Personality Disorders in DSM-5: A Commentary on the Perceived Process and Outcome of the Proposal of the Personality and Personality Disorders Work Group.

There has been much discussion and controversy concerning the process undertaken and the decisions made with respect to the Personality and Personality Disorders Work Group (PPDWG) proposal for DSM-5, as well as the rejection of the work group's final proposal, by the American Psychiatric Association Board of Trustees. This commentary suggests that the way the PPDWG members were selected and the perceived secrecy associated with the PPDWG's deliberations almost assured that, despite the hard work and good intentions of the group members, the proposal would raise controversy and could ultimately fail. This commentary provides a personal perspective on some of the issues, assumptions, and preconceptions that arose between members of different theoretical and conceptual camps within the field of personality disorders. It concludes with suggestions as to how we might avoid these mistakes in the future and also how we might take advantage of the PPDWG's substantive work as we make future attempts to improve diagnosis in the area of personality disorders.

Management and effectiveness of psychopharmacology in emotionally unstable and borderline personality disorder.

The article by Paton and colleagues on the use of psychotropic medication in patients with emotionally unstable personality disorder (EUPD) in the current issue of JCP is an important article. Making the assumption that EUPD as defined by ICD-10 (F60.3) is reasonably equivalent to borderline personality disorder (BPD) as defined in the United States by DSM, we are provided some insight into how practitioners think about prescribing medications to people with EUPD/BPD. The article not only offers information as to the class of medication these practitioners are using but also provides reasons why, ie, for what clinical signs and symptoms, the medications are being prescribed.

Caught in an unconscious split: commentary on "the ironic fate of the personality disorders in DSM-5".

Silk comments that "The Ironic Fate of the Personality Disorders in DSM-5" (see record 2013-45025-004) is a clearly written, accurate account of events attendant to the development and eventual rejection by the American Psychiatric Association (APA) of the Personality and Personality Disorders Work Group's (PPDWG's) proposal for a substantially revised system for diagnosing personality disorders (PD) in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013). Silk appreciates the authors' dispassionate account of what was a difficult and, at times, affect-laden process for not only those in the PPDWG but also other clinicians and researchers in the wider PD community.

A comparison of UK and US guidelines for drug treatment in borderline personality disorder.

The UK and USA differ considerably in their guidance regarding the use of drug treatment for borderline personality disorder, but generally agree over the use of psychological treatment. The 2009 UK guidelines from the National Institute for Health and Clinical Excellence (NICE) do not recommend any form of drug treatment except in a crisis with the intention of ceasing such treatment shortly afterwards. The US guidelines from the American Psychiatric Association (APA), published in 2001, are much more positive and suggest that there is a place for selective serotonin reuptake inhibitors (SSRIs), mood stabilizers and antipsychotic drugs as adjunctive treatments in borderline personality disorder. The guidelines are summarized and two main reasons for the differences identified. First, the separation of the borderline personality group into those with 'affective dysregulation', 'impulsive behaviour dyscontrol' and 'cognitive-perceptual' symptoms in the US guidelines was felt by the guideline development group for the NICE guideline to be a post hoc classification not supported by any other evidence. Second, the threshold of evidence necessary for making recommendations was much higher for the UK than the US guideline. Both guidelines recognize that we need more substantial trials, preferably independent of the pharmaceutical industry, before we can have any real confidence in our recommendations.

The process of managing medications in patients with borderline personality disorder.

Patients with borderline personality disorder (BPD) are a challenge to treat both psychotherapeutically and psychopharmacologically. While a set of effective psychotherapeutic interventions for BPD has now emerged, no hard evidence exists concerning the effectiveness of any psychopharmacologic agent for the core symptoms of BPD. Nonetheless, more than 75% of patients with BPD regularly take psychotropic medications. Given the complex interpersonal interactions of these patients as well as their obvious psychological pain, it would be helpful if we could begin to discuss the nuts and bolts of prescribing psychotropic medications for patients with BPD with the goal of assisting the psychopharmacologist in this process of prescribing. This paper is an attempt to begin such a discussion of the process of prescribing medications to patients with BPD. The suggestions presented in this article should be considered only the beginning of a dialogue that will surely become more complex and demand increased clinical acumen and more rigorous scientific study as we continue to learn more about these complicated and multi-faceted patients.

State of the art in the pharmacologic treatment of borderline personality disorder.

