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John F Clarkin

Publications and source records attributed to John F Clarkin.

18 recordsLinked to original sources
PubMed2007

The Personality Disorders Institute/Borderline Personality Disorder Research Foundation Randomized Control Trial for Borderline Personality Disorder: reliability of Axis I and II diagnoses.

The Personality Disorder Institute/Borderline Personality Disorder Research Foundation randomized control trial (PDI/BPDRF RCT) is a randomized control trial comparing three treatments for borderline personality disorder (BPD). An important issue for any RCT is diagnostic reliability, demonstration of which is necessary to evaluate claims of a treatment's efficacy for a given population. The present paper examines the interrater reliability of Axis I and II disorders in the context of a high base rate of BPD features for participants referred for inclusion in the RCT. Our results indicate good to excellent levels of interrater reliability for all Axis I and II disorders in this context. Assessors were able to reliably diagnose BPD, exclusionary criteria, and comorbid diagnoses. This data is important for comparing findings and sample composition across different studies using similar sampling strategies, especially as treatments are increasingly being developed and tested for BPD.

Adult↗
PubMed2006

Psychotherapy for patients with borderline personality disorder: focusing on the mechanisms of change.

A major development in the field of psychotherapy research is the growing recognition of the need for evidence on the mechanisms of change in psychotherapy. The empirical evidence that psychotherapy has a positive and significant effect must be amplified with data on the mechanisms of action in the various psychotherapies. This special issue is devoted to the articulation of putative mechanisms of change in the psychotherapy of patients with borderline personality disorder by leading researchers in this field.

Borderline Personality Disorder↗
PubMed2006

The mechanisms of change in the treatment of borderline personality disorder with transference focused psychotherapy.

We address how Transference Focused Psychotherapy (TFP) conceptualizes mechanisms in the cause and maintenance of borderline personality disorder (BPD) as well as change mechanisms both within the patient and in terms of specific therapists' interventions that engender patient change. Mechanisms of change at the level of the patient involve the integration of polarized representations of self and others; mechanisms of change at the level of the therapist's interventions include the structured treatment approach and the use of clarification, confrontation, and "transference" interpretations in the here and now of the therapeutic relationship. In addition, we briefly review evidence from our group regarding the following hypothesized mechanisms of change: contract setting, integration of representations, and changes in reflective functioning (RF) and affect regulation.

Borderline Personality Disorder↗
PubMed2006

Change in attachment patterns and reflective function in a randomized control trial of transference-focused psychotherapy for borderline personality disorder.

Changes in attachment organization and reflective function (RF) were assessed as putative mechanisms of change in 1 of 3 year-long psychotherapy treatments for patients with borderline personality disorder (BPD). Ninety patients reliably diagnosed with BPD were randomized to transference-focused psychotherapy (TFP), dialectical behavior therapy, or a modified psychodynamic supportive psychotherapy. Attachment organization was assessed with the Adult Attachment Interview and the RF coding scale. After 12 months of treatment, participants showed a significant increase in the number classified secure with respect to attachment state of mind for TFP but not for the other 2 treatments. Significant changes in narrative coherence and RF were found as a function of treatment, with TFP showing increases in both constructs during treatment. No changes in resolution of loss or trauma were observed across treatments. Findings suggest that 1 year of intensive TFP can increase patients' narrative coherence and RF. Future research should establish the relationship between these 2 constructs and relevant psychopathology, identify treatment components responsible for effecting these changes, and examine the long-term outcome of these changes.

Adult↗
PubMed2005

Executive neurocognition, memory systems, and borderline personality disorder.

Borderline Personality Disorder (BPD) is a common, disabling, and burdensome psychiatric condition. It is characterized by turbulent fluctuations of negative emotions and moods, unstable and conflictual interpersonal relationships, an incoherent and often contradictory sense of self, and impulsive, potentially lethal self-injurious behaviors. The neurobehavioral facets of BPD have not been extensively studied. However, clinical theoreticians and researchers have proposed that the symptoms and behaviors of BPD are, in part, associated with disruptions in basic neurocognitive processes. This review summarizes and evaluates research that has investigated the relationship between executive neurocognition, memory systems, and BPD. Three historical phases of research are delineated and reviewed, and the methodological and conceptual challenges this body of investigation highlights are discussed. Laboratory-based assessment of executive neurocognition and memory systems is integral to an interdisciplinary approach to research in BPD. Such an approach holds promise in elucidating the neurobehavioral facets, development, diagnostic boundaries, prevention, and optimal interventions for this debilitating and enigmatic disorder.

Borderline Personality Disorder↗
PubMed2005

Defining the mechanisms of borderline personality disorder.

