The contribution of familial internalizing and externalizing liability factors to borderline personality disorder.

BACKGROUND: Individuals with borderline personality disorder (BPD) frequently display co-morbid mental disorders. These disorders include 'internalizing' disorders (such as major depressive disorder and anxiety disorders) and 'externalizing' disorders (such as substance use disorders and antisocial personality disorder). It is hypothesized that these disorders may arise from latent 'internalizing' and 'externalizing' liability factors. Factor analytic studies suggest that internalizing and externalizing factors both contribute to BPD, but the extent to which such contributions are familial is unknown. METHOD: Participants were 368 probands (132 with BPD; 134 without BPD; and 102 with major depressive disorder) and 885 siblings and parents of probands. Participants were administered the Diagnostic Interview for DSM-IV Personality Disorders, the Revised Diagnostic Interview for Borderlines, and the Structured Clinical Interview for DSM-IV. RESULTS: On confirmatory factor analysis of within-person associations of disorders, BPD loaded moderately on internalizing (factor loading 0.53, S.E. = 0.10, p < 0.001) and externalizing latent variables (0.48, S.E. = 0.10, p < 0.001). Within-family associations were assessed using structural equation models of familial and non-familial factors for BPD, internalizing disorders, and externalizing disorders. In a Cholesky decomposition model, 84% (S.E. = 17%, p < 0.001) of the association of BPD with internalizing and externalizing factors was accounted for by familial contributions. CONCLUSIONS: Familial internalizing and externalizing liability factors are both associated with, and therefore may mutually contribute to, BPD. These familial contributions account largely for the pattern of co-morbidity between BPD and internalizing and externalizing disorders.

Comparison of alternative models for personality disorders, II: 6-, 8- and 10-year follow-up.

BACKGROUND: Several conceptual models have been considered for the assessment of personality pathology in DSM-5. This study sought to extend our previous findings to compare the long-term predictive validity of three such models: the five-factor model (FFM), the schedule for nonadaptive and adaptive personality (SNAP), and DSM-IV personality disorders (PDs). METHOD: An inception cohort from the Collaborative Longitudinal Personality Disorder Study (CLPS) was followed for 10 years. Baseline data were used to predict long-term outcomes, including functioning, Axis I psychopathology, and medication use. RESULTS: Each model was significantly valid, predicting a host of important clinical outcomes. Lower-order elements of the FFM system were not more valid than higher-order factors, and DSM-IV diagnostic categories were less valid than dimensional symptom counts. Approaches that integrate normative traits and personality pathology proved to be most predictive, as the SNAP, a system that integrates normal and pathological traits, generally showed the largest validity coefficients overall, and the DSM-IV PD syndromes and FFM traits tended to provide substantial incremental information relative to one another. CONCLUSIONS: DSM-5 PD assessment should involve an integration of personality traits with characteristic features of PDs.

The association of personality disorders with the prospective 7-year course of anxiety disorders.

BACKGROUND: This study prospectively examined the natural clinical course of six anxiety disorders over 7 years of follow-up in individuals with personality disorders (PDs) and/or major depressive disorder. Rates of remission, relapse, new episode onset and chronicity of anxiety disorders were examined for specific associations with PDs. METHOD: Participants were 499 patients with anxiety disorders in the Collaborative Longitudinal Personality Disorders Study, who were assessed with structured interviews for psychiatric disorders at yearly intervals throughout 7 years of follow-up. These data were used to determine probabilities of changes in disorder status for social phobia (SP), generalized anxiety disorder (GAD), obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), panic disorder and panic disorder with agoraphobia. RESULTS: Estimated remission rates for anxiety disorders in this study group ranged from 73% to 94%. For those patients who remitted from an anxiety disorder, relapse rates ranged from 34% to 67%. Rates for new episode onsets of anxiety disorders ranged from 3% to 17%. Specific PDs demonstrated associations with remission, relapse, new episode onsets and chronicity of anxiety disorders. Associations were identified between schizotypal PD with course of SP, PTSD and GAD; avoidant PD with course of SP and OCD; obsessive-compulsive PD with course of GAD, OCD, and agoraphobia; and borderline PD with course of OCD, GAD and panic with agoraphobia. CONCLUSIONS: Findings suggest that specific PD diagnoses have negative prognostic significance for the course of anxiety disorders underscoring the importance of assessing and considering PD diagnoses in patients with anxiety disorders.

