Pretreatment cognitive performance is associated with differential self-harm outcomes in 6 v. 12-months of dialectical behavior therapy for borderline personality disorder.

BACKGROUND: Recent findings suggest that brief dialectical behavior therapy (DBT) for borderline personality disorder is effective for reducing self-harm, but it remains unknown which patients are likely to improve in brief v. 12 months of DBT. Research is needed to identify patient characteristics that moderate outcomes. Here, we characterized changes in cognition across brief DBT (DBT-6) v. a standard 12-month course (DBT-12) and examined whether cognition predicted self-harm outcomes in each arm. METHODS: In this secondary analysis of 240 participants in the FASTER study (NCT02387736), cognitive measures were administered at pre-treatment, after 6 months, and at 12 months. Self-harm was assessed from pre-treatment to 2-year follow-up. Multilevel models characterized changes in cognition across treatment. Generalized estimating equations examined whether pre-treatment cognitive performance predicted self-harm outcomes in each arm. RESULTS: Cognitive performance improved in both arms after 6 months of treatment, with no between-arm differences at 12-months. Pre-treatment inhibitory control was associated with different self-harm outcomes in DBT-6 v. DBT-12. For participants with average inhibitory control, self-harm outcomes were significantly better when assigned to DBT-12, relative to DBT-6, at 9-18 months after initiating treatment. In contrast, participants with poor inhibitory control showed better self-harm outcomes when assigned to brief DBT-6 v. DBT-12, at 12-24 months after initiating treatment. CONCLUSIONS: This work represents an initial step toward an improved understanding of patient profiles that are best suited to briefer v. standard 12 months of DBT, but observed effects should be replicated in a waitlist-controlled study to confirm that they were treatment-specific.

Maladaptive defense mechanisms moderate treatment outcome in 6 months versus 12 months dialectical-behavior therapy for borderline personality disorder.

OBJECTIVE: We investigated whether defense mechanisms in patients with borderline personality disorder (BPD) predict treatment response of dialectical behavior therapy (DBT) and whether they moderate outcome in different treatment lengths. METHOD: We analyzed a subsample of 60 outpatients with BPD, randomized into either 6 (n = 30) or 12 (n = 30) months of DBT. The average level of defensive adaptiveness, assessed with observer-rated overall defensive functioning (ODF) and "immature" (i.e., maladaptive) defenses were used as predictors and moderators of self-reported frequency of self-harm. We conducted a Generalized Linear Mixed Model (GLMM). RESULTS: A lower ODF at treatment onset predicted smaller reductions in self-harm, irrespective of treatment length (IRR = 0.92, 95% CI = [0.86, 0.99], p = .020). Lower order "immature" ("major image distorting") defenses showed significantly smaller (IRR = 1.13, 95% CI = [1.06, 1.21], p < .001) and higher order "immature" ("minor image distorting") defenses showed significantly larger (IRR = .91, 95% CI = [.85, .97], p = .006) reductions in self harm in the 6-month but not in the 12-month treatment. CONCLUSION: Even though the results have to be regarded as preliminary due to the small sample size, findings might indicate that patients with BPD and lower average defensive adaptiveness may benefit from individualized treatment plans including specific interventions targeting defense function.

The Effectiveness of 6 versus 12 Months of Dialectical Behavior Therapy for Borderline Personality Disorder: A Noninferiority Randomized Clinical Trial.

INTRODUCTION: Evidence-based psychotherapies for borderline personality disorder (BPD) are lengthy, posing a barrier to their access. Brief psychotherapy may achieve comparable outcomes to long-term psychotherapy for BPD. Evidence is needed regarding the comparative effectiveness of short- versus long-term psychotherapy for BPD. OBJECTIVE: The aim was to determine if 6 months of Dialectical Behavior Therapy (DBT) is noninferior to 12 months of DBT in terms of clinical effectiveness. METHODS: This two-arm, single-blinded, randomized controlled noninferiority trial with suicidal or self-harming patients with BPD was conducted at two sites in Canada. Participants (N = 240, M (SD)age = 28.27 (8.62), 79% females) were randomized to receive either 6 (DBT-6) or 12 months (DBT-12) of comprehensive DBT. Masked assessors obtained measures of clinical effectiveness at baseline and every 3 months, ending at month 24. DBT-6 and DBT-12 were outpatient treatments consisting of weekly individual therapy sessions, weekly DBT skills training group sessions, telephone consultation as needed, and weekly therapist consultation team meetings. RESULTS: The noninferiority hypothesis was supported for the primary outcome, total self-harm (6 months: margin = -1.94, Mdiff [95% CI] = 0.16 [-0.14, 0.46]; 12 months: margin = -1.47, Mdiff [95% CI] = 0.04 [-0.17, 0.23]; 24 months: margin = -1.25, Mdiff [95% CI] = 0.12 [-0.02, 0.36]). Results also supported noninferiority of DBT-6 for general psychopathology and coping skills at 24 months. Furthermore, DBT-6 participants showed more rapid reductions in BPD symptoms and general psychopathology. There were no between-group differences in dropout rates. CONCLUSIONS: The noninferiority of a briefer yet comprehensive treatment for BPD has potential to reduce barriers to treatment access.

