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.

Prediction of time-to-attainment of recovery for borderline patients followed prospectively for 16 years.

OBJECTIVE: The purpose of this study was to determine the most clinically relevant baseline predictors of time-to-recovery from borderline personality disorder. METHOD: Two hundred and ninety in-patients meeting rigorous criteria for borderline personality disorder were assessed during their index admission using a series of semistructured interviews and self-report measures. Recovery status, which was defined as concurrent symptomatic remission and good social and full-time vocational functioning, was reassessed at eight contiguous 2-year time periods. Survival analytic methods (Cox regression), which controlled for overall baseline severity, were used to estimate hazard ratios and their confidence intervals. RESULTS: All told, 60% of the borderline patients studied achieved a 2-year recovery. In bivariate analyses, seventeen variables were found to be significant predictors of earlier time-to-recovery. Six of these predictors remained significant in multivariate analyses: no prior psychiatric hospitalizations, higher IQ, good full-time vocational record in 2 years prior to index admission, absence of an anxious cluster personality disorder, high extraversion, and high agreeableness. CONCLUSION: Taken together, the results of this study suggest that prediction of time-to-recovery for borderline patients is multifactorial in nature, involving factors related to lack of chronicity, competence, and more adaptive aspects of temperament.

Predictors of suicide attempts in patients with borderline personality disorder over 16 years of prospective follow-up.

BACKGROUND: It is clinically important to understand the factors that increase the likelihood of the frequent and recurrent suicide attempts seen in those with borderline personality disorder (BPD). Although several studies have examined this subject in a cross-sectional manner, the aim of this study was to determine the most clinically relevant baseline and time-varying predictors of suicide attempts over 16 years of prospective follow-up among patients with BPD. METHOD: Two-hundred and ninety in-patients meeting Revised Diagnostic Interview for Borderlines (DIB-R) and DSM-III-R criteria for BPD were assessed during their index admission using a series of semistructured interviews and self-report measures. These subjects were then reassessed using the same instruments every 2 years. The generalized estimating equations (GEE) approach was used to model the odds of suicide attempts in longitudinal analyses, controlling for assessment period, yielding an odds ratio (OR) and 95% confidence interval (CI) for each predictor. RESULTS: Nineteen variables were found to be significant bivariate predictors of suicide attempts. Eight of these, seven of which were time-varying, remained significant in multivariate analyses: diagnosis of major depressive disorder (MDD), substance use disorder (SUD), post-traumatic stress disorder (PTSD), presence of self-harm, adult sexual assault, having a caretaker who has completed suicide, affective instability, and more severe dissociation. CONCLUSIONS: The results of this study suggest that prediction of suicide attempts among borderline patients is complex, involving co-occurring disorders, co-occurring symptoms of BPD (self-harm, affective reactivity and dissociation), adult adversity, and a family history of completed suicide.

The 10-year course of PTSD in borderline patients and axis II comparison subjects.

OBJECTIVE: The first objective is to detail the prevalence of post-traumatic stress disorder (PTSD) over a decade of follow-up for those in both study groups. The second is to determine time-to-remission, recurrence, and new onset of PTSD, and the third is to assess the relationship between sexual adversity and the likelihood of remission and recurrence of PTSD. METHOD: The SCID I was administered to 290 borderline in-patients and 72 axis II comparison subjects during their index admission and re-administered at five contiguous 2-year follow-up periods. RESULTS: The prevalence of PTSD declined significantly over time for patients with borderline personality (BPD) (61%). Over 85% of borderline patients meeting criteria for PTSD at baseline experienced a remission by the time of the 10-year follow-up. Recurrences (40%) and new onsets (27%) were less common. A childhood history of sexual abuse significantly decreased the likelihood of remission from PTSD, and an adult history of sexual assault significantly increased the likelihood of a recurrence of PTSD. CONCLUSION: Taken together, the results of this study suggest that PTSD is not a chronic disorder for the majority of borderline patients. They also suggest a strong relationship between sexual adversity and the course of PTSD among patients with BPD.

Temperamental and acute symptoms of borderline personality disorder: associations with normal personality traits and dynamic relations over time.

