Interpersonal precipitants and suicide attempts in borderline personality disorder

Borderline personality disorder (BPD) is often characterized by multiple low lethality suicide attempts triggered by seemingly minor incidents, and less commonly by high lethality attempts that are attributed to impulsiveness or comorbid major depression. The relationships among life events, impulsiveness, and type of suicidal behavior has hardly been studied in BPD and mood disorders. This study compared depressed attempters with and without BPD to identify specific suicide precipitants and risk factors in BPD and their relationship to severity of suicidal behavior. Attempters with comorbid BPD and major depressive disorder (MDD) had a higher number of lifetime suicide attempts; made their first attempt at a younger age; reported more interpersonal triggers; and had higher levels of lifetime aggression, hostility, and impulsivity, compared with attempters with major depression only. Environmental triggers of attempts in BPD are more likely to be interpersonal stressors. Lethality of attempts in BPD plus MDD is equal to that in MDD only, indicating that the seriousness of precipitants is unrelated to the lethality of the suicidal behavior. The differences between groups suggest that risk assessment and treatment should target both depression and personality disorder in those with combined illness.     

Borderline Personality Disorder in 3-D: Dimensions,Symptoms, and Measurement Challenges

Borderline personality disorder (BPD) is a pervasive pattern of psychopathology characterized by unstable affect, suicidal behaviors, and identity problems (Diagnostic and statistical manual of mental disorders. Washington, DC: Author; 2000). BPD is heterogeneous in nature, highly prevalent in clinical settings, and increasingly studied by clinical and social psychologists. This review highlights affective instability, impulsivity, and interpersonal hypersensitivity, the interaction of which we believe accounts for the symptoms of BPD, the BPD criteria most associated with these features, and the interrelationships among these underlying dimensions. We also discuss difficulties in measurement of these dimensions. Real-world assessment methods will assist in the measurement of time-dependent processes and identify causes, covariates, or consequences of these processes to determine how these features manifest themselves in real life.     

Childhood abuse as a risk factor for suicidal behavior in borderline personality disorder

A childhood history of sexual or physical abuse is highly prevalent in borderline personality disorder (BPD) and is associated with self-destructive behavior in clinical and nonclinical samples. Viewing BPD as a "high risk" disorder, we asked if childhood abuse was a risk factor for adult suicidal behavior or if it was related to other known risk factors for suicide in BPD. A semistructured Abuse History was obtained in 61 criteria-defined BPD patients, who were characterized by structured interviews and self-reports for Axis I disorders, Suicide History, BPD severity, hopelessness, impulsivity, impulsive-aggression, and antisocial traits. Occurrence and severity of childhood sexual abuse, but not physical abuse, predicted adult suicidal behavior independent of other known risk factors. The odds of a sexually abused patient attempting suicide in adulthood was over 10 times that of a patient who was never sexually abused. Given a history of childhood sexual abuse, the risk of adult suicidal behavior in BPD was increased by antisocial traits, severity of BPD, hopelessness, or comorbid major depressive episode (MDE).     

The nature of borderline personality disorder: multiple dimensions, multiple symptoms, but one category

Borderline personality disorder (BPD) is a multidimensional syndrome that is not rooted in a single diathesis. Each of its features (affective instability, impulsivity, unstable relationships, and cognitive defects) reflects different diatheses. BPD differs from other Axis II disorders in its high level of symptoms, but is not a variant of an Axis I disorder and is difficult to describe through dimensional traits. This review suggests that BPD needs to be diagnosed with a narrower set of criteria that cover all of its domains. In the long run, the disorder will need to be redefined on the basis of its etiology and pathogenesis.     