This article reviews the most recent studies of the pharmacologic treatment of borderline personality disorder (BPD). Although research continues using randomized controlled trials with a placebo arm as well as active medication, meta-analyses and systematic reviews have revealed that the use of any specific medication or medication class in BPD remains at best uncertain and inconclusive. Studies indicate that the selective serotonin reuptake inhibitors have fallen out of favor, and researchers have turned their attention to the study of mood stabilizers and atypical antipsychotics. Thus, it is not surprising that trends in prescribing appear to be shifting toward the use of these two classes over the selective serotonin reuptake inhibitors; yet we remain without any medication that has a specific indication for treatment of BPD or an indication for any symptom that is seen as part of the BPD syndrome.

Attitudes toward borderline personality disorder: a survey of 706 mental health clinicians.

OBJECTIVE: We sought to determine attitudes toward patients with borderline personality disorder (BPD) among mental health clinicians at nine academic centers in the United States. METHODS: A self-report questionnaire was distributed to 706 mental health clinicians, including psychiatrists, psychiatry residents, social workers, nurses, and psychologists. RESULTS: The study showed that most clinicians consider BPD a valid diagnosis, although nearly half reported that they preferred to avoid these patients. The clinician's occupational subgroup was significantly related to attitude. Staff nurses had the lowest self-ratings on overall caring attitudes, while social workers had the highest. Social workers and psychiatrists had the highest ratings on treatment optimism. Social workers and psychologists were most optimistic about psychotherapy effectiveness, while psychiatrists were most optimistic about medication effectiveness. Staff nurses had the lowest self-ratings on empathy toward patients with BPD and treatment optimism.DiscussionNegative attitudes persist among clinicians toward BPD, but differ among occupational subgroups. Overall, caring attitudes, empathy, and treatment optimism were all higher among care providers who had cared for a greater number of BPD patients in the past 12 months. CONCLUSION: These findings hold important implications for clinician education and coordination of care for patients with BPD.

Dysregulation of regional endogenous opioid function in borderline personality disorder.

OBJECTIVE: Borderline personality disorder is characterized by a lack of effective regulation of emotional responses. The authors investigated the role of the endogenous opioid system and mu-opioid receptors in emotion regulation in borderline personality disorder. METHOD: Mu-opioid receptor availability in vivo (nondisplaceable binding potential, or BP(ND)) was measured with positron emission tomography and the selective radiotracer [(11)C]carfentanil during neutral and sustained sadness states in 18 unmedicated female patients with borderline personality disorder and 14 healthy female comparison subjects. RESULTS: Patients showed greater regional mu-opioid BP(ND) than did comparison subjects at baseline (neutral state) bilaterally in the orbitofrontal cortex, caudate, and nucleus accumbens and in the left amygdala, but lower BP(ND) in the posterior thalamus. Sadness induction was associated with greater reductions in BP(ND) (endogenous opioid system activation) in the patient group than in the comparison group in the pregenual anterior cingulate, left orbitofrontal cortex, left ventral pallidum, left amygdala, and left inferior temporal cortex. Patients showed evidence of endogenous opioid system deactivation in the left nucleus accumbens, the hypothalamus, and the right hippocampus/parahippocampus relative to comparison subjects. Correlations of baseline measures with the Dissociative Experiences Scale and endogenous opioid system activation with the Barratt Impulsiveness Scale did not remain significant after correction for multiple comparisons. CONCLUSIONS: Differences exist between patients with borderline personality disorder and comparison subjects in baseline in vivo mu-opioid receptor concentrations and in the endogenous opioid system response to a negative emotional challenge that can be related to some of the clinical characteristics of patients with borderline personality disorder. The regional network involved is implicated in the representation and regulation of emotion and stress responses.

The quality of depression in borderline personality disorder and the diagnostic process.

The quality of the depressive experience in borderline personality disorder has always been perceived to be different from the depression experienced in major depression (MDD). This paper reviews those observations and studies of the particular ways in which this borderline personality disorder (BPD) depression/dysphoria has been described in the literature and makes note of the fact the patients with BPD often score more highly on self-rated scales of depression than on corresponding observer-rated scales. Often patients with BPD without MDD score as highly on depression rating scales as BPD patients with MDD and as highly as patients with MDD without BPD. Clinician-rated scales and operationalized diagnostic interviews do not easily capture the distinction between the depression of BPD and the depression of MDD. A fuller appreciation of the BPD patient's object relations, i.e., the nature of the interpersonal relationships and the person's reactions and affects to and within those relationships holds the key to understanding the nature of the quality of the depression of BPD.

Personality trait dimensions and the pharmacological treatment of borderline personality disorder.