Future Challenges in Psychotherapy Research for Personality Disorders.

PURPOSE OF REVIEW: Individuals with personality disorders are frequently seen in mental health settings. Their symptoms typically reflect a high level of suffering and burden of disease, with potentially harmful societal consequences, including costs related to absenteeism at work, high use of health services, ineffective or harmful parenting, substance use, suicidal and non-suicidal self-harming behavior, and aggressiveness with legal consequences. Psychotherapy is currently the first-line treatment for patients with personality disorders, but the study of psychotherapy in the domain of personality disorders faces specific challenges. RECENT FINDINGS: Challenges include knowing what works for whom, identifying which putative mechanisms of change explain therapeutic effects, and including the social interaction context of patients with a personality disorder. By following a dimensional approach, psychotherapy research on personality disorders may serve as a model for the development and study of innovative psychotherapeutic interventions. We recommend developing the following: (a) an evidence base to make treatment decisions based on individual features; (b) a data-driven approach to predictors, moderators, and mechanisms of change in psychotherapy; (c) methods for studying the interaction between social context and psychotherapy.

Treatment selection in borderline personality disorder between dialectical behavior therapy and psychodynamic psychiatric management.

BACKGROUND: No evidence-based therapy for borderline personality disorder (BPD) exhibits a clear superiority. However, BPD is highly heterogeneous, and different patients may specifically benefit from the interventions of a particular treatment. METHODS: From a randomized trial comparing a year of dialectical behavior therapy (DBT) to general psychiatric management (GPM) for BPD, long-term (2-year-post) outcome data and patient baseline variables (n = 156) were used to examine individual and combined patient-level moderators of differential treatment response. A two-step bootstrapped and partially cross-validated moderator identification process was employed for 20 baseline variables. For identified moderators, 10-fold bootstrapped cross-validated models estimated response to each therapy, and long-term outcomes were compared for patients randomized to their model-predicted optimal v. non-optimal treatment. RESULTS: Significant moderators surviving the two-step process included psychiatric symptom severity, BPD impulsivity symptoms (both GPM > DBT), dependent personality traits, childhood emotional abuse, and social adjustment (all DBT > GPM). Patients randomized to their model-predicted optimal treatment had significantly better long-term outcomes (d = 0.36, p = 0.028), especially if the model had a relatively stronger (top 60%) prediction for that patient (d = 0.61, p = 0.004). Among patients with a stronger prediction, this advantage held even when applying a conservative statistical check (d = 0.46, p = 0.043). CONCLUSIONS: Patient characteristics influence the degree to which they respond to two treatments for BPD. Combining information from multiple moderators may help inform providers and patients as to which treatment is the most likely to lead to long-term symptom relief. Further research on personalized medicine in BPD is needed.

Evaluating the effectiveness of the Family Connections program for caregivers of youth with mental health challenges, part II: A qualitative analysis.

BACKGROUND: The Family Connections™ (FC) program is a 12-week support and skill-training program for caregivers of youth with mental health challenges. The intervention was originally developed with a focus on borderline personality disorder (BPD). It is important to understand the experiences of caregivers in such interventions, as well as its applicability beyond BPD, for the purposes of evaluation and ongoing program improvement. OBJECTIVE: To explore and analyse the experiences of caregivers of youth with diverse mental health challenges and who participated in FC. DESIGN: Semi-structured interviews with thirteen FC-participating caregivers of youth with mental health challenges. RESULTS: Thematic analysis uncovered three major themes regarding caregivers' experience with FC: (a) FC increased the caregivers' ability to manage their youth's mental health challenges; (b) participating in FC impacted their intra- and interpersonal spheres; and (c) improvements to the program were proposed. Following participation in FC, caregivers felt they learned a new approach to understanding themselves, their youth and mental health, and were better able to manage their youth's mental health challenges. DISCUSSION AND CONCLUSION: FC is a promising intervention for caregivers of youth with mental health challenges, beyond the traditional BPD focus. The intervention has the potential to provide broad-based benefits for caregivers and should be considered for implementation and scale-up across youth- and caregiver-serving organizations. Potential areas of intervention flexibility and improvement are discussed. PATIENT/PUBLIC CONTRIBUTION: Caregivers were involved in the program development and facilitation of FC. A person with lived experience was involved with the analysis.