Understanding the biological connections to mental processes was one of the original goals of psychoanalysis, and the development of cognitive and affective neuroscience and its methods might contribute to actualizing this goal. Personality disorders provide an opportunity to examine the complex mental structures of individuals experiencing extreme difficulties in interacting with their social environment. We provide initial information on a collaboration exploring an approach to one of the most serious personality disorders, borderline personality disorder, based upon the study of normal attention, individual differences in temperament, self definition and attachment organization, with the potential to illuminate the psychology and psychobiology of the disorder and to contribute to psychotherapeutic intervention. This developing model of borderline personality disorder can relate the symptoms to more enduring temperamental aspects of the patients. The goal is to understand the development of neural networks that underlie the abnormalities of adults, and eventually work out the interaction between temperament, genes, and experience that produce the disorder, and potentially inform intervention.

Borderline Personality Disorder↗
PubMed2005

Attachment and borderline personality disorder: implications for psychotherapy.

BACKGROUND: Psychopathology researchers and theorists have begun to understand fundamental aspects of borderline personality disorder (BPD) such as unstable and intense interpersonal relationships, feelings of emptiness, bursts of rage, chronic fears of abandonment, intolerance for aloneness, and lack of a stable sense of self as stemming from impairments in the underlying attachment organization. In the present study, we will examine self-reported attachment in a study group of well-characterized patients reliably diagnosed with BPD. SAMPLING AND METHODS: Ninety-nine outpatients reliably diagnosed with BPD using the International Personality Disorders Examination, completed a number of attachment measures including the Relationship Questionnaire, Relationship Style Questionnaire, and Experiences in Close Relationships inventory. RESULTS: Factor analysis revealed six factors that clustered into three groups corresponding to an avoidant attachment pattern, a preoccupied attachment pattern, and a fearfully preoccupied pattern. The preoccupied pattern showed more concern and behavioral reaction to real or imagined abandonments, whereas the avoidant group had higher ratings of inappropriate anger. The fearfully preoccupied group had higher ratings on identity disturbance, although only at the trend level. CONCLUSIONS: The psychometric properties and response characteristics of the ECR items suggest that the scales, keying, and domains are appropriate for assessment of attachment in BPD samples. The scales generally retain their factor structure and show a similar pattern of correlations and inter-relationships. Nevertheless, consistent with a developmental psychopathology model, there are some important differences in factor structure, indicating the need to look at both typical and atypical samples when constructing models of attachment. Further research is needed to delineate the prognostic and prescriptive significance of attachment patterns for treating patients with BPD.

Adolescent↗
PubMed2005

The construct of effortful control: an approach to borderline personality disorder heterogeneity.

BACKGROUND: The present study investigated the heterogeneity of DSM-IV borderline personality disorder (BPD) diagnosis as a function of the construct of effortful control. We hypothesized 3 subgroups of BPD patients based on effortful control, that would also differ in other areas of functioning, such as symptoms, interpersonal relations and personality organization. SAMPLING AND METHODS: Forty-seven clinically referred individuals were reliably diagnosed as meeting DSM-IV criteria for BPD using semistructured interviews. Effortful control, symptomatology, interpersonal functioning and personality organization were assessed using self-report questionnaires. RESULTS: Cluster and profile analyses were performed and identified 3 subgroups. Subgroup 1, with high effortful control, exhibited the fewest problems in symptoms, interpersonal functioning and personality organization. Subgroup 3, with low ratings of effortful control, had the most problems in these areas, and subgroup 2, a group high in some aspects of effortful control but low in others, ranged midway between groups 1 and 3. DISCUSSION: The findings indicate a relationship between attentional mechanisms and the clinical expression of borderline personality pathology. Effortful control is a valuable construct for identifying subgroups of BPD patients, thus helping to understand the heterogeneity in BPD. Limitations of the study include the exclusive use on self-report of effortful control, as well as the small sample size. Future research should further investigate the associations of neurocognition and borderline pathology, as well as different approaches to treatment of the different BPD subgroups.

Adult↗
PubMed2005

The association between attentional and executive controls in the expression of borderline personality disorder features: a preliminary study.

BACKGROUND: Basic neurocognitive functions such as attention and executive cognitive control represent promising endophenotypes that may improve understanding of the development and expression of borderline personality disorders (BPD). We evaluated the association between performance on the Attention Network Task (ANT) and the Wisconsin Card Sorting Test (WCST), two neurocognitive laboratory instruments, and the extent of BPD psychopathology. SAMPLING AND METHODS: We studied 22 BPD-diagnosed individuals who were independently administered these two laboratory assays. Performance on these tests was used as a predictor of the extent of BPD psychopathology. RESULTS: Indexes of the ANT and the WCST were correlated with one another in this sample. Further, the extent of impairment in attention networks, specifically the orienting network, was associated with a greater spectrum of BPD psychopathology, independent of the effects of age and medication status. Finally, ANT and WCST performance were uncorrelated with general psychosocial functioning in this sample, implicating relative specificity to the extent, as contrasted with functional severity, of BPD psychopathology. CONCLUSIONS: Attentional and executive functions are promising endophenotypic markers of BPD psychopathology. The implications of these findings are considered from developmental, experimental, and clinical perspectives.