Recommending Interventions for a Borderline Personality Disorder Patient

Borderline personality disorder (BPD) is a severe personality disorder leading to unstable emotional state, impulsivity, disturbed relationships and personal distress. This paper suggests a 12-step intervention plan including Dialectical Behavior Therapy (DBT) to Mr. X, a 21 year old male psychiatric inpatient having BPD, to promote his mental health. Therapy could not be conducted as the patient dropped out of treatment and got himself discharged from the hospital. This paper outlines implications for treatment on the basis of the clinical presentation of Mr. X. Mr. X presents himself with the BPD features showing suicidal tendencies, substance abuse and disturbed emotions. In depth interview of the patient showed extreme emotional disturbance and difficulty in controlling emotions and suicidal ideations. He was admitted at the Nur Manzil Psychiatric Centre, Lucknow, India and was kept under close observation because of being obsessed with suicidal thoughts; he also tried to kill himself. The DBT skills training and problem solving approach along with contingency management and behavioral chain analysis are suggested according to the clinical profile of Mr. X in order to reduce his self mutilating acts and substance abuse. Thus a general feeling of personal well being can be achieved thereby reducing personal distress.     

Suicidal behavior in borderline personality disorder: prevalence, risk factors, prediction, and prevention

Suicidal behavior is frequent in patients with borderline personality disorder (BPD); at least three-quarters of these patients attempt suicide and approximately 10% eventually complete suicide. Borderline patients at greatest risk for suicidal behavior include those with prior attempts, comorbid major depressive disorder, or a substance use disorder. Comorbidity with major depression serves to increase both the number and seriousness of the suicide attempts. Hopelessness and impulsivity independently increase the risk of suicidal behavior, as does a turbulent early life and the presence of antisocial traits. In summary, because BPD is frequently complicated by suicidal behavior, clinicians must avoid the mistake of thinking that a pattern of repeated attempts indicates little desire to die. Clinicians have an important role in preventing suicide attempts and completed suicides by understanding the risk factors.     

Childhood antisocial behaviors as predictors of psychotic symptoms and DSM-III-R borderline criteria among inpatients with borderline personality disorder.

Structured clinical interviews of 107 female inpatients diagnosed with borderline personality disorder (BPD) were used to determine whether antisocial personality disorder (APD) diagnostic criteria evident prior to age 15 could be used to predict current Axis I and Axis II psychopathology. Diagnostic information was gathered using the Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II) and the Structured Clinical Interview for DSM-III-R-Patient Version (SCID-P). Childhood APD criteria were subjected to principal-components analysis, and three factors--rule-breaking, assault, and sadism--emerged. The severity of the childhood APD criteria was related to psychotic symptoms, as well as to the unstable relationships and labile affect BPD criteria and the current overall severity of BPD criteria. Sadism predicted psychotic symptoms and BPD severity, while rule-breaking predicted unstable relationships and BPD severity. Childhood APD severity also had a larger effect on BPD severity than on psychotic symptoms. Possible explanations for these findings are explored and discussed.     

Relations between cyclothymic temperament and borderline personality disorder traits in non-clinical adolescents

ObjectivesThe aim of the present study was to examine the relation between cyclothymic temperament and borderline personality disorder traits in adolescents and to identify a typology of adolescents based on temperamental traits (cyclothymic temperament and BPD traits).Participants and methodsA sample of 312 adolescents completed several questionnaires assessing cyclothymic temperament, borderline personality disorder traits, depressive symptoms, suicidal ideation, antisocial behaviors and frequency of cannabis use.ResultsThe Cyclothymic-Hypersensitive Temperament (CHT) questionnaire and the Borderline Personality Features Scale for Children (BPFS-C) were highly correlated which suggests that these scales may measure the same construct. Factor analyses of the pooled items of both scales yielded two factors, ‘anger–impulsivity’ and ‘affective instability’, both composed half of items from both scales. The relation between these traits and suicidal ideation was fully mediated by depressive symptomatology. Cluster analysis showed that these traits may occur independently and that adolescents with both traits had the highest levels of depressive symptoms, suicidal ideations and antisocial behaviors.DiscussionThe CHT questionnaire and the BPFS-C may measure the same construct which appeared relevant for defining a subgroup of adolescents with high levels of depressive symptoms, suicidal ideations and antisocial behaviors.     