Evaluating the effectiveness of the Family Connections program for caregivers of youth with mental health challenges, part I: A quantitative analysis.

INTRODUCTION: Caregivers of youth with mental health (MH) challenges are often faced with complex problems in relation to caring for their youth. Family Connections™ (FC) is a 12-week skills training program for families of individuals with MH challenges, developed originally for Borderline Personality Disorder. Research is needed to examine the effectiveness of FC for caregivers of youth with diverse MH challenges. OBJECTIVE: To examine the effectiveness of FC for caregivers of youth with MH challenges. METHODS: A total of 94 caregivers of youth with MH challenges participated in FC, across three sites in Ontario, Canada. Assessments occurred at baseline, 6 weeks, 12 weeks and follow-up. Primary outcomes include the Burden Assessment Scale and The Stress Index for Parents of Adolescents. Secondary outcomes included the caregiver's report of child behaviour, affect, mastery, coping and grief. Linear mixed model analyses were conducted, where time and the time × site interaction were defined as the fixed effects. RESULTS: Statistically significant improvements over time were observed across outcome measures, including caregiver burden, grief, coping, and other measures. The time × site interaction was only significant for burden (P = .005). CONCLUSION: This study demonstrates the effectiveness of FC for caregivers of youth with MH challenges. Future research should focus on differences across geographical sites and facilitation models. PATIENT OR PUBLIC CONTRIBUTION: Caregivers were involved in the facilitation of FC. A person with lived experience was involved in analysing the data, reporting the results, and drafting the manuscript.

Alliance rupture and repair in early sessions of dialectical behavior therapy: The case of Rachel.

Emotional and interpersonal instability are core features of borderline personality disorder (BPD) and can pose a challenge for the therapeutic relationship. In dialectical behavior therapy (DBT) for BPD, ruptures in the therapeutic alliance are considered through a behavioral lens that examines the client's relational learning history, the function and context of the rupture, as well as the patterns of emotional processing difficulties that underlie interpersonal conflict. In this article, we use the case of Rachel to illustrate how alliance-focused approach can be integrated with DBT case formulation to enhance treatment planning and the successful negotiation of alliance ruptures.

Clinical, personality, and neurodevelopmental phenotypes in borderline personality disorder: a family study.

BACKGROUND: Borderline personality disorder (BPD) is characterized by a heterogeneous clinical phenotype that emerges from interactions among genetic, biological, neurodevelopmental, and psychosocial factors. In the present family study, we evaluated the familial aggregation of key clinical, personality, and neurodevelopmental phenotypes in probands with BPD (n = 103), first-degree biological relatives (n = 74; 43% without a history of psychiatric disorder), and non-psychiatric controls (n = 99). METHODS: Participants were assessed on DSM-IV psychiatric diagnoses, symptom dimensions of emotion dysregulation and impulsivity, 'big five' personality traits, and neurodevelopmental characteristics, as part of a larger family study on neurocognitive, biological, and genetic markers in BPD. RESULTS: The most common psychiatric diagnoses in probands and relatives were major depression, substance use disorders, post-traumatic stress disorder, anxiety disorders, and avoidant personality disorder. There was evidence of familial aggregation for specific dimensions of impulsivity and emotion dysregulation, and the big five traits neuroticism and conscientiousness. Both probands and relatives reported an elevated neurodevelopmental history of attentional and behavioral difficulties. CONCLUSIONS: These results support the validity of negative affectivity- and impulse-spectrum phenotypes associated with BPD and its familial risk. Further research is needed to investigate the aggregation of neurocognitive, neural and genetic factors in families with BPD and their associations with core phenotypes underlying the disorder.

The effectiveness of 6 versus 12-months of dialectical behaviour therapy for borderline personality disorder: the feasibility of a shorter treatment and evaluating responses (FASTER) trial protocol.

