient is able to accept the exploration and

interpretation of primitive defense mechanisms• The patient can contain and tolerate the awareness of

previously projected affects• The patient can experience guilt/remorse and enter

into the depressive position• The patient can tolerate fantasies and the

development of a transitional space• The evolution of predominant transferences

Clinical Manifestations of Structural ChangeChange at the level of psychological structures with a more integrated psychological experience will lead to:

• Better functioning, with a reduction of symptoms and maladaptive behaviors

• Change in the patient’s sense of self and experience of the world

• Ability to cope with stress and adversity• Living a “full” life with a realistic measure of satisfaction in love and work

TFP IS EMPIRICALLY DEVELOPED AND SUPPORTED

Steps in Empirical Development of Treatment (Kazdin, 2004)Conceptualization of the pathologyConceptualization of the treatment and clinical testing

Manualization of treatmentTherapist training to adherence and competencePreliminary data with effect sizesRandomized controlled trialInvestigation of moderators and mediatorsGeneralizability of treatment (patients not excluded; treatment in community; transport to another setting)

Our Progress• Conceptualization of the pathology:

• Theory: Object relations theory: Kernberg, 1975, 1982, 1984; Kernberg & Caligor, 2005

• Phenomenology: • Attachment: Levy et al, 2006• Measurement: IPO, STIPO (Stern et al, 2010;

Hoerz, Clarkin, Stern & Caligor, in press)• Borderline subgroups: Lenzenweger, Clarkin,

Yeomans, et al, 2008• Neurocognitive functioning:

• Processing negative affect: Silbersweig, et al, 2007

• Attention network (ANT): Posner et al, 2005

Our Progress• Conceptualization of the treatment and clinical testing: NIMH R21 Grant (PI: J. Clarkin): Clarkin, Foelsch, Levy et al, 2001

• Manualization of treatment: Clarkin, Yeomans & Kernberg, 2006

• Preliminary data with effect sizes: Clarkin et al, 2001

Our Progress

Randomized controlled trial: Clarkin et al, 2007; Doering et al, 2010

Investigation of moderators and mediators: Levy, et al, 2006; Lenzenweger et al, 2012

Generalizability of treatment: transport to another setting: Doering, et al, 2010

Examine efficacy of TFP N=90; randomized to TFP vs. DBT

vs. STP Primary outcomes:

Improvements in suicidality only in TFP & DBT

Anger and impulsivity in TFP & SPT

Verbal & direct assault only in TFP Secondary outcomes:

improvements in depression, anxiety and psychosocial functioning in all 3 groups

TFP only improvements in irritability

• Only in TFP improvements in coherence of AAI narratives, secure attachment, Reflective Functioning (RF; mentalization)

Change in RF as a Function of Time and Treatment (Levy et al, 2006)

2.52.72.93.13.33.53.73.94.14.34.5

RF Time 1 RF Time 2

TFPDBTSPT

RCT of TFP vs. treatment by experienced community psychotherapists (ECP)

n=104 Multi-center: Munich, Vienna 1 year TFP superior in drop out (38.5% vs. 67.3%), suicide

attempts, BPD symptoms, psychosocial functioning, and personality organization and inpatient admissions. Both improved in depression and anxiety.

Current Empirical Status of TFP • TFP is a treatment closely tied to a clinical theory• TFP has been articulated and manualized• TFP has been taught to therapists from multiple disciplines, levels of

experience and across the world (not just at our own location)• TFP has been show to be effective in three uncontrolled studies and

efficacious in relation to community therapist who are experienced with BPD as well as DBT (comparable results)

• These findings are consistent with recent meta-analyses• TFP not only produces symptom change (e.g, suiciduality) but results in

structural changes as shown in changes in reflective functioning, attachment security/narrative coherence and personality organization.• The RF finding has been replicated in an independent sample and the

attachment finding has been replicated in two additional independent samples

• These structural changes have been related to both neurocognitive and neuroscience findings

LIMITATIONS OF EXISTING BPD TREATMENT RESEARCH

Recent Meta-analysis (Levy et al, 2012)

• Exhaustive search for treatment studies of BPD• No differences related to treatment orientation• There were differences related to date of study and

methodology

Summary• There are a number of promising therapies for BPD (e.g., DBT, MBT, TFP, SFPT, and DDP)

• The studies that have compared well delivered bonafide treatments generally suggest few differences between these treatments• For example, there is not one study in which DBT is compared with

an active treatment that it shows clear superiority

Levy, Ellison, Temes, Khalsa (in prep)