Improvement in borderline personality disorder in relationship to age.

OBJECTIVE: It is commonly believed that some features of borderline personality disorder (BPD) improve as individuals reach their late 30s and 40s. This study examined age-related change in borderline criteria and functional impairment, testing the hypothesis that older age would be associated with relatively more improvement than younger age. METHOD: A total of 216 male and female participants with BPD were followed prospectively with yearly assessments over 6 years. RESULTS: Participants showed similar rates of improvement in borderline features regardless of age. A significant age by study year interaction showed functioning in older subjects to reverse direction and begin to decline in the latter part of the follow-up, in contrast to younger subjects who maintained or continued improvement over the 6 years. Despite the decline, functioning for the older subjects was comparable with or slightly better at year 6 than at year 1. CONCLUSION: Improvement in borderline features is not specific to the late 30s and 40s. There may be a reversal of improvement in functioning in some borderline patients in this older-age range.

Personality traits as prospective predictors of suicide attempts.

OBJECTIVE: To examine higher order personality factors of negative affectivity (NA) and disinhibition (DIS), as well as lower order facets of impulsivity, as prospective predictors of suicide attempts in a predominantly personality disordered sample. METHOD: Data were analyzed from 701 participants of the Collaborative Longitudinal Personality Disorders Study with available follow-up data for up to 7 years. Cox proportional hazards regression analyses was used to examine NA and DIS, and facets of impulsivity (e.g. urgency, lack of perseverance, lack of premeditation and sensation seeking), as prospective predictors of suicide attempts. RESULTS: NA, DIS and all facets of impulsivity except for sensation seeking were significant in univariate analyses. In multivariate models which included sex, childhood sexual abuse, course of major depressive disorder and substance use disorders, only NA and lack of premeditation remained significant in predicting suicide attempts. DIS and the remaining impulsivity facets were not significant. CONCLUSION: NA emerged as a stronger and more robust predictor of suicide attempts than DIS and impulsivity, and warrants greater attention in suicide risk assessment. Distinguishing between facets of impulsivity is important for clinical risk assessment.

The 10-year course of physically self-destructive acts reported by borderline patients and axis II comparison subjects.

OBJECTIVE: The purpose of this paper was to determine the frequency and methods of two forms of physically self-destructive acts (i.e. self-mutilation and suicide attempts) reported by borderline patients and axis II comparison subjects over 10 years of prospective follow-up. METHOD: Two hundred and ninety borderline patients and 72 axis II comparison subjects were interviewed about their physically self-destructive acts during their index admission and at five contiguous 2-year follow-up periods. RESULTS: It was found that a high percentage of borderline patients reported multiple acts and methods of each of these two forms of physically self-destructive behavior prior to their index admission. It was also found that the percentage of borderline patients reporting multiple acts and methods declined significantly over time. However, these acts remained significantly more common among borderline patients than axis II comparison subjects. CONCLUSION: The course of self-mutilation and suicide attempts among borderline patients is initially more serious and ultimately more benign than previously recognized.

Diagnosing borderline patients with a semistructured interview.

As a part of an ongoing effort to provide operational criteria for a diagnosis of borderline personality disorder, the Diagnostic Interview for Borderlines (DIB) has been developed. The DIB is an hour-long, semistructured interview that evaluates five areas of borderline pathologic features--social adaptation, impulse/action patterns. affects, psychotic symptoms, and interpersonal relations. The DIBs were administered to 70 hospitalized patients and compared with clinical diagnoses made at the time of discharge. The DIB discriminates borderline patients from others, especially from schizophrenic and neurotic depressives. It reflects clinical diagnosis, yielding higher scores for patients on whom there is more agreement on the diagnosis of borderline. The instrument can be used flexibly to identify populations of borderline patients for research purposes.