BACKGROUND: Although Dialectical Behaviour Therapy (DBT) is an evidence-based psychosocial treatment for borderline personality disorder (BPD), the demand for it exceeds available resources. The commonly researched 12-month version of DBT is lengthy; this can pose a barrier to its adoption in many health care settings. Further, there are no data on the optimal length of psychotherapy for BPD. The aim of this study is to examine the clinical and cost-effectiveness of 6 versus 12 months of DBT for chronically suicidal individuals with BPD. A second aim of this study is to determine which patients are as likely to benefit from shorter treatment as from longer treatment. METHODS/DESIGN: Powered for non-inferiority testing, this two-site single-blind trial involves the random assignment of 240 patients diagnosed with BPD to 6 or 12 months of standard DBT. The primary outcome is the frequency of suicidal or non-suicidal self-injurious episodes. Secondary outcomes include healthcare utilization, psychiatric and emotional symptoms, general and social functioning, and health status. Cost-effectiveness outcomes will include the cost of providing each treatment as well as health care and societal costs (e.g., missed work days and lost productivity). Assessments are scheduled at pretreatment and at 3-month intervals until 24 months. DISCUSSION: This is the first study to directly examine the dose-effect of psychotherapy for chronically suicidal individuals diagnosed with BPD. Examining both clinical and cost effectiveness in 6 versus 12 months of DBT will produce answers to the question of how much treatment is good enough. Information from this study will help to guide decisions about the allocation of scarce treatment resources and recommendations about the benefits of briefer treatment. TRIAL REGISTRATION: NCT02387736 . Registered February 20, 2015.

Cognitive Emotion Regulation Strategies in Borderline Personality Disorder: Diagnostic Comparisons and Associations with Potentially Harmful Behaviors.

BACKGROUND: Although difficulties in emotion regulation (ER) are considered a core feature of borderline personality disorder (BPD), the specific strategies that individuals with BPD most commonly use, their diagnostic specificity, and their associations with harmful behaviors have not been firmly established. SAMPLING AND METHODS: Individuals with BPD (n = 30), mixed anxiety and/or depressive disorders (MAD; n = 30), and healthy controls (HC; n = 32) completed questionnaires assessing both cognitive ER strategies (e.g., cognitive reappraisal) and potentially harmful behaviors that individuals might use to regulate their emotions (e.g., self-injury). RESULTS: BPD subjects endorsed more maladaptive cognitive ER strategies and fewer adaptive strategies compared to HC. Compared to MAD subjects, BPD individuals endorsed more maladaptive cognitive ER strategies, but only when those with subthreshold symptoms in the MAD group were excluded. BPD also endorsed engaging in potentially harmful behaviors more often than both HC and MAD. Discriminant analysis revealed that MAD endorsed lower rates of problem-solving and cognitive reappraisal compared to both HC and BPD. Higher maladaptive and lower adaptive ER strategies were associated with higher rates of potentially harmful behaviors, although the specific strategies differed for MAD versus BPD. CONCLUSIONS: BPD and MAD endorse cognitive ER strategies with a comparable frequency, although BPD subjects engage in potentially harmful behaviors more often. Subthreshold BPD symptoms may also affect rates of ER strategy use in individuals with other mental disorders.

A randomized trial of brief dialectical behaviour therapy skills training in suicidal patients suffering from borderline disorder.

OBJECTIVE: Evidence-based therapies for borderline personality disorder (BPD) are lengthy and scarce. Data on brief interventions are limited, and their role in the treatment of BPD is unclear. Our aim was therefore to evaluate the clinical effectiveness of brief dialectical behaviour therapy (DBT) skills training as an adjunctive intervention for high suicide risk in patients with BPD. METHOD: Eighty-four out-patients were randomized to 20 weeks of DBT skills (n = 42) or a waitlist (WL; n = 42). The primary outcome was frequency of suicidal or non-suicidal self-injurious (NSSI) episodes. Assessments were conducted at baseline 10, 20 and 32 weeks. RESULTS: DBT participants showed greater reductions than the WL participants on suicidal and NSSI behaviours between baseline and 32 weeks (P < 0.0001). DBT participants showed greater improvements than controls on measures of anger, distress tolerance and emotion regulation at 32 weeks. CONCLUSIONS: This abbreviated intervention is a viable option that may be a useful adjunctive intervention for the treatment of high-risk behaviour associated with the acute phase of BPD.