Major Limitations of Existing Treatment Research

• Focus on symptom change; outcomes in work and intimate relations are limited

• Very little focus on mechanisms of change (see Kazdin, 2006)

• Heterogeneity of BPD patients, in terms of overall severity and domains of dysfunction

• Treatment packages investigated (e.g., TFP, DBT, MBT, Schema) have multiple elements, much overlap especially in terms of structure and support for improvement

Existing Treatments Are Most Effective With Symptoms, Not Functioning• Consider McMain et al, 2012, DBT and General

Psychiatric Management:• Two years after 1-year treatment, effects of treatments persisted in

reduced frequency and severity of suicidal and nonsuicidal self-injurious behaviors, health service utilization, symptom severity, general psychopathology

• However, at follow-up 51.8% were neither working nor in school, compared to 60.3% before treatment.

• Before treatment, 39.7% receiving disability benefits, and 38.8% on such benefits at the end of follow-up

Symptom and Social Functioning in BPD Over Time (Zanarini et al, 2012)

• Symptom remission is substantially more common in BPD than social and functional recovery

• Only 40% of BPD patients compared to 75% of axis II comparison patients attained a social and functional recovery lasting 8 years or longer

• Vocational impairment is the main reason that BPD fail to attain or maintain symptomatic and social/vocational functioning

LIMITATIONS OF EXISTING BPD TREATMENT RESEARCH

Recent Meta-analysis (Levy et al, 2012)

• Exhaustive search for treatment studies of BPD• No differences related to treatment orientation• There were differences related to date of study and

methodology

Summary• There are a number of promising therapies for BPD (e.g., DBT, MBT, TFP, SFPT, and DDP)

• The studies that have compared well delivered bonafide treatments generally suggest few differences between these treatments• For example, there is not one study in which DBT is compared with

an active treatment that it shows clear superiority

Levy, Ellison, Temes, Khalsa (in prep)

Major Limitations of Existing Treatment Research

• Focus on symptom change; outcomes in work and intimate relations are limited

• Very little focus on mechanisms of change (see Kazdin, 2006)

• Heterogeneity of BPD patients, in terms of overall severity and domains of dysfunction

• Treatment packages investigated (e.g., TFP, DBT, MBT, Schema) have multiple elements, much overlap especially in terms of structure and support for improvement

Existing Treatments Are Most Effective With Symptoms, Not Functioning• Consider McMain et al, 2012, DBT and General

Psychiatric Management:• Two years after 1-year treatment, effects of treatments persisted in

reduced frequency and severity of suicidal and nonsuicidal self-injurious behaviors, health service utilization, symptom severity, general psychopathology

• However, at follow-up 51.8% were neither working nor in school, compared to 60.3% before treatment.

• Before treatment, 39.7% receiving disability benefits, and 38.8% on such benefits at the end of follow-up

Symptom and Social Functioning in BPD Over Time (Zanarini et al, 2012)

• Symptom remission is substantially more common in BPD than social and functional recovery

• Only 40% of BPD patients compared to 75% of axis II comparison patients attained a social and functional recovery lasting 8 years or longer

• Vocational impairment is the main reason that BPD fail to attain or maintain symptomatic and social/vocational functioning

RECENT FINDINGS BY OUR RESEARCH GROUP

Study 1: Different Types of Borderline Patients (Lenzenweger, Clarkin, Yeomans, et al, 2012)

• A theoretical orientation toward BPD pathology was matched with a sophisticated statistical technique (finite mixture modeling)

• Three groups of borderline patients emerged.• Group 1: low in aggression, paranoia, antisocial; less

negative emotion, less childhood abuse, better social/work functioning

• Group 2: high paranoid and low aggression and antisocial; less affiliative, higher rates of childhood sexual abuse

• Group 3: aggressive, antisocial, non-paranoid; impulsive, identity diffused, psychopathic

• This finding of different types of BPD patients has been replicated (Yun et al, 2012; Hallquist & Pilkonis, 2012)

Study 2: Effortful Control, Interpersonal Functioning, and Symptom Distress• Low effortful control in children is associated with

aggression, poor peer relations, lack of moral development

• Low effortful control in children is predictive of interpersonal difficulties in adults

Current Approach to Pathology: Research Domain Criteria Project (NIMH)• Focus on pathophysiology that will help identify new

targets for treatment development, detect subgroups for treatment selection, provide better match between research findings and clinical decision making

• RDoC classification rests on three assumptions: 1) mental disorders are disorders of brain circuits, that 2) can be identified with tools of neuroscience, and 3) data will yield biosignatures useful for clinical management