The role of the therapeutic alliance in the treatment of schizophrenia. Relationship to course and outcome.

This study examined the relationship of the therapeutic alliance to the treatment course and outcome of 143 patients with nonchronic schizophrenia. Results showed that patients who formed good alliances with their therapists within the first 6 months of treatment were significantly more likely to remain in psychotherapy, comply with their prescribed medication regimens, and achieve better outcomes after 2 years, with less medication, than patients who did not. These results underscored the prognostic value of assessing the alliance and the need to identify factors that contribute to its development and maintenance with schizophrenic patients.

The search for a schizotype. Crossing the border again.

We reexamined case records from the Danish Extended Family Study to find so-called borderline schizophrenic (B3) persons who were clustered in the biologic relatives of chronic schizophrenic adoptees. A syndrome can be identified in these B3 cases that is distinguishable from borderline personality disorder and other personality disorders. Its discriminating features suggest that current DSM III criteria for schizotypal personality disorder be revised to include new criteria for somatization and social role dysfunction and a shift away from the past emphasis on psychoticlike experiences. Although the methodological limitations in this and other studies that have searched for a schizotype necessitate further research on the criteria for this new category, there is growing evidence to support its validity as a psychiatric diagnosis.

The families of borderlines. A comparative study.

The families of 12 carefully diagnosed patients with borderline personality disorder are compared with the families of both paranoid schizophrenic patients and patients with neurotic personality disorders. The families of the borderline patients were distinguished by the rigid tightness of the marital bond to the exclusion of the attention, support, or protection of the children. This pattern of neglect conforms to one theme in the clinical literature, and its implications for understanding and treating borderline patients are discussed. Limitations in the research methodology make the conclusions from this study tentative, but the results suggest new areas in need of research attention.

The diagnostic interview for narcissistic patients.

This report describes the content and development of a semistructured interview, the Diagnostic Interview for Narcissism. The interview evaluates 33 features of pathological narcissism covering five domains of function: grandiosity, interpersonal relations, reactiveness, affects and moods, and social and moral adaptation. Its utility is established by reliability studies and by developing a scoring system from a sample of 24 prototypic narcissistic patients who were compared with 58 others. Because narcissistic personality disorder is a widely used diagnosis whose inclusion in DSM-III-R was without reference to an empirical base, this instrument offers a method for doing much-needed research.

The validity of DSM-III borderline personality disorder. A phenomenologic, family history, treatment response, and long-term follow-up study.

To test the validity of the DSM-III diagnosis of borderline personality disorder (BPD), we examined the phenomenology, family history, treatment response, and four-to-seven-year long-term outcome of a cohort of 33 patients meeting DSM-III criteria for BPD. We found that (1) BPD could be distinguished readily from DSM-III schizophrenia; (2) BPD did not appear to represent "borderline affective disorder," although many patients displayed BPD and major affective disorder concomitantly; and (3) BPD could not be distinguished on any of the indices from histrionic and antisocial personality disorders.

The borderline patient's intolerance of aloneness: insecure attachments and therapist availability.

OBJECTIVE: This article describes the clinical and theoretical significance of intolerance of aloneness for patients with borderline personality disorder. It is intended to make their treatment more effective and less burdensome. METHOD: Clinical observations from the author's more than 9,000 hours of psychotherapeutic work and 500 psychotherapy consultations with borderline patients are synthesized with findings of relevant empirical studies and attachment theory. RESULTS: Intolerance of aloneness is a deficit that is associated with the borderline patient's typical clinging and attention-seeking or detached forms of attachment. Suggestions are given for ways in which clinicians can respond to these dysfunctional attachment behaviors to diminish the patient's feared aloneness without encouraging unnecessary regressions. A framework for understanding the long-term attachment processes required to correct this deficit is offered. CONCLUSIONS: Intolerance of aloneness is a core deficit in borderline patients that can become less handicapping with reliable, but not excessive, responsiveness of the therapist.

Patient-therapist matching: a research evaluation.

