Patterns of altered regional brain glucose metabolism in borderline personality disorder and bipolar II disorder.

OBJECTIVE: The relationship between borderline personality disorder (BPD) and bipolar II disorder (BIP-II) is disputed but understudied. Here, we investigated brain glucose metabolism in these patient groups and healthy control subjects (HCs). METHODS: Sixty-five subjects, 22 BPD (19 females), 22 BIP-II (17 females), and 21 HC (14 females), were examined using 2-deoxy-2[18F]-fluoro-d-glucose positron-emission tomography (PET) scanning. Only patients without reciprocal comorbidity were recruited; BPD participants without bipolar spectrum pathology; BIP-II participants without cluster A/B personality pathology. Groups were compared pairwise. Associations with mood state and childhood trauma were analyzed. RESULTS: Both patient groups exhibited hypometabolism compared with HCs in insula, brainstem, and frontal white matter. Additionally, BPD patients showed hypometabolism in hypothalamus, midbrain, and striatum; BIP-II patients in cerebellum. Uncorrected analyses showed cortical areas of higher metabolism in BIP-II than BPD, and associations with clinical variables differed between the groups. CONCLUSION: Reduced metabolism in the insula regions was shown in both disorders, suggesting shared pathophysiological mechanisms. The observed patterns of altered metabolism specific to each patient group, as well as the uncorrected results, may also suggest differential pathophysiology. However, these latter findings must be interpreted cautiously given the non-significant corrected results in the direct comparison between the disorders.

Regional cortical thinning may be a biological marker for borderline personality disorder.

OBJECTIVE: We investigated cerebral cortical thickness and its relation to measurements of difficulties with identifying and describing emotions in patients with borderline personality disorder (BPD). METHOD: Eighteen SCID-II-diagnosed female patients with BPD and 21 healthy female controls underwent magnetic resonance imaging and completed the Toronto Alexithymia Scale (TAS). First, regional cortical thickness across the cerebral surface was compared between patients and healthy controls. Then, analyses of the association between cortical thickness and TAS subscales were performed in patients. RESULTS: Compared with controls, patients exhibited clusters of significantly reduced cortical thickness in the left medial and lateral prefrontal cortex, left temporoparietal junction, bilateral temporal poles, and bilateral paracentral lobules. Significant negative associations were observed between cortical thickness and the 'Difficulties Describing Feelings' TAS subscale (DDF) scores in patients. The anatomical distribution of these associations was highly overlapping with the group differences in cortical thickness. CONCLUSION: The pattern of regions exhibiting cortical thinning in patients resembles a network of cortical structures repeatedly shown to be involved in social cognition. The results of the DDF analyses suggest that the thinning may partly be related to interpersonal dysfunction in patients with BPD. The pattern of thinning may represent a potential biological marker for BPD.

The impact of extended longitudinal observation on the assessment of personality disorders.

Multiple sources of information are necessary for a valid assessment of personality disorders (PDs). This study investigates the impact of longitudinal observation. The sample comprised 1217 patients from 15 different treatment units. PDs were assessed at admission to treatment using the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II) and additional clinical information (best estimate diagnosis). After approximately 18 weeks of treatment, the SCID-II protocols were re-examined at clinical conferences and the diagnostic status reassessed on the basis of longitudinal observations in multiple group situations (longitudinal, expert, all data principle). Using this procedure, 78% of the patients' diagnostic criteria sets were changed, and 32% of patients' diagnostic statuses were changed. Many (32%) patients who were evaluated initially as not having a PD received a PD diagnosis after re-examination. The information provided by customary clinical assessment has important limitations, and longitudinal observation provides additional information that may change the diagnostic status in approximately one-third of PD cases.

Interpersonal problems: self-therapist agreement and therapist consensus.

This study investigated patient-therapist agreement and therapist consensus of patients' interpersonal problems. The sample comprised 199 patients, who answered a questionnaire addressing interpersonal problems. At the same time, each patient was rated by two therapists on an observer version of the same questionnaire. The participants came from 10 different treatment units within the Norwegian Network of Personality-Focused Treatment Programs. Interpersonal problems were measured by a short version of the Inventory of Interpersonal Problems-Circumplex (IIP-C). The results of both patient-therapist agreements and therapist consensus of patients' interpersonal problems was low to moderate. The therapists perceived the patients to have somewhat higher levels of interpersonal problems than the patients reported, although the profile similarity between self-reports and observer reports was high. Some gender differences were revealed, but in terms of self-therapist agreement, no interaction with the therapists' length of clinical experience or acquaintance with the patient was found.

Self-esteem in patients with borderline and avoidant personality disorders.

