Axis II comorbidity of borderline personality disorder: description of 6-year course and prediction to time-to-remission.

OBJECTIVE: The purpose of this study was to compare the axis II comorbidity of 202 patients whose borderline personality disorder (BPD) remitted over 6 years of prospective follow-up to that of 88 whose BPD never remitted. METHOD: The axis II comorbidity of 290 patients meeting both DIB-R and DSM-III-R criteria for BPD was assessed at baseline using a semistructured interview of demonstrated reliability. Over 96% of surviving patients were reinterviewed about their co-occurring axis II disorders blind to all previously collected information at three distinct follow-up waves: 2-, 4-, and 6-year follow-up. RESULTS: Both remitted and non-remitted borderline patients experienced declining rates of most types of axis II disorders over time. However, the rates of avoidant, dependent, and self-defeating personality disorders remained high among non-remitted borderline patients. Additionally, the absence of these three disorders was found to be significantly correlated with a borderline patient's likelihood-of-remission and time-to-remission; self-defeating personality disorder by a factor of 4, dependent personality disorder by a factor of 3 1/2, and avoidant personality disorder by a factor of almost 2. CONCLUSION: The results of this study suggest that axis II disorders co-occur less commonly with BPD over time, particularly for remitted borderline patients. They also suggest that anxious cluster disorders are the axis II disorders which most impede symptomatic remission from BPD.

Predictors of psychosocial outcomes for patients with mood disorders: the effects of self-help group participation.

This study examined the predictors of psychosocial outcomes (daily functioning and management of illness) for people with mood disorders. After controlling for demographic, severity of illness, and social support predictor variables, the study evaluated whether participation in self-help groups would predict improved psychosocial outcomes. Post-hospitalization data were examined for 144 mood disorder patients using hierarchic multiple regression. More education predicted improved daily functioning; self-help involvement and education predicted management of illness. The implications of these findings for providing recovery-oriented rehabilitation services are discussed.

Psychiatrists' referrals to self-help groups for people with mood disorders.

The study examined psychiatrists' referrals to and support for participation in self-help groups by people with mood disorders. Massachusetts and Michigan psychiatrists with a special interest in patients with mood disorders were surveyed; the 278 respondents represented a 78 percent response rate. About three-fourths of the psychiatrists reported that they made referrals to and felt knowledgeable about self-help groups. However, less than half had self-help literature available or discussed self-help groups with their patients. Beliefs that a patient would gain a better understanding of the illness and would receive support after an episode of illness were positively related to support for self-help. Beliefs that the program was inappropriate and that it lacked professional oversight were negatively related.

Borderline personality disorder. Overview of biologic factors.

Exploring the biology of neurotransmitters and polymorphic genes that influence behavior most certainly will increase understanding of the complexity of personality disorders and the people who suffer with them. Continuing biologic exploration of the personality disorders will also provide new and valuable information that will inform and direct ever more sophisticated and specific psychiatric treatments. Further, it will supply knowledge that might begin to erode the strong biases and negative labels that have for too long been applied to these patients. These labels may have been applied not because these patients are bad people, but because of ignorance in understanding their complexity and limited ability to improve their condition. Nonetheless, clinicians must refrain from concluding that the answers to all problems in psychiatric treatment can be answered by the molecular geneticist or biologic researcher. As Reiss et al have written when speaking about nonshared environmental effects and its role in the development of psychopathology: "Psychiatry has been forced into the chronically uncomfortable position of straddling biomedicine and the social sciences and seems always to hunger for relief.... [Yet] the data simply do not permit a conception of the future centered on a straightforward biomedical answer to the fundamental question of the pathogenesis of major disorders. Indeed, a balanced image of the future contains a growing and equal partnership of the social sciences and molecular biology."

The effect of a restricted smoking policy on motivation to quit smoking in psychiatric patients.

UNLABELLED: As dissatisfaction with unrestricted smoking in institutional settings has grown, a number of psychiatric facilities have banned smoking. A compromise, restricted smoking, was recently introduced on an inpatient psychiatric unit at a University of Michigan Hospital. The subsequent rescission of the restricted smoking policy enabled us to compare the effects of restricted smoking vs. ad lib smoking on motivation to quit smoking. METHOD: Current smokers admitted to an inpatient psychiatry unit were asked to participate in this study. As soon as possible after intake, the patient completed a smoking history questionnaire, depression and anxiety scales, and a stage of change measure. The stage of change measure was readministered upon discharge from the unit. RESULTS: Repeated measures ANOVA revealed an interaction for Condition (Restricted vs. Ad Lib) by Time (Admission vs. Discharge) for the Action scale, which assesses current level of activity in smoking cessation efforts. Restricted smokers decreased while ad lib smokers increased in motivation over time. CONCLUSIONS: Results suggest that the restricted smoking policy does not have beneficial motivational effects. Alternative strategies for controlling smoking on an inpatient psychiatric unit are suggested.