The author tested the predictive power of 10 hypotheses about the personality qualities of therapists that match with those of schizophrenic inpatients to affect therapeutic course. The personality matching traits predicted with significant accuracy the quality of the therapeutic relationship and even the type of overall clinical outcome. Examination of the data revealed that most of this surprising predictive strength derived from a group of highly intercorrelated personality qualities. Taken together, these qualities reflected a capacity of therapists to be comfortable while being involved with a variety of strong affects in their schizophrenic inpatients. The limitations of this study and its advantages over the A-B typology are discussed.

The phenomenological and conceptual interface between borderline personality disorder and PTSD.

OBJECTIVE: The authors explore the conceptual and phenomenological interface between posttraumatic stress disorder (PTSD) and borderline personality disorder as well as the therapeutic and research implications of this interface. METHOD: They systematically review the relevant empirical, conceptual, and clinical literature. RESULTS: These seemingly separate disorders are related. Borderline personality disorder is often shaped in part by trauma, and individuals with borderline disorder are therefore vulnerable to developing PTSD. CONCLUSIONS: The authors draw a distinction between the enduring effects that traumas can have on formation (or change) of axis II personality traits (including those found in borderline personality disorder) and acute symptomatic reactions to trauma, called PTSD, that are accompanied by specific psychophysiological correlates. They describe the implications of these conclusions for DSM-IV, therapy, and future research.

Discriminating features of borderline patients.

Borderline patients were compared with schizophrenic patients, neurotic depressed patients, and a group of patients with differing diagnoses. The purpose of this comparison was to find out whether borderline patients could be discriminated from other psychopathological groups and whether a discrete list of recognizable characteristics discriminating borderline patients could be isolated. According to the results of the comparison, borderline patients can be discriminated with high accuracy from matched comparison groups with whom diagnostic confusion is common. Seven criteria provided a clinically sensible and practical means of approaching the diagnosis of borderline disorder.

The cost of schizophrenia.

The cost of schizophrenia has been estimated at $11.6 to $19.5 billion annually. About two-thirds of this cost is due to lack of productivity by schizophrenic patients and about one-fifth to treatment costs. The estimate might be considerably higher if better figures were available on the cost of maintaining patients in the community. In the absence of more effective treatment, the savings from the current trend toward shorter hospitalization cannot be expected to decrease-and may actually increase-the overall costs of schizophrenia to society. The authors make recommendations aimed at reducing the cost by helping schizophrenic patients to be more productive through a system of community alternative-care facilities, increased rehabilitation services, aftercare, and research.

Defining borderline patients: an overview.

This review of the descriptive literature on borderline patients indicates that accounts of such patients vary depending upon who is describing them, in what context, how the samples are selected, and what data are collected. The authors identify six features that provide a rational means for diagnosing borderline patients during an initial interview: the presence of intense affect, usually depressive or hostile; a history of impulsive behavior; a certain social adaptiveness; brief psychotic experiences; loose thinking in unstructured situations; and relationships that vacillate between transient superficiality and intense dependency. Reliable identification of these patients will permit better treatment planning and clinical research.

The interface between borderline personality disorder and affective disorder.

The authors review the available literature on the interface between borderline personality disorder and affective disorder. Three competing hypotheses have been offered to explain the substantial overlap between these diagnostic categories; they postulate that borderline disorder arises from affective disorder, that affective disorder arises from borderline disorder, or that the two are independent and overlap coincidentally. None of these hypotheses satisfactorily explains the existing data. The authors propose a fourth hypothesis focusing on the multiple etiologies of the signs and symptoms used to diagnose both affective and borderline disorders and suggesting that some patients in the resulting heterogeneous population have symptom clusters that fit both syndromes.

A current view of the interface between borderline personality disorder and depression.

The recent and dramatic expansion in studies about borderline and depressive disorders is reviewed with respect to the implications about their interface. Revisiting this subject 6 years after an earlier review reveals that intervening research has altered the conclusions that should be drawn. Growing evidence from family history, comorbidity, phenomenology, psychopharmacology, biological markers, and a new domain, pathogenesis, indicates that a surprisingly weak and nonspecific relationship exists between these disorders. Implications are drawn with respect to classification, therapeutics, and defining the borderline construct.