The role of affective instability and impulsivity in predicting future BPD features

Models of borderline personality disorder (BPD) suggest that extreme levels of affective instability/emotional dysregulation, impulsivity, or the combination of these two traits account for the symptoms characteristic of BPD. The present study utilized longitudinal data to evaluate the ability of Personality Assessment Inventory-Borderline Features (PAI-BOR; Morey, 1991) subscale scores to predict BPD features two years later as a test of these models of BPD. Participants were 156 male and 194 female young adults who completed the PAI-BOR at age 18 and again two years later. Three models were compared: (a) Wave 1 affective instability scores predicting Wave 2 BPD features (AI model); (b) Wave 1 self-harm/impulsivity scores predicting Wave 2 BPD features (IMP model); and (c) both Wave 1 affective instability and self-harm/impulsivity scores predicting Wave 2 BPD features (AI-IMP model), all controlling for stabilities and within-time covariances. Results indicated that the AI model provided the best fit to the data, and improved model fit over a baseline stabilities model and the other models tested. These results are consistent with Linehan's theory (1993) that emotional dysregulation drives the other BPD symptoms.     

High-lethality status in patients with borderline personality disorder

Recurrent suicidal behaviors in patients with Borderline Personality Disorder (BPD) are often considered communicative gestures; however, 10% complete suicide. This study seeks to identify risk factors for suicide within a BPD sample by comparing patients with High- and Low-Lethality attempts. BPD attempters (n = 113) were assessed on demographic, diagnostic, and personality variables: clinical symptoms, suicidal behaviors; childhood, family, and treatment histories; social adjustment; and recent life events. Forty-four High-Lethality attempters, defined by a score of 4 or more on Beck's Medical Lethality Scale, were compared to 69 Low-Lethality attempters. Discriminating variables were entered in a multivariate logistic regression model to define predictors of High-Lethality status. High-Lethality attempters were older, with children, less education, and lower socioeconomic class (SES) than Low-Lethality attempters. They were more likely to have Major Depressive Disorder (MDD), co-morbid Antisocial Personality Disorder (ASPD), and family histories of substance abuse. They reported greater intent to die, more lifetime attempts, hospitalizations, and time in the hospital. High-Lethality status was best predicted by low SES, co-morbid ASPD, extensive treatment histories, and greater intent to die. These characteristics resemble profiles of patients who complete suicide, are not specific for BPD, and do not include impulsivity, aggression, or severity of BPD criteria.     

Effects of the dialectical behavioral therapy-mindfulness module on attention in patients with borderline personality disorder

It is known that patients with borderline personality disorder (BPD) show attention deficits and impulsivity. The main aim of this study was to explore the effects of Dialectical Behavioral Therapy-Mindfulness training (DBT-M), used as an adjunct to general psychiatric management (GPM), on attention variables in patients diagnosed with BPD. A second objective was to assess the relation of mindfulness formal practice on clinical variables. A sample of 60 patients with BPD was recruited. Forty of them were allocated to GPM + DBT-M treatment and the other 20 received GPM alone. At the termination of the mindfulness training, DBT-M + GPM group showed a significant improvement on commissions, hit reaction time, detectability scores from the CPT-II neuropsychological test, and also on the composite scores of inattention and impulsivity. Further, the more minutes of mindfulness practice were correlated to greater improvement in general psychiatric symptoms and affective symptomatology, but not in CPT-II measures. This is probably the first study so far assessing the effects of this single DBT module in patients with BPD. The results suggest a positive effect of such intervention on attention and impulsivity variables.     

Sustained efficacy of dialectical behaviour therapy for borderline personality disorder

Dialectical Behaviour Therapy (DBT) is considered one of the most promising treatments for borderline personality disorder (BPD). Recently, we reported significantly positive effects of 12 months DBT on parasuicidal behaviour and impulsivity in a mixed group of female BPD patients with and without substance abuse. Fifty-eight women with BPD were randomly assigned to either 52 weeks of DBT or treatment as usual (TAU). Follow-up assessment took place at 78 weeks, i.e., 6 months after discontinuation of DBT. Participants were clinical referrals from addiction treatment and psychiatric services. Outcome measures included parasuicidal behaviour, impulsivity and substance abuse. Six months after treatment discontinuation, the benefits of DBT over TAU in terms of lower levels of parasuicidal and impulsive behaviours, and in alcohol use, sustained. No differences between the treatment conditions were found for drug abuse. In conclusion, DBT seems to have a sustained effect on some of the core symptoms of BPD and on alcohol problems in a mixed population of female borderline patients with and without substance abuse problems.     