BACKGROUND: Recent research suggests the utility of distinguishing temperamental and acute symptoms of borderline personality disorder (BPD). Temperamental symptoms, such as chronic anger and odd thinking, remit relatively slowly and have been hypothesized to reflect a hyperbolic predisposition to emotional pain and negativistic cognitions, whereas acute symptoms, such as substance abuse and chaotic relationships, remit relatively quickly and have been hypothesized to represent the consequences of maladaptations to triggering environmental events. METHOD: The relationships of temperamental and acute BPD symptoms with normal personality traits and stability and dynamic associations over time across these symptom sets were tested in a 10-year longitudinal study of 362 patients with personality disorders. RESULTS: Temperamental symptoms were associated with high neuroticism, whereas acute symptoms were associated with low agreeableness. These symptoms had similar rank-order stabilities and relative changes in symptom sets were reciprocally linked in a cross-lagged path model suggesting dynamic associations between temperamental and acute symptoms over time. CONCLUSIONS: The distinction between temperamental and acute BPD symptoms is supported by differential relations of these symptom sets to normal personality traits. Moreover, these symptoms appear to be linked in a mutually reinforcing dynamic over time. This distinction should be kept in mind in future studies of the aetiology of BPD and in diagnostic and treatment considerations.

The 10-year course of psychosocial functioning among patients with borderline personality disorder and axis II comparison subjects.

OBJECTIVE: The purpose of this study was to determine the 10-year course of the psychosocial functioning of patients with borderline personality disorder (BPD). METHOD: The social and vocational functioning of 290 inpatients meeting both the Revised Diagnostic Interview for Borderlines (DIB-R) and DSM-III-R criteria for BPD and 72 axis II comparison subjects were carefully assessed during their index admission. Psychosocial functioning was reassessed using similar methods at five contiguous 2-year time periods. RESULTS: Borderline patients without good psychosocial functioning at baseline reported difficulty attaining it for the first time. Those who had such functioning at baseline reported difficulty retaining and then regaining it. In addition, over 90% of their poor psychosocial functioning was due to poor vocational but not social performance. CONCLUSION: Good psychosocial functioning that involves both social and vocational competence is difficult for borderline patients to achieve and maintain over time. In addition, their vocational functioning is substantially more compromised than their social functioning.

Psychotherapy of borderline personality disorder.

OBJECTIVE: Psychotherapy is considered the primary treatment for borderline personality disorder (BPD). Currently, there are four comprehensive psychosocial treatments for BPD. Two of these treatments are considered psychodynamic in nature: mentalization-based treatment and transference-focused psychotherapy. The other two are considered to be cognitive-behavioral in nature: dialectical behavioral therapy and schema-focused therapy. METHOD: A review of the relevant literature was conducted. RESULTS: Each of these lengthy and complex psychotherapies significantly reduces the severity of borderline psychopathology or at least some aspects of it, particularly physically self-destructive acts. CONCLUSION: Comprehensive, long-term psychotherapy can be a useful form of treatment for those with BPD. However, less intensive and less costly forms of treatment need to be developed.

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.

The course of dissociation for patients with borderline personality disorder and axis II comparison subjects: a 10-year follow-up study.

OBJECTIVE: The purpose of this study was to assess the severity of dissociation reported by borderline patients and axis II comparison subjects over 10 years of prospective follow-up. METHOD: The Dissociative Experiences Scale (DES) - a 28-item self-report measure - was administered to 290 borderline in-patients and 72 axis II comparison subjects during their index admission. It was also re-administered at five contiguous 2-year follow-up periods. RESULTS: The overall severity of dissociative experiences of those in both study groups decreased significantly over time but was discernibly greater in borderline patients (61% vs. 43%). The same pattern emerged for the subtypes of dissociation that were studied: absorption, depersonalization and amnesia. CONCLUSION: The severity of dissociation declines significantly over time for even severely ill borderline patients. However, it remains as a recurring problem for over a third of those with DES scores that initially were in the range associated with trauma-spectrum disorders.

Parent-adolescent concordance on the Revised Diagnostic Interview for Borderlines (DIB-R) and the Childhood Interview for Borderline Personality Disorder (CI-BPD).

While the degree of concordance between parent and adolescent self-report of internalizing and externalizing pathology is well studied, virtually nothing is known about concordance in borderline pathology and the implication of parent-adolescent discrepancies for outcomes. The present study aimed to (1) examine discrepancies between parents and adolescents on two interview-based measures of borderline personality disorder (BPD)-the Revised Diagnostic Interview for Borderlines (DIB-R22 ) and the Childhood Interview for Borderline Personality Disorder (CI-BPD23 ); and (2) investigate the implications of discrepancies for clinical outcomes. Diagnostic concordance on the DIB-R and CI-BPD showed rates of 82% and 94% respectively, with lower concordance demonstrated for dimensionally scored variables. Standardized difference scores between adolescent and parent reports on both borderline measures were significantly correlated with few interview-based axis I diagnoses as reported by parents, but not adolescents themselves. Implications regarding the use of each measure for the assessment and diagnosis of borderline personality disorder are discussed. Copyright © 2017 John Wiley & Sons, Ltd.

