Borderline personality disorder: a comprehensive review of diagnosis and clinical presentation, etiology, treatment, and current controversies.

Borderline personality disorder (BPD) was introduced in the DSM-III in 1980. From the DSM-III to the DSM-5, no major changes have occurred in its defining criteria. The disorder is characterized by instability of self-image, interpersonal relationships and affects. Further symptoms include impulsivity, intense anger, feelings of emptiness, strong abandonment fears, suicidal or self-mutilation behavior, and transient stress-related paranoid ideation or severe dissociative symptoms. There is evidence that BPD can be reliably diagnosed and differentiated from other mental disorders by semi-structured interviews. The disorder is associated with considerable functional impairment, intensive treatment utilization, and high societal costs. The risk of self-mutilation and suicide is high. In the general adult population, the lifetime prevalence of BPD has been reported to be from 0.7 to 2.7%, while its prevalence is about 12% in outpatient and 22% in inpatient psychiatric services. BPD is significantly associated with other mental disorders, including depressive disorders, substance use disorders, post-traumatic stress disorder, attention-deficit/hyperactivity disorder, bipolar disorder, bulimia nervosa, and other personality disorders. There is convincing evidence to suggest that the interaction between genetic factors and adverse childhood experiences plays a central role in the etiology of BPD. In spite of considerable research, the neurobiological underpinnings of the disorder remain to be clarified. Psychotherapy is the treatment of choice for BPD. Various approaches have been empirically supported in randomized controlled trials, including dialectical behavior therapy, mentalization-based therapy, transference-focused therapy, and schema therapy. No approach has proved to be superior to others. Compared to treatment as usual, psychotherapy has proved to be more efficacious, with effect sizes between 0.50 and 0.65 with regard to core BPD symptom severity. However, almost half of the patients do not respond sufficiently to psychotherapy, and further research in this area is warranted. It is not clear whether some patients may benefit more from one psychotherapeutic approach than from others. No evidence is available consistently showing that any psychoactive medication is efficacious for the core features of BPD. For discrete and severe comorbid anxiety or depressive symptoms or psychotic-like features, pharmacotherapy may be useful. Early diagnosis and treatment of BPD can reduce individual suffering and societal costs. However, more high-quality studies are required, in both adolescents and adults. This review provides a comprehensive update of the BPD diagnosis and clinical characterization, risk factors, neurobiology, cognition, and management. It also discusses the current controversies concerning the disorder, and highlights the areas in which further research is needed.

Is alexithymia associated with specific mental disorders?

BACKGROUND: Alexithymia is characterized by restrictions in the perception, differentiation and regulation of affects. It is considered to be an important vulnerability factor for the development of mental disorders. Little is known, however, of whether alexithymia is associated with specific mental disorders. SAMPLING AND METHODS: Data from 1,461 patients of an outpatient clinic for psychosomatic medicine with various mental disorders (depressive disorders, anxiety disorders, adjustment disorders, somatoform disorders, eating disorders, and psychological and behavioral factors of physical illness) were collected between January 2007 and October 2009. The 20-item Toronto Alexithymia Scale (TAS-20) was administered to study alexithymia. The diagnoses were made following ICD-10 guidelines. RESULTS: In our sample, the total prevalence of alexithymia (TAS-20 ≥ 61) was 21.36%. The percentage of alexithymic patients was significantly increased in the group of patients with depressive disorders (26.9%) as compared to other diagnostic groups. Using TAS-20 as a continuous measure, multiple hierarchical regression analyses revealed that higher TAS-20 total scores were significantly associated with depressive and anxiety disorders. However, after controlling for the level of depression, the association of anxiety disorders with alexithymia was no longer significant. With regard to TAS-20 subscales, 'difficulty describing feelings' (subscale 2) was also significantly related to depressive disorders. CONCLUSIONS: According to the results, the prevalence of alexithymia is relatively high in patients with mental disorders. The increased prevalence of highly alexithymic subjects suggests that alexithymia is associated with a higher vulnerability to mental illness. The prevalence of alexithymia was especially increased for depressive disorders. Thus, further evidence supporting the concept of 'alexithymic depression' was provided. From a therapeutic perspective, treatments should be developed that take the specific needs of highly alexithymic patients into account.