Trajectories of Attention Deficit Hyperactivity Disorder and Oppositional Defiant Disorder Symptoms as Precursors of Borderline Personality Disorder Symptoms in Adolescent Girls

Little empirical evidence exists regarding the developmental links between childhood psychopathology and borderline personality disorder (BPD) in adolescence. The current study addresses this gap by examining symptoms of attention deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD) as potential precursors. ADHD and BPD share clinical features of impulsivity, poor self-regulation, and executive dysfunction, while ODD and BPD share features of anger and interpersonal turmoil. The study is based on annual, longitudinal data from the two oldest cohorts in the Pittsburgh Girls Study (N = 1,233). We used piecewise latent growth curve models of ADHD and ODD scores from age 8 to 10 and 10 to 13 years to examine the prospective associations between dual trajectories of ADHD and ODD symptom severity and later BPD symptoms at age 14 in girls. To examine the specificity of these associations, we also included conduct disorder and depression symptom severity at age 14 as additional outcomes. We found that higher levels of ADHD and ODD scores at age 8 uniquely predicted BPD symptoms at age 14. Additionally, the rate of growth in ADHD scores from age 10 to 13 and the rate of growth in ODD scores from 8 to 10 uniquely predicted higher BPD symptoms at age 14. This study adds to the literature on the early development of BPD by providing the first longitudinal study to examine ADHD and ODD symptom trajectories as specific childhood precursors of BPD symptoms in adolescent girls.     

Understanding heterogeneity in borderline personality disorder: Differences in affective reactivity explained by the traits of dependency and self-criticism

This study examined whether the personality traits of self-criticism and dependency respectively moderated the effects of perceived inferiority and emotional insecurity on negative affect during interpersonal interactions in individuals with borderline personality disorder (BPD). A sample of 38 patients with BPD and matched community comparison participants completed event-contingent record forms after each significant interaction for a 20-day period. Multilevel models showed that, controlling for baseline levels of depressive symptoms and neuroticism, as well as lagged negative affect, event-level elevations in perceived inferiority and emotional insecurity were related to more negative affect in both groups. Event-level perceived inferiority was more strongly associated with negative affect in patients with BPD who reported higher levels of self-criticism, while event-level perceived emotional insecurity was more strongly associated with negative affect in patients with BPD who reported higher levels of dependency. No significant interactions emerged for the comparison group. These findings further our understanding of differences among patients with BPD and support the application of personality-vulnerability or diathesis-stress models in predicting negative affect in BPD. Results have implications for the design of therapies for patients with BPD. (PsycINFO Database Record (c) 2012 APA, all rights reserved).     

A systematic review of the evidence-based psychosocial risk factors for understanding of borderline personality disorder

Borderline personality disorder (BPD) is a serious personality disorder characterized by affective instability, impulsivity and interpersonal disturbance. Currently, intensive research is being conducted concerning the aetiology of BPD, including research on neurobiological, temperamental, psychosocial and cultural risk factors. This study focuses on psychosocial risk factors while other risk factors are taken into account in the discussion of the development of BPD. To our knowledge, no systematic review of the evidence-based medicine literature concerning this theme has been made thus far. However, understanding psychosocial risk factors of BPD is important in order to develop psychotherapeutic treatment models and methods. We provide a systematic review of the literature focusing on psychosocial risk factors for BPD. Utilizing this knowledge, we discuss how these data may be used when studying the development of borderline personality disorder and the treatment of borderline personality disorder.     