Clozapine and body mass change.

BACKGROUND: Patients treated with clozapine have been reported to gain weight. We hypothesized that patients would also experience an increase in body mass, which can be more directly related to cardiovascular morbidity. METHODS: Forty-two patients who had been treated with clozapine for at least 1 year were weighed and measured, and waist-hip ratios (WHR) and body mass index (BMI), measured as kg/m2, were calculated. Patients were also asked about a series of factors potentially related to change in body mass. RESULTS: Female patients gained both weight and body mass. Their WHR after 37 months of clozapine therapy was .83, with a significant increase in BMI from 23.2 to 29.1 kg/m2 (p = .001). Male subjects also gained weight and body mass. Their WHR after 39 months of clozapine therapy was .93, with a significant increase in BMI from 26.4 to 29.7 kg/m2 (p < .001). Stepwise multiple-regression analysis showed that factors related to final body mass were initial body mass, dose of clozapine, and decrease in smoking. Baseline BMI contributed most to the final BMI, but the addition of dose and decrease in smoking made significant contributions to the model. CONCLUSIONS: Both female and male patients treated with clozapine gain body mass. This may place them at greater risk for cardiovascular morbidity.

Transitional object use and borderline psychopathology.

The authors examined whether transitional object use distinguishes borderline patients from patients with other personality disorders or schizophrenia and from normal subjects. One hundred five subjects were given a structured interview to assess present and past transitional object use. The borderline group had the highest scores on the interview, and the group with nonborderline axis II diagnoses the lowest. Although transitional object use was not specific to the borderline diagnosis, it did emerge as a potentially useful developmental and psychodynamic marker for borderline persons.

Cognitive features of borderline personality disorder.

Of 50 patients with borderline personality disorder, 100% reported disturbed but nonpsychotic thought, 40% (N = 20) reported quasi-psychotic thought, and none reported true psychotic thought during the past 2 years; only 14% (N = 7) reported ever experiencing true psychotic thought. Disturbed and quasi-psychotic thought was significantly more common among these patients than among patients with other axis II disorders or schizophrenia and normal control subjects; however, true psychotic thought was significantly more common among schizophrenic patients. While disturbed thought was also common among axis II disorder and schizophrenic patients, quasi-psychotic thought was reported by only one of these subjects, suggesting that quasi-psychotic thought may be a marker for borderline personality disorder.

The face validity of the DSM-III and DSM-III-R criteria sets for borderline personality disorder.

OBJECTIVE: The main objective of this study was to determine the congruence between DSM-III and DSM-III-R diagnoses of borderline personality disorder derived through the use of semistructured research interviews or given by experienced clinicians after lengthy consultations with an interdisciplinary team. METHOD: The presence of the DSM-III and DSM-III-R criteria sets for borderline personality disorder was assessed in a study group of 253 patients with personality disorders (148 inpatients and 105 outpatients) by raters who were blind to clinical diagnoses and who used information from two semistructured interviews of proven reliability. These diagnoses were then compared with "longitudinal expert all data" (LEAD) standard clinical diagnoses provided by therapists specifically asked to base their diagnoses on DSM criteria. RESULTS: Both criteria sets were found to be overinclusive when compared with the LEAD standard. Most criteria were also found to lack specificity. However, the three DSM-III-R criteria that are new or revisions of DSM-III criteria were found to be more specific, and raising the cutoff on the DSM-III-R criteria from five to six improved specificity. CONCLUSIONS: Both the DSM-III and DSM-III-R criteria sets for borderline personality disorder as assessed by semistructured interview lack face validity because they are nonspecific when compared with a rigorous but representative clinical standard, and the results of studies using these criteria sets may prove misleading to researchers and clinicians because they seem to define a nonspecific type of serious character pathology.

Discriminating borderline personality disorder from other axis II disorders.

The authors used the Revised Diagnostic Interview for Borderline Patients to assess 22 clinical features of 120 patients with borderline personality disorder and 103 control subjects with other axis II disorders. Four of the 22 features were common in but nondiscriminating for borderline disorder, 11 were discriminating for but nonspecific to borderline disorder, and seven were more specific to borderline disorder. The authors conclude that many clinical features thought to be indicative of borderline disorder are better viewed as personality disorder traits and that the seven more specific features, alone or in conjunction with one another, may be particularly useful markers for borderline personality disorder.