The number of well-designed placebo-controlled studies on pharmacological treatment of borderline personality disorder has been small. We present a breakdown of results of placebo-controlled pharmacological studies, sorting target symptoms into the trait dimensions of affective instability, anxiety inhibition, cognitive-perceptual disturbances, and impulsivity-aggression. Twenty randomized placebo-controlled pharmacological trials studying typical and atypical antipsychotics, selective serotonin reuptake and monoamine oxidase inhibitors, tricyclic antidepressants, mood stabilizers, and benzodiazepines were included. A relative measure of the weight of an outcome was determined by (1) dividing the number of positive comparisons for a drug class by the total number of comparisons of all drugs of all classes for each dimension and (2) dividing the number of positive comparisons for a drug class by the total number of comparisons for that particular drug class for that trait dimension. Antipsychotics (neuroleptics and atypicals) had the most evidence for each of the traits with both methods. Our results are compared with the results of 2 meta-analyses, 1 guideline set, and 1 other systematic review. We found little concordance across these studies. We propose a consortium to discuss guidelines for future studies, including agreement as to what should be measured to determine the outcome and adoption of standardized instruments to measure that outcome.

The subsyndromal phenomenology of borderline personality disorder: a 10-year follow-up study.

OBJECTIVE: The purpose of this study was to characterize the course of 24 symptoms of borderline personality disorder in terms of time to remission. METHOD: The borderline psychopathology of 362 patients with personality disorders, all recruited during inpatient stays, was assessed using two semistructured interviews of proven reliability. Of these, 290 patients met DSM-III-R criteria as well as Revised Diagnostic Interview for Borderlines criteria for borderline personality disorder, and 72 met DSM-III-R criteria for another axis II disorder. Over 85% of the patients were reinterviewed at five distinct 2-year follow-up waves by interviewers blind to all previously collected information. RESULTS: Among borderline patients, 12 of the 24 symptoms studied showed patterns of sharp decline over time and were reported at 10-year follow-up by less than 15% of the patients who reported them at baseline. The other 12 symptoms showed patterns of substantial but less dramatic decline over the follow-up period. Symptoms reflecting core areas of impulsivity (e.g., self-mutilation and suicide efforts) and active attempts to manage interpersonal difficulties (e.g., problems with demandingness/entitlement and serious treatment regressions) seemed to resolve the most quickly. In contrast, affective symptoms reflecting areas of chronic dysphoria (e.g., anger and loneliness/emptiness) and interpersonal symptoms reflecting abandonment and dependency issues (e.g., intolerance of aloneness and counterdependency problems) seemed to be the most stable. CONCLUSIONS: The results suggest that borderline personality disorder may consist of both symptoms that are manifestations of acute illness and symptoms that represent more enduring aspects of the disorder.

The role of functional neuroimaging in exploring the overlap between borderline personality disorder and bipolar disorder.

In light of the recent discussions of possible diagnostic overlap between borderline personality disorder and bipolar disorder, we explored the neuroimaging literature to determine if findings from this literature might illuminate the issue of overlap between the two diagnoses. We looked at studies of executive functions and emotion-related functions. Although similar brain areas have been explored in each population and several findings are suggestive of overlap, as well as differences between the two disorders, conclusions are limited because of the lack of studies that employed the exact same paradigm in the two patient groups. The authors suggest methods for conducting future neuroimaging research that may better clarify some of these issues of possible diagnostic overlap.

Prediction of the 10-year course of borderline personality disorder.

OBJECTIVE: The purpose of this study was to determine the most clinically relevant baseline predictors of time to remission for patients with borderline personality disorder. METHOD: A total of 290 inpatients meeting criteria for both the Revised Diagnostic Interview for Borderlines and DSM-III-R for borderline personality disorder were assessed during their index admission with a series of semistructured interviews and self-report measures. Diagnostic status was reassessed at five contiguous 2-year time periods. Discrete survival analytic methods, which controlled for baseline severity of borderline psychopathology and time, were used to estimate hazard ratios. RESULTS: Eighty-eight percent of the patients with borderline personality disorder studied achieved remission. In terms of time to remission, 39.3% of the 242 patients who experienced a remission of their disorder first remitted by their 2-year follow-up, an additional 22.3% first remitted by their 4-year follow-up, an additional 21.9% by their 6-year follow-up, an additional 12.8% by their 8-year follow-up, and another 3.7% by their 10-year follow-up. Sixteen variables were found to be significant bivariate predictors of earlier time to remission. Seven of these remained significant in multivariate analyses: younger age, absence of childhood sexual abuse, no family history of substance use disorder, good vocational record, absence of an anxious cluster personality disorder, low neuroticism, and high agreeableness. CONCLUSIONS: The results of this study suggest that prediction of time to remission from borderline personality disorder is multifactorial in nature, involving factors that are routinely assessed in clinical practice and factors, particularly aspects of temperament, that are not.