Biological implications of childhood sexual abuse in borderline personality disorder.

This article explores which aspects of the clinical presentation of psychopathology in borderline personality disorder (BPD) might be thought to be most closely linked to a history of childhood sexual abuse (CSA). The article describes which particular types of sexual abuse experiences are thought to be most prevalent in patients with BPD, and proceeds to review our current understanding of the biological substrates that may be involved in the clinical picture of BPD. The article then turns to the concept of trauma, and examines what are thought to be the biological underpinnings and/or reactions to trauma (particularly with respect to Post Traumatic Stress Disorder) and, by extension, to overwhelming and/or chronic stress, while making the logical assumption that childhood sexual abuse can be categorized most understandably as trauma. Finally, the article tries to integrate these observations by pulling together the commonalties of the biology of stress and trauma with the biology of BPD, in order to put forth an hypothesis as to the possible implications of a history of childhood sexual abuse upon the biology of BPD. The article concludes that the type and breadth of the patient with BPD's hyperreactivity to the environment, which often manifests itself as hypersensitivity in interpersonal situations, is probably mediated through noradrenergic mechanisms, and these processes may be most closely related to a history of CSA. On the other hand, impulsivity, which is related to serotonergic mechanisms, is the major constitutional predisposition to BPD, regardless of whether or not there is a history of trauma. Combining environmental hyperactivity with impulsivity may lead to a clinical picture, often seen in BPD, where impulsivity and self-destructive behavior is employed in order to deal with the stress, distress, and dysphoria of being hypersensitive to interpersonal and other environmental stimuli.

Transitional objects and borderline personality disorder.

OBJECTIVE: The relationship of possession of transitional objects to the borderline personality disorder diagnosis was explored in a psychiatric inpatient setting. It was hypothesized that a greater proportion of inpatients who bring objects of special meaning with them to the hospital have borderline personality disorder. METHOD: Psychiatric inpatients (N = 146) were administered a semistructured interview to determine the presence of special (i.e., transitional) objects in the hospital, at home, or during childhood. Borderline personality disorder was determined by criteria on a DSM-III-R borderline personality disorder checklist and by DSM-III-R discharge diagnosis. RESULTS: Significantly more patients who endorsed having transitional objects in the hospital or at home had the diagnosis of borderline personality disorder. Sensitivity, specificity, positive predictive power, and negative predictive power of the possession of the transitional object for the borderline personality disorder diagnosis were calculated. Specificity was higher than sensitivity, and negative predictive power was higher than positive predictive power in each instance. While these results suggest that absence of a transitional object is more likely to be associated with absence of borderline personality disorder than the presence of a transitional object is with the presence of borderline personality disorder, the sensitivity of a transitional object during adulthood to predict a diagnosis of borderline personality disorder was 63%, and the positive predictive power was 45%. CONCLUSIONS: A transitional object brought to the hospital may help remind the inpatient with borderline personality disorder of home or provide soothing during separation from home. The persistence of transitional objects into adulthood may inform the therapist of possible transference paradigms that may develop in treatment.

History of childhood sexual abuse and general psychopathology.

Reported history of childhood sexual abuse (CSA) was correlated with general measures of psychopathology on the SCL-90-R in a sample that included inpatients with borderline personality disorder (BPD), inpatients with major depression, and a nonpatient control group. When subjects who reported abuse were compared with those who did not, scores for the Global Severity Index (GSI) and all subscales of the SCL-90-R, except for the obsessive-compulsive and somatization subscales, were significantly-higher. When only those subjects who reported CSA were studied and when specific measures of CSA were the independent variables and SCL-90-R subscales were the dependent variables, scores on the hostility, interpersonal sensitivity, and paranoia subscales of the SCL-90-R were significantly higher. Because a large proportion of the sample consisted of borderline patients, and because both the specific measures of CSA and the borderline diagnosis could predict similar SCL-90-R subscale results, a series of stepwise regressions were performed. In the first regression, diagnosis, gender, and specific measures of CSA were the predictor variables and SCL-90-R subscale scores were the dependent variables; in the second regression, SCL-90-R subscales and specific measures of CSA were the predictor variables and diagnosis was the dependent variable. Interpersonal sensitivity was the only significant predictor of the borderline diagnosis. We suggest that, at least in some cases, interpersonal sensitivity may be the constitutional/environmental substrate on which traumatic experiences interact to arrive at the borderline diagnosis.