Reported pathological childhood experiences associated with the development of borderline personality disorder.

OBJECTIVE: The purpose of this study was to assess a full range of pathological childhood experiences reported by patients with criteria-defined borderline personality disorder and comparison patients with other personality disorders. METHOD: The pathological childhood experiences reported by 467 inpatients with personality disorders were assessed by interviewers who used a semistructured research interview and were blind to clinical diagnosis. RESULTS: Of the 358 patients with borderline personality disorder, 91% reported having been abused, and 92% reported having been neglected, before the age of 18. The borderline patients were significantly more likely than the 109 patients with other personality disorders to report having been emotionally and physically abused by a caretaker and sexually abused by a noncaretaker. They were also significantly more likely to report having a caretaker withdraw from them emotionally, treat them inconsistently, deny their thoughts and feelings, place them in the role of a parent, and fail to provide them with needed protection. The borderline patients with a childhood history of sexual abuse were significantly more likely than those without such a history to report having experienced all but one of the types of abuse and neglect studied. When all significant risk factors were considered together, four were found to be significant predictors of a borderline diagnosis: female gender, sexual abuse by a male noncaretaker, emotional denial by a male caretaker, and inconsistent treatment by a female caretaker. CONCLUSIONS: The results suggest that sexual abuse is neither necessary nor sufficient for the development of borderline personality disorder and that other childhood experiences, particularly neglect by caretakers of both genders, represent significant risk factors.

Axis I comorbidity of borderline personality disorder.

OBJECTIVE: The purpose of this study was to assess the lifetime rates of occurrence of a full range of DSM-III-R axis I disorders in a group of patients with criteria-defined borderline personality disorder and comparison subjects with other personality disorders. METHOD: The axis I comorbidity of 504 inpatients with personality disorders was assessed by interviewers who were blind to clinical diagnosis and who used a semistructured research interview of demonstrated reliability. RESULTS: Four new findings emerged from this study. First, anxiety disorders were found to be almost as common among borderline patients (N=379) as mood disorders but far more discriminating from axis II comparison subjects (N=125). Second, posttraumatic stress disorder (PTSD) was found to be a common but not universal comorbid disorder among borderline patients, a finding inconsistent with the view that borderline personality disorder is actually a form of chronic PTSD. Third, male and female borderline patients were found to differ in the type of disorder of impulse in which they "specialized." More specifically, substance use disorders were significantly more common among male borderline patients, while eating disorders were significantly more common among female borderline patients. Fourth, a lifetime pattern of complex comorbidity (i.e., met DSM-III-R criteria for both a disorder of affect and a disorder of impulse at some point before the patients' index admission) was found to have strong positive predictive power for the borderline diagnosis as well as a high degree of sensitivity and specificity. CONCLUSIONS: These results suggest that the lifetime pattern of axis I comorbidity characteristic of borderline patients and distinguishing for the disorder is a particularly good marker for borderline personality disorder.

Treatment utilization by patients with personality disorders.

OBJECTIVE: Utilization of mental health treatment was compared in patients with personality disorders and patients with major depressive disorder without personality disorder. METHOD: Semistructured interviews were used to assess diagnosis and treatment history of 664 patients in four representative personality disorder groups-schizotypal, borderline, avoidant, and obsessive-compulsive-and in a comparison group of patients with major depressive disorder. RESULTS: Patients with personality disorders had more extensive histories of psychiatric outpatient, inpatient, and psychopharmacologic treatment than patients with major depressive disorder. Compared to the depression group, patients with borderline personality disorder were significantly more likely to have received every type of psychosocial treatment except self-help groups, and patients with obsessive-compulsive personality disorder reported greater utilization of individual psychotherapy. Patients with borderline personality disorder were also more likely to have used antianxiety, antidepressant, and mood stabilizer medications, and those with borderline or schizotypal personality disorder had a greater likelihood of having received antipsychotic medications. Patients with borderline personality disorder had received greater amounts of treatment, except for family/couples therapy and self-help, than the depressed patients and patients with other personality disorders. CONCLUSIONS: These results underscore the importance of considering personality disorders in diagnosis and treatment of psychiatric patients. Borderline and schizotypal personality disorder are associated with extensive use of mental health resources, and other, less severe personality disorders may not be addressed sufficiently in treatment planning. More work is needed to determine whether patients with personality disorders are receiving adequate and appropriate mental health treatments.