• Major RDoC domains: negative valence systems, positive valence systems, cognitive systems, systems for social processes, arousal/modulatory systems

(Insel, et al., 2010; Insel, 2013)

Definition of Effortful Control

• The ‘voluntary’ aspect of temperament:• Successful regulation & conflict resolution among emotions, thoughts and

behaviors (Posner & Rothbart, 2007, 2009; Derryberry & Rothbart, 1997)

• Reflects the maturation & efficiency of executive attention: • Ability to inhibit a prepotent response and activate a subdominant one

when necessary, according to situational demands and long-term goals (Gerardi-Caulton, 2000; Simonds et al, 2007; Chang & Burns, 2005)

• Long-term implications:• Children’s executive attention predicts self-control abilities in adulthood

(Casey et al, 2012; Eigsti et al, 2006)

Results

De Panfilis, Meehan, Cain & Clarkin. Comprehensive Psychiatry, in press.

EC GSI

IIP-Distress

Bootstrapping procedure for indirect effects (Preacher & Hayes, 2008):• significant total indirect effect of EC on GSI through IIP-distress

• ab=−.14, 95%CI=−.07- −.24

a=−.31* b=.46*

c= −.24*

*p<.00

(c’= −.09)

Conclusions

1. Among adults, low EC is associated with increasing distress related to general aspects of psychopathology

• A basic domain of functioning potentially relevant for various psychiatric disorders, throughout the life span

2. An impairment in interpersonal functioning explains this effect

• EC may foster psychological adjustment through promoting successful resolution of interpersonal problems

De Panfilis, Meehan, Cain & Clarkin. Comprehensive Psychiatry, in press.

Study 3: Affect Regulation Before and After TFP

• Amygdala hyperresponsivity to social and emotional stimuli in BPD patients (Donegan et al, 2003; Herpertz et al, 2001; Silbersweig et al, 2007)

• BPD show mistrust in tasks involving interpersonal cooperation

• Attempts to reappraise situations involving reduction of negative affect are deficient in BPD patients

Emotional Go-NoGo TaskPOSITIVE VERBAL STIMULI

Go No-go

NEUTRAL VERBAL STIMULI

Go No-go

NEGATIVE VERBAL STIMULI

Go No-go

Behavioral Results• Patients rated negative words more negative• Longer reaction times for patients during no-go blocks• Greater errors of omission for patients during no-go

and negative no-go• Greater errors of commission for patients under

negative no-go condition

Neuroimaging Results

Behavioral inhibition and negative emotion: Patients manifested decreased ventromedial prefrontal (medial orbitofrontal, subgenal anterior cingulate) activity

Behavioral inhibition and negative emotion: Patients manifested decreasing vetromedial prefrontal

& increasing extended amygdalar-venral striatal activities

These activites signficantly correlated with trait measures (MPQ) of decreased constraint and increased negative emotion

Discussion

• OFC lesions/dysfunction associated clinically with socio-emotional dyscontrol

• In BPD, a bias toward intense negative feelings may dominate the process coupled with failure of top-down control

• Negative affective memories/states may propel behavior, unchecked by evolving socioemotional contexts

Our Latest TFP Treatment Study: Psychological Results• BPD (N=10) selected for Diagnosis and Affective Lability• Outcome measured over time on symptoms (affective

lability), interpersonal behavior (IIP), and performance in love and work

• We found significant change in patient affective lability, positive affect, interpersonal behavior (sensitivity, paranoia, intrusiveness, vindictiveness), and work

• At the end of treatment, all patients were working; intimate relations are slower to evolve and improve

Our Latest TFP Treatment Study: Neurocognitive Functioning• Post Treatment vs Pre Treatment:

• Affective lability improvement correlated with decreased amygdala activity and increase cingulate activity

• MPQ constraint correlated with increase in orbital medial prefrontal cortex activity

• Neurocognitive functioning at baseline as predictor of change: • Increased right amygdala functioning predicted affective lability

total change• Decreased pre-frontal activity predicted improvement in MPQ

constraint

IN CONCLUSION…

Take-Home Message• Take empirically supported with a grain of salt: this is only the beginning;

we know very little• Focus on the individual patient; each borderline is unique; probably one-

size treatment does not fit all• Develop your own local way of matching borderline patients to a

treatment; context (public health system vs. private practice) makes a difference

• The treatments are growing in number (MBT, TFP, DBT, Schema, General Psychiatric Management, etc); why not take the best from each?

• Some form of integrated treatment focused on the individual patient may emerge

• More treatment development focus on work and social functioning is needed

• Future treatment studies must focus on specific domains of dysfunction most relevant to the broad category of BPD