This study compared self-esteem in patients with avoidant personality disorder (APD) and borderline personality disorder (BPD). Patients diagnosed with one or more personality disorders answered the questionnaire Index of Self Esteem as part of a comprehensive evaluation within the setting of a treatment trial. Our hypotheses were that (1) both patients with APD and patients with BPD would report low levels of self-esteem, (2) patients with APD would report lower self-esteem than patients with BPD. We further expected that (3) patients with higher levels of depression would report lower levels of self-esteem, but that (4) both borderline and avoidant personality pathology would contribute to explained variance in self-esteem beyond what would be accounted for by depression. All of our hypotheses were supported. The results from our study showed a significant difference in self-esteem level between the two personality disorders, patients with APD reporting lower self-esteem than patients with BPD. Subjects with both disorders were measured to have self-esteem levels within the range that presumes clinical problems. Self-esteem represents an important quality of subjective experience of the self, and the study of self-esteem in PDs can offer new and important knowledge of PDs as self-pathology.

Is SCL-90R helpful for the clinician in assessing DSM-IV symptom disorders?

OBJECTIVE: To investigate associations between six of the Symptom Check-List 90R (SCL-90R) subscales and specific DSM-IV symptom disorders in a sample of patients with high comorbidity of axis I and axis II disorders. METHOD: SCL-90R questionnaires from 1202 patients admitted for treatment in the Norwegian Network of Psychotherapeutic Day Hospitals. Mean score differences on subscales among diagnostic categories were investigated. With diagnoses as external criteria, cut-off scores for different diagnostic groups were used to calculate diagnostic efficacy. Multiple regressions were conducted in order to disentangle variance of the subscales accounted for by symptom disorders. Frequency distributions of subscales for patients with and without symptom disorders were compared. RESULTS: Poor diagnostic efficacy was found for most of the subscales, except for the phobic anxiety subscale. The strongest association with each subscale was with its associated symptom disorder, except for dysthymia. CONCLUSION: Diagnostic inferences about DSM-IV symptom disorders based on SCL-90R should be conducted with care.

An investigation of the prototype validity of the borderline DSM-IV construct.

OBJECTIVE: To investigate the prototype validity of the borderline personality disorder (BPD) DSM-IV construct. METHOD: Patients (n = 930) from the Norwegian Network of Psychotherapeutic Day Hospitals. Exploratory/confirmatory factor analyses, correlation and reliability statistics, chi-square, and frequency distributions. RESULTS: Number of BPD criteria showed no distinct threshold between No-BPD and BPD patients among whom 136 different combinations of criteria occurred. Both factor analyses supported that one component/latent variable accounted for the variance of the BPD criteria, showing a high convergent and discriminant validity. The criterion of unstable relationships displayed the highest diagnostic efficiency, and that of chronic feelings of emptiness the lowest. CONCLUSION: The prototype theoretical model for BPD fitted the data well and appeared to be satisfactory described by the current criteria. The emptiness criterion needs a more appropriate definition and the hierarchy of the criteria in DSM-IV should be revised.

One-year follow-up of day treatment for poorly functioning patients with personality disorders.

OBJECTIVE: The study evaluated the effectiveness of day treatment for poorly functioning patients with personality disorders who participated in day treatment consisting of analytically oriented and cognitive-behavioral therapy groups as part of a comprehensive group therapy program. METHODS: At admission, discharge, and one year after discharge, patients completed the Global Severity Index (GSI) of the Symptom Check List 90-R and the circumplex version of the Inventory of Interpersonal Problems (IIP-C) and were assessed using the Global Assessment of Functioning (GAF) scale. At one-year follow-up, patients also completed a questionnaire covering social adaptation and clinical information and participated in a telephone interview with a clinician. The clinician used the completed instruments and results of the interview to assign patients follow-up GAF scores. RESULTS: Follow-up data were available for 96 patients who completed the study, or 53 percent of the patients who were admitted to the study. Improvements in GAF, GSI, and IIP-C scores during day treatment were maintained at follow-up. Seventy-four percent of the treatment completers improved clinically from program admission to follow-up, as indicated by change in GAF scores, and 64 percent of the treatment completers continued in the outpatient group program. For the 26 percent of patients whose change in GAF score did not indicate clinical improvement, lack of improvement was most strongly predicted by the expression of suicidal thoughts during treatment. No patients committed suicide. CONCLUSIONS: The day treatment program appears to be effective in improving the symptoms and functioning of poorly functioning patients with personality disorders and in encouraging patients to continue in longer-term outpatient therapy.

Borderline and avoidant personality disorders and the five-factor model of personality: a comparison between DSM-IV diagnoses and NEO-PI-R.