Advances in the Treatment of Borderline Personality Disorder: An Introduction to the Special Issue.

The past few decades have seen major progress in the treatment of borderline personality disorder (BPD), a condition that historically has been viewed as difficult to treat. Currently, several evidence-based psychotherapies are available that have generated excitement and hope, yet these developments have also raised new problems that must be addressed. In this special issue, experts in the field of BPD have been invited to share their ideas on some viable directions in the treatment field. This commentary reviews the challenges we currently face and describes the treatment directions presented by the contributors.

Cognitive behavioral therapy: current status and future research directions.

Cognitive behavioral therapy (CBT), an umbrella term that includes a diverse group of treatments, is defined by a strong commitment to empiricism. While CBT has a robust empirical base, areas for improvement remain. This article reviews the status of the current empirical base and its limitations, and presents future directions for advancement of the field. Ultimately, studies are needed that will identify the predictors, mediators, and moderators of treatment response in order to increase knowledge on how to personalize interventions for each client and to strengthen the impact of CBT. Efforts to advance the dissemination and implementation of CBT, innovative approaches such as practice-oriented research, and the advantages of incorporating new and existing technologies, are discussed as well.

The role of mindfulness and emotion regulation in dialectical behavioral therapy for borderline personality disorder.

Despite nearly 30 years of research demonstrating its effectiveness in the treatment of borderline personality disorder (BPD) and related problems, few studies have investigated mechanisms of change for dialectical behavior therapy (DBT; Linehan, 1993a). Improvements in mindfulness and emotion regulation have been highlighted as key potential mechanisms of change in DBT (Lynch et al., 2006). The present study examined the time course of and associations between mindfulness, emotion regulation, and BPD symptoms during DBT. Participants were 240 repeatedly and recently self-harming adults (Mage = 27.75) with BPD who were randomly assigned to receive either 6 or 12 months of standard DBT. Primary hypotheses were that: (a) changes in mindfulness would occur before changes in emotion regulation, and (b) changes in emotion regulation would mediate the association of changes in mindfulness with changes in BPD symptoms. Results from changepoint analysis illuminated the proportion of participants for whom first changes occurred in emotion regulation (40.7%), mindfulness (32.4%), or both (26.9%). Contrary to hypotheses, five-wave, cross-lagged analyses did not indicate mediational effects of either mindfulness or emotion regulation on the association of either variable with change in BPD symptoms. Supplemental analyses, however, suggested that changes in emotion regulation mediated the inverse association of changes in mindfulness with changes in BPD symptoms. Findings highlight patterns of change in key, proposed mechanisms of change in DBT and suggest important future research directions. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

The role of emotion dysregulation and interpersonal dysfunction in nonsuicidal self-injury during dialectical behavior therapy for borderline personality disorder.

Dialectical Behaviour Therapy (DBT) is an evidence-based treatment for borderline personality disorder (BPD), with findings demonstrating improvements in various BPD features and related behaviours, such as nonsuicidal self-injury (NSSI). Theory and research suggest that reductions in emotion dysregulation and interpersonal dysfunction could account for at least some of the reduction in NSSI observed during the course of DBT. The current research investigated: 1) the trajectory of changes in emotion dysregulation, interpersonal dysfunction, and NSSI over the course of DBT, and 2) whether changes in emotion dysregulation mediate the relationship between changes in interpersonal dysfunction and changes in NSSI over treatment. One hundred and twenty individuals with BPD enrolled in a multi-site randomized-clinical trial were assessed at five timepoints over 12 months of standard DBT. Results indicated that interpersonal dysfunction and NSSI decreased over the course of DBT. Emotion dysregulation decreased in a quadratic manner such that most of the gains in emotion dysregulation occurred in earlier phases of DBT. Although changes in interpersonal dysfunction predicted changes in emotion dysregulation, changes in emotion dysregulation did not mediate the relationship between changes in interpersonal dysfunction and changes in NSSI.

An exploratory study of the relationship between changes in emotion and cognitive processes and treatment outcome in borderline personality disorder.

This exploratory study examined specific emotion processes and cognitive problem-solving processes in individuals with borderline personality disorder (BPD), and assessed the relationship of these changes to treatment outcome. Emotion and cognitive problem-solving processes were assessed using the Toronto Alexithymia Scale, the Linguistic Inquiry Word Count, the Derogatis Affect Balance Scale, and the Problem Solving Inventory. Participants who showed greater improvements in affect balance, problem solving, and the ability to identify and describe emotions showed greater improvements on treatment outcome, with affect balance remaining statistically significant under the most conservative conditions. The results provide preliminary evidence to support the theory that specific improvements in emotion and cognitive processes are associated with positive treatment outcomes (symptom distress, interpersonal functioning) in BPD. The implications for treatment are discussed.