Adolescent↗
PubMed2005

Use of mental health and primary care services by caregivers of patients with bipolar disorder: a preliminary study.

OBJECTIVES: Caring for a relative with schizophrenia or dementia has been associated with reports of caregiver burden, symptoms of anxiety, depression, poor self-rated health, and elevated health service use; however, comparable data for caregivers of relatives with bipolar disorder are lacking. This study reports preliminary data on the health, psychological distress and health service use of caregivers of patients with bipolar disorder. It additionally evaluates the relationship of the level of burden caregivers report experiencing to their use of health services, controlling for level of psychological distress and health status. METHODS: Subjects were primary caregivers of 264 patients with Research Diagnostic Criteria-diagnosed bipolar disorder and their bipolar relatives. Caregiver mental health and primary care service use were assessed retrospectively for the 7-month period prior to inpatient or outpatient admission of the bipolar patient. Caregiver depression, anxiety, medical conditions and patient symptomatology were assessed as well. RESULTS: Hierarchical logistic regression analysis demonstrated that caregiver burden significantly increased the likelihood of mental health service use (OR = 13.53, p < 0.001) even after controlling for caregiver psychological distress and medical conditions, while anxiety and depression level, but not burden, significantly increased the likelihood of primary care service use, controlling for other variables (OR = 1.72, p = 0.02). CONCLUSIONS: Burdens experienced by family caregivers appear to increase use of health services, and presumably cost, and may be reduced by psychosocial intervention.

Adult↗
PubMed2004

Impact of family burden and affective response on clinical outcome among patients with bipolar disorder.

OBJECTIVE: This study evaluated the direct and indirect effects of family burden and affective response on medication adherence and outcome among patients with bipolar disorder. METHODS: Data were examined for 126 patients who were consecutively admitted to the psychiatric service at a university-affiliated hospital and who met research diagnostic criteria for bipolar I or II disorder or for schizoaffective disorder, manic type, and their family caregivers. A total of 101 pairs of patients and family caregivers (80 percent) completed 15 months of study and were included in the analyses. Patients and their identified caregivers were assessed within two weeks of either discharge from the index inpatient admission or initiation of outpatient treatment (baseline assessment). Patients and caregivers were also assessed seven and 15 months after the baseline assessment. Structural equation modeling was used to evaluate caregivers' influences on patients' medication adherence seven months after baseline and on clinical outcome 15 months after baseline. RESULTS: The indexes of overall fit for the path model confirmed the a priori measurement model. Significant paths were found from the caregiver's perceived burden at baseline to the caregiver's emotional overinvolvement at baseline, from the caregiver's emotional overinvolvement at baseline to the patient's medication adherence at the seven month follow-up, and from the patient's medication adherence at the seven-month follow-up to the patient's outcome at the 15-month follow-up. The paths from the caregiver's perceived burden at baseline to the patient's medication adherence seven months after baseline and the patient's outcome 15 months after baseline were not significant. CONCLUSIONS: When caregivers of patients with bipolar illness experience a high burden, patient outcome is adversely affected. This relationship is mediated through families' affective response and patients' medication adherence.

Adult↗
PubMed2004

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

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

Adult↗
PubMed2004

Executive neurocognitive functioning and neurobehavioral systems indicators in borderline personality disorder: a preliminary study.

It is argued that borderline personality disorder (BPD) represents the interaction of underlying neurobehavioral systems that are reflected principally in the phenotypic constructs of positive emotion, negative emotion, and nonaffective constraint (Depue & Lenzenweger, 2001). This preliminary and exploratory study sought to examine predictions made from the Depue-Lenzenweger model with respect to controlled (effortful) information processing in BPD. It was hypothesized that (a) BPD subjects may display deficits on tasks that require controlled information processing (sustained attention, spatial working memory, and executive functioning), (b) they may reveal elevated negative emotion as well as decreased positive emotion and nonaffective constraint, and (c) nonaffective constraint should be substantially inversely associated with accurate performance on controlled information processing tasks. The results of this study, which examined 24 BPD diagnosed individuals and 68 normal adults, found support for each of these predictions in relation to performance on the Wisconsin Card Sorting Test. The implications of these results for further experimental psychopathology investigations of BPD as well as further refinement of theoretical models of the disorder are discussed.