A self-report measure of the Five-Factor Model (FFM) of personality, NEO-PI-R, was administered to a sample of patients with borderline (BPD, N = 29) or avoidant PD (AVPD, N = 34), admitted to a day treatment program, to investigate the NEO-PI-R profiles of the disorders, and the ability of NEO-PI-R to discriminate between the two disorders. The diagnoses were assessed according to the LEAD standard. AVPD was associated with high levels of Neuroticism and Agreeableness, and low levels of Extraversion and Conscientiousness. BPD was associated with high levels of Neuroticism and low levels of Agreeableness, Extraversion, and Conscientiousness. Eighty-eight percent of the AVPD group had high scores on Neuroticism and low scores on Extraversion, whereas 65% of the BPD group were high on Neuroticism and low on Agreeableness. The Extraversion and Agreeableness scales of NEO-PI-R discriminated between patients with BPD and those with AVPD. Patients with BPD scored significantly higher on the Angry Hostility and Impulsiveness subscales of Neuroticism and significantly lower on three Extraversion subscales, three Agreeableness subscales, and one Conscientiousness subscale. At the DSM-IV criterion level, there were more significant relationships between the subscales of NEO-PI-R and the AVPD criteria than with the BPD criteria. The findings suggest that the FFM has good discriminating ability regarding BPD and AVPD. However, there may be a closer conceptual relationship between the FFM and AVPD than between the FFM and BPD.

Outcomes of poorly functioning patients with personality disorders in a day treatment program.

OBJECTIVE: Rates of completion, complications, and outcome were examined in a sample of poorly functioning patients who participated in a group-oriented day treatment program for patients with personality disorders. METHODS: The study was a naturalistic prospective study of 183 patients admitted to a day treatment program in Oslo, Norway. The program consists of a combination of group analytically oriented groups and cognitive-behavioral groups. The Global Severity Index (GSI) of the Symptom Check List, the circumplex version of the Inventory of Interpersonal Problems (IIP-C), and the Global Assessment of Functioning (GAF) were administered at admission and discharge. RESULTS: A total of 138 [corrected] patients (77 percent) completed the day treatment program. Few patients experienced treatment complications. Effect sizes for GAF, GSI, and IIP-C scores for treatment completers were in the medium-to-high range, indicating a fair level of improvement. Patients' rating of benefit was positive. CONCLUSIONS: The results are promising as a first step toward development of a cost-efficient comprehensive long-term treatment program for patients with severe personality disorders.

Patterns of short-term course in patients treated in a day unit for personality disorders.

The objectives of the study were (1) to explore differences in the course for patients treated in a day unit specializing in personality disorders (PDs), and (2) to determine characteristics of patients with different courses and predictors of various courses. K-mean cluster analysis was applied to partition a sample of 128 patients, 101 with various PDs and 27 with axis I disorders only, into four groups representing different courses. The course was defined on the basis of global functioning (Health Sickness Rating Scale [HSRS]) at admission, discharge, and 3-years follow-up evaluation. The four courses were labeled good, fair, late improvement, and poor, demonstrating great variation in the short-term course among patients with PDs. Predictors were studied by means of polychotomous logistic regression using the patients with a fair course as the reference group. The dichotomy no PD/cluster C versus cluster A/B predicted a good versus a fair course. A poor work status the last year before admission and irregular discharge predicted a poor or late improvement course versus a fair course, also when controlling for PD clusters. None of the included variables discriminated between patients with a poor versus late improvement course.

[Assessment of medical students' ability to communicate unpleasant news]. / Testing av medisinske studenters evne til å formidle et vanskelig budskap.

At one station in an objective structured clinical examination (OSCE) medical students were assessed for their ability to inform a mock patient that the diagnosis was an incurable and fatal disease. The "patient" was a profession actor. The performances were videotaped with the permission of all parties involved. In spite of methodological problems, the test papers to reflect the communicative skills of the students and satisfies the requirements for validity, fairness and reliability. The advantages and disadvantages of using "standardized patients" are discussed.

Block training in group analysis: the Norwegian program.

Block training in group psychotherapy makes it possible to train professionals living far apart and to import conductors to an area or country lacking sufficient expertise. This article reports experience with such a training program in Norway. Training is given in blocks of 5 weekends a year, each weekend containing small group therapy, supervision, theory courses, lectures, and large group experiences. The participants were questioned about their personal and professional gains from the training. These findings and the effect of the program in relation to stated goals are discussed.

The longitudinal pattern of suicidal behaviour in borderline personality disorder: a prospective follow-up study.