Neuropsychological Dysfunction in Children with Borderline Personality Disorder Features: A Preliminary Investigation

Borderline personality disorder (BPD) is often linked to neuropsychological deficits, yet few studies have examined BPD or its features and concomitant neuropsychological dysfunction in childhood. This study examined children with borderline features (n = 21) using the Coolidge Personality and Neuropsychological Inventory for Children and compared them to controls (n = 21) with features of at least one personality disorder, but not BPD. As hypothesized, the BPD group scored significantly higher than the control group on the Attention Deficit/Hyperactivity Disorder, Executive Functions Deficits, Mild Neurocognitive Disorder, Conduct Disorder, and Oppositional Defiant Disorder scales. It appears that behavioral disturbances associated with BPD are linked strongly with neuropsychological dysfunction. Because none of the children with BPD features in the present sample had a history of traumatic brain injury (TBI), it appears likely that TBI in the histories of adult BPD patients may not be the cause of BPD, but traits such as anger and impulsivity in BPD may cause TBI. Clinical implications and future research directions are discussed.     

Impulsivity mediates the association between borderline personality pathology and body mass index

Borderline personality disorder (BPD) is associated with obesity, a major risk factor for a number of chronic illnesses (e.g., cardiovascular disease). We examined whether impulsivity and affective instability mediate the association between BPD pathology and body mass index (BMI). Participants were a community sample of adults ages 55–64 and their informants. The Structured Interview for DSM-IV Personality measured BPD symptoms and the Revised NEO Personality Inventory measured self- and informant-report impulsivity and affective instability. Mediation analyses demonstrated that only higher self-report impulsivity significantly mediated the association between greater BPD pathology and higher BMI. A subsequent model revealed that higher scores on the impulsiveness (lack of inhibitory control) and deliberation (planning) facets of impulsivity mediated the BPD–BMI association, with impulsiveness exerting a stronger mediation effect than deliberation. Obesity interventions that improve inhibitory control may be most effective for individuals with BPD pathology.     

A preliminary, randomized trial of psychoeducation for women with borderline personality disorder

The main objective of this study was to determine whether being taught the latest information concerning borderline personality disorder (BPD) leads to a decline in core BPD symptoms and an improvement in psychosocial functioning. Fifty-five late adolescent women participated in a rigorous diagnostic assessment and 50 met DIB-R and DSM-IV criteria for BPD. All 50 were informed that they met criteria for BPD. Then 30 were randomized to a psychoeducation workshop that took place within a week of diagnostic disclosure. The other 20 were assigned to a waitlist and participated in the workshop at the end of this 12-week study. The two primary outcome measures were readministered each week of the trial: the Zanarini Rating Scale for DSM-IV Borderline Personality Disorder (ZAN-BPD) and the Sheehan Disability Scale (SDS). Immediate psychoeducation concerning the BPD diagnosis was associated with a significantly greater decline in general impulsivity and the storminess of close relationships. However, it did not result in significantly improved psychosocial functioning. Taken together, the results of this study suggest that informing patients about BPD soon after diagnostic disclosure may help to alleviate the severity of two of the core elements of borderline psychopathology-general impulsivity and unstable relationships. They also suggest that such instruction may prove to be a useful and cost-efficient form of pre-treatment.     

Borderline psychopathology in the first-degree relatives of borderline and axis II comparison probands

The purpose of this study was to assess the prevalence of each of the nine DSM criteria for borderline personality disorder and the prevalence of the disorder itself in the first-degree relatives of borderline probands and Axis II comparison subjects. Four hundred and forty-five inpatients were interviewed about familial borderline psychopathology using the Revised Family History Questionnaire--a semistructured interview of demonstrated reliability. Of these 445 subjects, 341 met both DIB-R and DSM-III-R criteria for BPD and 104 met DSM-III-R criteria for another type of personality disorder (and neither criteria set for BPD). The psychopathology of 1,580 first-degree relatives of borderline probands and 472 relatives of Axis II comparison subjects was assessed. Both DSM-III-R and DSM-IV BPD were found to be more common among the relatives of borderline than Axis II comparison probands. However, five of the criteria for BPD (inappropriate anger, affective instability, paranoia/dissociation, general impulsivity, and intense, unstable relationships) and all four sectors of borderline psychopathology (affect, cognition, impulsivity, and interpersonal relationships) were found to be both more common and discriminating than the BPD diagnosis itself. Taken together, the results of this study suggest that the subsyndromal phenomenology of BPD may be more common than the borderline diagnosis itself.