A review of inpatient group therapy for borderline personality disorder.

Because the average length of psychiatric hospitalization is decreasing, effective short-term treatments for patients with borderline personality disorder (BPD) are in greater demand. Of particular interest are group therapies, which have traditionally been a treatment of choice on inpatient units. We review empirical research and clinical descriptions of group psychotherapy for inpatients with personality disorders, especially BPD. Based on the existing literature on inpatient groups, supplemented by the most recent literature on outpatient groups for patients with BPD, we propose a framework within which an effective short-term group treatment may be developed for inpatients with this disorder. In particular, we discuss the advantages and disadvantages of adapting Linehan's Dialectical Behavior Therapy for short-term inpatient use.

A preliminary report of short-term cognitive-behavioral group therapy for inpatients with personality disorders.

A randomized, controlled study evaluated the effectiveness of a cognitive-behavioral therapy group, based on Linehan's dialectical behavior therapy, for inpatients with personality disorders. The treatment, a problem-solving skills group focused on parasuicidality, was compared with a discussion control group. Change was assessed by self-report measures and behavioral observations on the unit. Subjects in both groups improved significantly on most change measures, although no significant between-group differences were found. However, the treatment group patients viewed the intervention as more beneficial to them in their lives outside the hospital. The usefulness of this type of group on a short-term unit is discussed.

Borderline personality disorder symptoms and severity of sexual abuse.

OBJECTIVE: This study explored the relationship of specific symptoms of borderline personality disorder to dimensions of severity of sexual abuse experiences in childhood. METHOD: A group of 41 patients with borderline personality disorder who retrospectively reported a childhood history of sexual abuse on the Familial Experiences Interview were studied. Six items from the Diagnostic Interview for Borderline Patients (DIB) were chosen on the basis of their univariate (chi-square) association with a sexual abuse severity scale that was developed by the authors and their research team. These six DIB items were each modeled in a logistic regression. Predictor variables were the most severe experience within each of three dimensions of sexual abuse: 1) perpetrator (sexual abuse by a parent), 2) duration (sexual abuse that was ongoing), and 3) type (sexual abuse that involved penetration). RESULTS: The severity dimension that was most frequently found to be a significant predictor of the sum of the six DIB items as well as the total scaled DIB score was the duration dimension. Ongoing sexual abuse predicted parasuicidal behavior as well. CONCLUSIONS: Ongoing sexual abuse may be a strong determinant of specific aspects of the disordered interpersonal behavior and functioning found in patients with borderline personality disorder. The expectation that the world is an empty, malevolent place may have some of its roots in the repetition of sexual abuse experiences in childhood. This expectation of malevolence among patients with borderline personality disorder may manifest itself in psychotherapy through regressive and distancing behavior.

Electroconvulsive therapy and intracranial aneurysm.

Little has been written regarding the safety of electroconvulsive therapy (ECT) administered to patients with intracranial aneurysms. The literature is reviewed and we report two additional cases of ECT safely and effectively employed to treat depressed patients with intracranial aneurysms. We found no reported cases of aneurysm rupture associated with ECT. We do not feel the presence of intracranial aneurysm is a contraindication to ECT, in most patients, with appropriate monitoring and control of arterial blood pressure.

Clinical assessment of object relations and social cognition using stories told to the picture arrangement subtest of the WAIS-R.

For many years clinicians have supplemented the Wechsler Adult Intelligence Scale-Revised (WAIS-R; Wechsler, 1981) Picture Arrangement (PA) subtest by asking subjects to "tell the story" made by the sequence of cards. Doing so allows assessment of the underlying reasoning behind the subject's response and adds a projective element to the task. This article describes a method for systematically assessing several dimensions of object relations and social cognition from the stories subjects tell to the PA subtest. Six scales, which have been validated in several studies, are described: Episode Integration, Accuracy of Causal Attributions, Affect-Tone of Relationship Paradigms, Capacity for Emotional Investment in Relationships and Moral Standards, Complexity of Representations, and Accuracy of Character Ascriptions. Evidence for convergent and discriminant validity is presented by comparing PA scale scores of reliably diagnosed borderline inpatients, depressed inpatients, and normal comparison subjects, with scores from self-report instruments measuring symptomatology and social adjustment. Clinical use of the scales is then illustrated by applying them to PA story texts of a borderline patient and a normal subject.