The aim was to study the longitudinal course of suicidal behaviour and ideation in patients with borderline personality disorder (BPD) compared with patients with other diagnoses. Ninety-seven patients (41 BPD, 33 other personality disorders, 23 no personality disorder) consecutively admitted to a day unit were given a prospective personal interview follow-up with evaluations at admission, discharge and at follow-up after 2-5 years. Even when controlled for Axis I disorders, BPD patients showed significantly more often a lifetime history of suicide attempts. BPD patients with a history of suicide attempts were more suicidal at index admission, continued to be so over the follow-up period and differed systematically in an unfavourable direction from other BPD patients on the major outcome measures. BPD patients without suicidal behaviour had an outcome nearly as good as non-BPD patients, and only 41% of them retained the BPD diagnosis at follow-up. Suicidal behaviour and ideation are highly prevalent in BPD. These suicidal expressions are of an enduring nature and seem as a diagnostic criterion to enhance the predictive capacity of the BPD diagnosis.

Day hospital therapeutic community treatment for patients with personality disorders. An empirical evaluation of the containment function.

Does a day hospital format represent an adequate level of treatment for decompensated patients with personality disorders? The study concerns 97 consecutive patients, 50 of whom belonged to cluster A and B personality disorders. The patients were referred partly from an acute admission ward and partly from outpatient departments. The mean treatment time was approximately 6 months. The dropout rate for schizotypal and borderline patients was 38%. No patient committed suicide. Two patients made suicidal attempts during treatment. The level of medication was moderate, and 58% of the patients were drug-free at discharge. Treatment results at discharge, measured by SCL-90 and Health Sickness Rating Scale, were very good for patients with axis I disorders only, good for cluster C personality disorders, modest for borderline patients, and very modest for schizotypal patients. In general, the results indicate that the containing capacity of a day hospital therapeutic community is substantial and that it may reduce the need for long-term inpatient treatment.

Personality disorders 2-5 years after treatment: a prospective follow-up study.

Ninety-seven patients consecutively admitted to a day unit specializing in the treatment of personality disorders were included in a prospective follow-up study. At follow-up an average of 3 years after index admission, patients with borderline personality disorder (BPD) displayed a moderate symptom reduction and a fair global outcome. Patients with schizotypal personality disorder (STP) showed a similar reduction in symptoms but retained relatively poor global functioning. Individuals with cluster C personality disorders, in contrast, showed both a good global outcome and a marked symptom reduction. STP individuals were the least socially adjusted, employed and self-supporting of all diagnostic subgroups. STP and BPD individuals had far more inpatient treatment in the follow-up period than other groups. The overall suicide rate was low compared with most similar studies.

A comparative study of six different inpatient groups with respect to their basic assumption functioning.

Seventy-five group therapy sessions of six different inpatient team groups in one short-term, one intermediate term, and one long-term psychiatric ward were studied with Group Focal Conflict Analysis and the Group Emotionality Rating System. The majority of the group sessions (41) functioned as fight-flight groups, twenty-four sessions functioned at a "pseudogroup" level, and ten sessions were dependency groups. The differences between the fight-flight groups and the dependency group on the variables aggression and dependency were highly significant statistically. A mixture of fight-flight groups and pseudogroups were found in the short-term ward with emergency obligations. The author discusses the assets and shortcomings of fight-flight and dependency cultures within psychiatric wards.

The valence theory of Bion and the significance of (DSM-III) diagnoses for inpatient group behavior.

The aim of this study was to investigate the validity of Bion's hypothesis of valence and the significance of (DSM-III) diagnoses for inpatient group behavior. All verbal statements (approximately 17,000) from 91 patients in 75 small group therapy sessions were assessed according to Group Emotionality Rating System, which contains the (Bion) categories of dependency, fight, flight and pairing. The results confirmed the valence theory, since diagnoses explained 7-20% of the variance in emotional group behavior, while sex and age only explained 1-2% of the variance. The personality disorders of the schizoid/paranoid spectrum had the strongest valence for fight(/flight). The major depressions and the dependent personality disorders had the strongest valence for dependency. Neuroses and personality disorders had a significantly higher (P less than 0.05) valence for pairing than psychoses. Tables demonstrating the valence strength for 9 diagnostic categories are presented. The group culture seemed to modify behavior differently according to the diagnoses.

What are the prerequisites and indications of the therapeutic community proper? A comparative study.

Is the therapeutic community model appropriate for short term psychiatric wards with catchment area responsibility and emergency obligations? A comparative study of group dynamics, measured by Group Emotionality Rating System and Group Focal Conflict Analysis within three different therapeutic community wards, revealed that the short term ward contained extreme fight/flight groups and pseudo-groups unable to deal with the delegated responsibility presupposed by the therapeutic community model. The intermediate ward functioned fairly well, while the long term ward for psychotherapy of schizophrenia and personality disorders also functioned badly from a therapeutic community proper point of view. The author discusses these findings in light of previous literature and concludes that the therapeutic community proper is predominantly a treatment model relevant for personality disorders and severe neuroses, and not adequate for the multiplicity of emergency tasks facing a short term psychiatric ward.