[Alexithymia and specific relationship patterns in a clinical sample]. / Alexithymie und spezifische Beziehungsmuster in einer klinischen Stichprobe.

OBJECTIVES: Alexithymia is characterized by deficits in perceiving, differentiating and regulating affects, both one's own affects and those of others. It is often related to interpersonal problems which are a major reason for seeking psychotherapy. This study assesses the relationship between alexithymia, specific relationship patterns and interpersonal problems in a clinical inpatient sample. METHODS: We evaluated alexithymia (Toronto-Alexithymia-Scale-26: TAS-26), relationship patterns (Relationship Patterns Questionnaire-II; RPQ-II) and interpersonal problems (Inventory of Interpersonal Problems: IIP) in 152 patients with various mental disorders upon admission to an inpatient clinic for psychosomatic medicine and psychotherapy. RESULTS: Alexithymia (TAS-20) was significantly negatively associated with self-assertion (RPQII) and significantly positively associated with overall interpersonal problems (IIP-total score). Specifically, the interpersonal style associated with alexithymia was characterized by cold, socially avoidant, nonassertive and exploitable behavior (IIP-subscales). CONCLUSIONS: Alexithymia in patients with mental disorders is linked to specific relationship patterns and interpersonal problems at the beginning of an inpatient psychotherapy. Because interpersonal problems, and especially the therapeutic alliance, are strong predictors of outcome in individual psychotherapy, specific attention should be paid to this relationship in the treatment of alexithymic patients.

Alexithymia and script-driven emotional imagery in healthy female subjects: no support for deficiencies in imagination.

Alexithymia is associated with a limited access to inner emotional processes. Furthermore, alexithymia is assumed to be characterized by a limited ability to use imagination. To evaluate the frequently proposed thesis of a reduced imagination ability in alexithymic persons, 25 high and 24 low alexithymic women self-rated their imagination ability. Furthermore, the electrodermal activity (EDA) during script-driven emotional imagination was determined and valence, arousal, and vividness of the respective imaginations were rated. Our results indicate no significant differences between high and low alexithymic women in the self-rated imagination ability, the EDA during imagination and the ratings of valence, arousal and vividness. The study provides evidence that healthy high alexithymic women are capable of differentiated emotional imagination.

Long-term outcomes of short-term and long-term psychosomatic inpatient treatment and their predictors.

OBJECTIVES: The Clinic for Psychosomatic Medicine and Psychotherapy at the University Giessen, Germany, offers short-term (STT) and long-term inpatient therapy (LTT). METHODS: In a prospective, 3-year follow-up study, we examined therapeutic indication, short- and long-term results, outcome predictors, and the utilization of aftercare for both settings. RESULTS: STT patients were more frequently acutely ill, suffered from stronger symptomatic manifestations, and were more frequently employed. LTT patients had a greater rate of chronic psychosomatic disorders, personality disorders and somatic comorbidity. In both settings, distress strongly declined during inpatient therapy and remained stable for 3 years. Negative predictors of outcome were infantile object relation patterns and interpersonal problems. We found no differences between STT and LTT patients in terms of the utilization of aftercare. CONCLUSION: Duration of psychosomatic inpatient treatment should be differentiated according to the chronicity and nature of the disorder.

[Integrative treatment of instable diabetes mellitus: education or psychotherapy?]. / Zur integrativen Behandlung des instabilen Diabetes mellitus im Jugendalter: Schulung oder Psychotherapie?

The term "brittle diabetes" describes a subtype of instable type-I diabetes, characterized by high variations of blood sugar without any evident cause and despite careful clinical management. Clear guidelines for a precise definition of the condition are still lacking; this fosters insecurities concerning diagnosis and therapy of the disease. Psychosocial influences, triggering these conditions, were discussed. The patient-doctor-relationship appears to be tensed due to an often missing compliance. Using a paradigmatic case study as background, the specific diagnostic and therapeutic problems in brittle diabetes were presented. Brittle diabetes advocates a close cooperation between internal and psychosomatic medicine units and a combination of patient education and psychotherapy. Seen under a psychosomatic paradigm, brittle diabetes can be detected early and effective treatment may avoid further complications in these young patients.