The impact of sexual and physical abuse on eating disordered and psychiatric symptoms: a comparison of eating disordered and psychiatric inpatients.

The authors compared rates of physical and sexual abuse in women with eating disorders (N = 102) and general psychiatric disorders (N = 49). Relationships between sexual abuse and severity of eating disordered and psychiatric symptoms were also examined. While high rates of sexual abuse were found in the eating disordered sample, these rates were not significantly higher than those found in the general psychiatric population. No relationship between a history of sexual abuse and severity of eating disordered symptoms was found. However, within the eating disordered group, sexually abuse subjects reported more severe psychiatric disturbances of an obsessive and phobic nature than nonabused subjects. These findings suggest that while sexually abusive experiences may be related to increased psychological distress, they do not serve to increase eating disordered symptomatology.

Malevolence, splitting, and parental ratings by borderlines.

Malevolent object relations as well as splitting have long been considered by psychodynamic theorists as central features of borderline personality disorder. We tested the hypotheses that borderlines would a) perceive their parents more negatively than both nonborderline major depressive patients and nonpatient normal controls, and b) split their representations of their parents into opposites more than the comparison subjects. Borderlines (N = 31), who were identified by the Diagnostic Interview for Borderlines, Research Diagnostic Criteria major depressives (N = 15), and nonpatient controls (N = 14) were asked to rate each parent on the Adjective Check List (ACL; Gough and Heilbrun, 1983). Seven ACL scales were studied: Favorable, Unfavorable, Critical Parent, Nurturing Parent, Nurturance, Aggression, and Dominance. Correlations were performed between scores for mother and father on the various scales for each of the three cohorts. Analysis of variance and one-way t-tests with Bonferroni correction were used to test group differences. Borderlines rated their parents, especially their fathers, not only as more unfavorable on negative scales than depressives or normals, but as less favorable on positive scales than the comparison groups. Analysis of covariance revealed that a significant portion of the variance in father scores, but not in mother scores, was related to age of respondent and history of sexual abuse. While borderlines did not appear to split their parents into one good and one bad parent, they did show significantly less correlation between parents on the Favorable scale when compared with either depressives or normal subjects. The results imply that borderlines have a greater tendency to view the world in negative, malevolent ways than to split their object representations.

Malevolent object representations in borderline personality disorder and major depression.

To study malevolent representations, earliest memories were reliably coded on scales of affect tone. Ss were diagnosed with borderline personality disorder: 31 without and 30 with concurrent major depression. Nonborderline comparison subjects had either major depressive disorder (n = 26) or no psychiatric diagnosis (n = 30). Borderline subjects were discriminated from comparison subjects by their more malevolent representations; they more frequently produced memories involving deliberate injury; and they portrayed potential helpers as less helpful. Results suggest the diagnostic significance of malevolent representations, which need to be explained by any theory of borderline personality disorder.

Object representations in the early memories of sexually abused borderline patients.

OBJECTIVE: This study analyzed psychological representations in 58 subjects in order to achieve a better understanding of the relation between adult borderline personality disorder and reported histories of childhood sexual and physical abuse. METHOD: The subjects were 29 inpatients with borderline personality disorder diagnosed according to the Diagnostic Interview for Borderlines, 14 nonborderline inpatients with major depressive disorder according to the Research Diagnostic Criteria, and 15 normal comparison subjects recruited from the community and screened for the absence of psychopathology. Earliest memories were used as the source of mental representations in all subjects. The memories were reliably coded for malevolent affect tone, presence of deliberate injury, and effectiveness of helpers. Family histories of childhood sexual and physical abuse were obtained with the Familial Experiences Interview, a structured interview. Abuse histories for a subset of the subjects were corroborated by interviews with family members. RESULTS: A reported history of sexual abuse, but not a reported history of physical abuse, predicted the presence of extremely malevolent representations in these earliest memories as well as representations involving deliberate injury. These two kinds of representations also discriminated borderline patients who reported histories of sexual abuse from borderline patients who did not report sexual abuse. Mean affect tone (from malevolent to benevolent) did not, however, discriminate sexually abused or physically abused subjects. CONCLUSION: The results suggest that malevolent representations associated with the borderline diagnosis in previous research may be partially related to a history of childhood sexual abuse. Implications for the object relations theory of borderline personality disorder are noted.