Subgroups of borderline personality disorder: A latent class analysis.

Borderline personality disorder (BPD) is characterized by instability in interpersonal, affective, cognitive, self-identity, and behavioral domains. For a BPD diagnosis, individuals must present at least five of nine symptoms, resulting in 256 possible symptom combinations; thus, individuals diagnosed with BPD can differ substantially. Specific symptoms of BPD tend to co-occur, suggesting BPD subgroups. To explore this potential, we analyzed data from 504 participants diagnosed with BPD enrolled in one of three randomized controlled trials conducted at center for Addiction and Mental Health in Toronto, Canada from 2002 to 2018. An exploratory latent class analysis (LCA) was conducted to identify symptom subgroups of BPD. Analyses indicated three latent subgroups. The first group (n = 53) is distinguished by a lack of affective instability and low levels of dissociative symptoms (non-labile type). The second group (n = 279) is characterized by high levels of dissociative and paranoid symptoms but low abandonment fears and identity disturbance (dissociative/paranoid type). The third group (n = 172) is characterized by high efforts to avoid abandonment and interpersonal aggression (interpersonally unstable type). Homogenous symptom subgroups of BPD symptoms exist and may have important implications for how to refine BPD treatment interventions.

A longitudinal approach to evaluating therapist and client contributions to alliance on outcomes in borderline personality disorder.

Methods for studying therapeutic alliance have primarily examined the impact of the early alliance on outcomes. This does not allow for an understanding of the contributions of client, therapist, and dyadic factors to the alliance. Also, the alliance may change over time, highlighting the need for longitudinal methods. Efforts have been made to develop approaches that decompose the contributing factors and their impact on outcomes, but these findings may not apply to clients with borderline personality disorder (BPD). Our study extends previous research by replicating Baldwin et al.'s (2007) approach to disentangling therapist versus client-therapist dyad effects while using a time-varying framework. Participants (n = 156) were individuals diagnosed with BPD randomized to 1 year of dialectical behavior therapy or general psychiatric management. Outcomes were general psychiatric severity and interpersonal functioning measured at baseline and every 4 months. Client-rated alliance was measured at these time points. Early alliance predicted interpersonal functioning (p = .0132) with a significant contribution from clients (p = .0248) but not therapists (p = .2854). In the time-varying analysis, client contribution to the alliance was significant (p = .0022). For general psychiatric severity, client contributions to the alliance were significant (p < .0001) but not therapist contributions (p = .6779). Client contribution to the alliance was significant (p = .0168) in the time-varying model. Results suggest that in a BPD sample, time-varying alliance is a better predictor of rate of change in outcomes compared with the alliance measured at a single time point. In contrast to other studies, client, not therapist, contributions to alliance were significant in predicting outcomes. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Gender identity and sexual orientation in women with borderline personality disorder.

INTRODUCTION: In the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, text revision (DSM-IV-TR) (and earlier editions), a disturbance in "identity" is one of the defining features of borderline personality disorder (BPD). Gender identity, a person's sense of self as a male or a female, constitutes an important aspect of identity formation, but this construct has rarely been examined in patients with BPD. AIMS: In the present study, the presence of gender identity disorder or confusion was examined in women diagnosed with BPD. MAIN OUTCOME MEASURES: We used a validated dimensional measure of gender dysphoria. Recalled gender identity and gender role behavior from childhood was also assessed with a validated dimensional measure, and current sexual orientation was assessed by two self-report measures. METHODS: A consecutive series of 100 clinic-referred women (mean age, 34 years) with BPD participated in the study. The women were diagnosed with BPD using the International Personality Disorder Exam-BPD Section. RESULTS: None of the women with BPD met the criterion for caseness on the dimensional measure of gender dysphoria. Women who self-reported either a bisexual or a homosexual sexual orientation had a significantly higher score on the dimensional measure of gender dysphoria than the women who self-reported a heterosexual sexual orientation, and they also recalled significantly more cross-gender behavior during childhood. Results were compared with a previous study on a diagnostically heterogeneous group of women with other clinical problems. CONCLUSION: The importance of psychosexual assessment in the clinical evaluation of patients with BPD is discussed.