The McLean Study of Adult Development (MSAD): overview and implications of the first six years of prospective follow-up.

The McLean Study of Adult Development (MSAD) began 12 years ago. It is the first NIMH-funded prospective study of the course and outcome of borderline personality disorder (BPD). After careful analysis of the first six years of follow-up, 5 main findings concerning the symptomatic and psychosocial course of BPD have emerged from this study. The first finding is that remissions are far more common than previously recognized (about 74%). The second is that these remissions are quite stable and thus, recurrences are quite rare (about 6%). The third finding is that completed suicides are far more rare than anticipated (about 4% vs. 10%). The fourth finding is that a "complex" model of borderline psychopathology best describes BPD. In this model, some symptoms resolve relatively quickly, are the best markers for the disorder, and are often the immediate reason for needing costly forms of treatment, such as psychiatric hospitalizations. We termed these symptoms (e.g., self-mutilation, help-seeking suicide threats or attempts) acute symptoms. Other symptoms resolve more slowly, are not specific to BPD, and are closely associated with ongoing psychosocial impairment. We termed such symptoms (e.g., chronic feelings of intense anger, profound abandonment concerns) temperamental symptoms. Fifth, it was also found that borderline patients were improving psychosocially over time, particularly remitted borderline patients; psychosocial functioning of remitted patients continued to improve as time progressed, suggesting that they were somewhat belatedly achieving the milestones of young adulthood and not simply returning to a prodromal level of functioning. Taken together, these results suggest that the prognosis for BPD is better than previously recognized.

Psychosocial functioning of borderline patients and axis II comparison subjects followed prospectively for six years.

The purpose of this study was to determine the course of the psychosocial functioning of patients with borderline personality disorder (BPD) over 6 years of prospective follow-up. The psychosocial functioning of 290 patients meeting both DIB-R and DSM-III-R criteria for BPD and 72 patients meeting DSM-III-R criteria for another Axis II disorder (and neither criteria set for BPD) was assessed at baseline using a semistructured interview of demonstrated reliability. Over 94% of surviving patients were reinterviewed about their psychosocial functioning blind to all previously collected information at three distinct follow-up waves: 2-, 4-, and 6-year follow-up. The psychosocial functioning of borderline patients improved substantially over time, with the percentage meeting criteria for good overall psychosocial functioning increasing from 26% at baseline to 56% during the third wave of follow-up. Despite this improvement, borderline patients functioned significantly more poorly than Axis II comparison subjects, particularly in the area of vocational achievement. However, a more detailed examination revealed that borderline patients who had experienced a symptomatic remission during the course of the study functioned significantly better both socially and vocationally than never-remitted borderline patients. More specifically, they were significantly more likely to have a good relationship with a spouse/partner and at least one parent, good work/school performance, a sustained work/school history, a GAF score of 61 or higher (43% vs. 0% 6 years after their index admission), and to have good overall psychosocial functioning (66% vs. 27% at 6 year follow-up). Taken together, the results of this study suggest that psychosocial improvement is both common among borderline patients and strongly related to their symptomatic status.

Adult experiences of abuse reported by borderline patients and Axis II comparison subjects over six years of prospective follow-up.

The main objective of this study was to assess the rates of adult experiences of verbal, emotional, physical, and sexual abuse reported by borderline patients and Axis II comparison subjects during 6 years of prospective follow-up. A semistructured interview was administered to 290 borderline patients and 72 Axis II comparison subjects during their index admission. A follow-up analogue to this interview was administered at three contiguous 2-year follow-up periods. Over 94% of surviving patients were re-interviewed at all three follow-up waves. The rates of all four forms of reported abuse declined significantly over time for all subjects considered together. However, each of these types of abuse was reported by a significantly higher percentage of borderline patients than Axis II comparison subjects. When the presence of these forms of abuse was used to predict time to remission, all but sexual abuse were strongly associated with the failure to achieve symptomatic remission from borderline personality disorder. Taken together, the results of this study suggest that the rates of adult abuse reported by borderline patients decline significantly with time but remain relatively high. They also suggest that adult experiences of abuse are strongly associated with a failure to remit from borderline personality disorder.