Adult↗
PubMed2004

The relationship between impulsivity, aggression, and impulsive-aggression in borderline personality disorder: an empirical analysis of self-report measures.

Impulsivity has been repeatedly identified as a key construct in BPD; however, its precise definition seems to vary especially regarding the overlap with aggression. The term impulsive-aggression , also generally seen as central to an understanding of BPD, seems to address itself to the interface between the two, but has itself been used inconsistently in the literature, sometimes having reference to a unitary phenotypic dimension, and at other times suggesting some combination of distinct traits. This study examined the relationship between multiple measures of impulsivity, aggression, and impulsive-aggression in a BPD sample ( N = 92) in order to clarify the relationship between these measured constructs in this clinical population. Results show little relationship between measures of aggression and impulsivity in BPD, with measures of impulsive-aggression correlating strongly with measures of aggression only. Implications of the present results for future research and clinical work with BPD are discussed.

Adolescent↗
PubMed2004

Attachment dimensions as predictors of medical hospitalizations in individuals with DSM IV cluster B personality disorders.

This study investigates predictors of health service utilization in individuals with cluster B personality disorders. We hypothesized an association of severity of psychopathology (that is, global psychosocial functioning and psychiatric comorbidity) and attachment style with the length of medical hospitalizations in this population. Forty-one female subjects were interviewed regarding their diagnoses, level of functioning and service utilization. Attachment style was assessed with a self-report questionnaire. Our findings indicate that degree of psychiatric comorbidity and level of psychosocial functioning do not predict length of hospital stays, whereas preoccupied attachment predicted 23.9% of the variance in the length of hospitalizations. We conclude that the quality of interpersonal relatedness appears to be a better predictor of health service use than severity of pathology in patients with cluster B personality disorders.

Adolescent↗
PubMed2003

Patient-therapist attachment in the treatment of borderline personality disorder.

The authors report preliminary findings from a longitudinal study on the impact of attachment state of mind and reflective function on therapeutic process and outcome with borderline patients in Transference-Focused Psychotherapy (TFP). TFP is a manualized, psychoanalytically oriented treatment based on an object relations model of understanding patients with severe personality disorders. The attachment theory constructs of internal working models of attachment and mentalization or reflective function provide an important means of both conceptualizing borderline disorders and assessing therapeutic process and change. In the Personality Disorders Institute at New York Presbyterian Hospital-Weill Medical College of Cornell University, the authors have been using the Adult Attachment Interview (AAI) to assess changes in state of mind with respect to attachment and reflective function over the course of 1 year in borderline patients in TFP treatment. As part of the authors' investigations of the impact of patients' attachment status on the therapeutic process, they have adapted the AAI to evaluate states of mind with respect to attachment within the therapeutic relationship through an interview called the Patient-Therapist Adult Attachment Interview (PT-AAI). The AAI is given at 4 months and 1 year, and the PT-AAI is given to patients after 1 year of TFP, and both interviews are scored for attachment classification and reflective function. The authors present preliminary findings on change in both attachment classification and reflective function ratings at 4 months and 1 year for a subsample of 10 patients and therapists. They also present two cases that illustrate how the quality of mentalization or reflective function in the therapeutic dyad may be seen as a bidirectional process in that therapists' and patients' levels of reflective function are mutually and reciprocally influential. In one case, the patient's and therapist's reflective function mirrored each other directly and remained at a low or rudimentary level for the treatment year. Such a pattern of direct imitation does not necessarily promote intrapsychic change. In the second case, the patient moved from a rejecting or bizarre stance toward mentalization on the AAI to some rudimentary consideration of mental states after 1 year of treatment with a therapist who showed a full and nuanced awareness of mental states, but who adjusted his level of mentalization to that of the patient. These findings suggest that optimally the therapist ought to be one step ahead of the patient in the capacity for mentalization.

Adult↗
PubMed2002

Attentional mechanisms of borderline personality disorder.

We consider whether disruption of a specific neural circuit related to self-regulation is an underlying biological deficit in borderline personality disorder (BPD). Because patients with BPD exhibit a poor ability to regulate negative affect, we hypothesized that brain mechanisms thought to be involved in such self-regulation would function abnormally even in situations that seem remote from the symptoms exhibited by these patients. To test this idea, we compared the efficiency of attentional networks in BPD patients with controls who were matched to the patients in having very low self-reported effortful control and very high negative emotionality and controls who were average in these two temperamental dimensions. We found that the patients exhibited significantly greater difficulty in their ability to resolve conflict among stimulus dimensions in a purely cognitive task than did average controls but displayed no deficit in overall reaction time, errors, or other attentional networks. The temperamentally matched group did not differ significantly from either group. A significant correlation was found between measures of the ability to control conflict in the reaction-time task and self-reported effortful control.

Adult↗