The MMPI, prototypal typology, and borderline personality disorder

This study demonstrates inherent features in the DSM-III diagnostic criteria for personality disorders (i.e., overlapping diagnoses and heterogeneous symptomatology) that limit efforts to identify a sensitive and specific MMPI profile for the borderline personality disorder. A sample of 71 inpatients was administered an MMPI and a semistructured interview that systematically evaluated each of 81 symptoms for the 11 DSM-III personality disorders. Interrater reliability was substantially higher than has been obtained with unstructured interviews. The effect on the borderline MMPI profile of variation in the number of borderline symptoms and overlap with the schizotypal, histrionic, and antisocial diagnoses was demonstrated. We discuss implications with respect to a prototypal model of classification.     

The MMPI,Prototypal Typology,and Borderline Personality Disorder

This study demonstrates inherent features in the DSM-III diagnostic criteria for personality disorders (i.e., overlapping diagnoses and heterogeneous symptomatology) that limit efforts to identify a sensitive and specific MMPI profile for the borderline personality disorder. A sample of 71 inpatients was administered an MMPI and a semistructured interview that systematically evaluated each of 81 symptoms for the 11 DSM-III personality disorders. Interrater reliability was substantially higher than has been obtained with unstructured interviews. The effect on the borderline MMPI profile of (a) variation in the number of borderline symptoms and (b) overlap with the schizotypal, histrionic, and antisocial diagnoses was demonstrated. We discuss implications with respect to a prototypal model of classification.     

Role of structure in disordered thinking in borderline and schizophrenic disorders

Qualitative studies have noted that individuals with "borderline" psychopathology exhibit extreme thought disorder on unstructured tests, yet manifest relatively normal performance on more structured tests of cognitive performance. The present study provides empirical support for this clinical observation. Borderline syndrome patients, defined by DSM-III criteria for borderline personality disorder and/or schizotypal personality disorder, demonstrated significantly greater thought disorder on the Rorschach, as measured by Johnston and Holzman's (1979) Thought Disorder Index (TDI), than did nonpsychiatric controls and were indistinguishable from patients with schizophrenic disorder of relatively recent onset. Borderline patients did not differ from controls on a structured test of cognitive slippage. Further examination of the role of structure in the assessment and treatment of borderline syndrome disorders seems warranted.     

Psychological test signs of borderline personality disorder: a review of the empirical literature

Recent empirical work aimed at identifying test signs of borderline personality disorder is reviewed. The review focuses on commonly employed clinical tests, including the Wechsler Adult Intelligence Scale (WAIS), the Rorschach, and the Minnesota Multiphasic Personality Inventory (MMPI). Possible test signs are considered in relation to their sensitivity to and specificity for the diagnosis and in relation to the criteria of DSM-III, which define the disorder. Although consistent patterns of potentially useful test signs have begun to appear, methodological difficulties have hampered any subsequent development of clinically useful indices. Greater attention to sample size and its composition and definition as well as demonstrations of adequate reliability and predictive utility are required for further development of these signs.     

A psychometric analysis of five DSM-III categories

Preliminary studies of interdiagnostician agreement have shown that the DSM-III holds promise for improving diagnostic reliability. This study examined the characteristics of five DSM-III diagnostic categories (schizophrenia, mania and schizotypal, narcissistic and borderline personality disorders) with respect to three psychometric criteria. Examined were the specificity, syndrome association and internal consistency of the diagnostic criteria for these disorders. Results suggested that of the diagnostic categories examined, the criteria for schizophrenia performed best under empirical scrutiny, while criteria for borderline and narcissistic personality disorders were more problematic. Suggestions are made for subsequent investigations into the internal validity of DSM-III.     

A preliminary report on defenses and conflicts associated with borderline personality disorder

The authors present preliminary psychodynamic findings from a naturalistic study of borderline personality disorder compared to antisocial personality disorder and bipolar type II (depression with hypomania) affective disorder. An independent psychodynamic interview of each subject was videotaped from which ratings were made of the presence of 22 defense mechanisms and 11 psychodynamic conflicts. A factor analysis of ratings from 81 subjects supported the separation of borderline (splitting, projective identification) from narcissistic defenses (devaluation, omnipotence, idealization, mood-incongruent denial). While certain groups of defenses were associated with each diagnosis, defense ratings did not significantly discriminate the three diagnostic groups, suggesting a limit to their diagnostic value. Among 27 subjects rated, borderline personality was strongly associated with two conflicts: separation-abandonment, and a global conflict over the experience and expression of emotional needs and anger. Antisocial personality was psychodynamically distinct and more heterogeneous. Bipolar type II was associated with two hypothesized depressive conflicts: dominant other and dominant goal. Chronic depression, which was more common in both personality disorder groups than in bipolar type II, was associated with a third depressive conflict, overall gratification inhibition. Overall, conflicts were powerful discriminators of the three diagnostic groups. The heuristic value of these findings is discussed.     

Some comments on the role of cotherapists in group psychotherapy with borderline patients

This paper points out examples of patients in a psychotherapy group who meet DSM-III criteria for the diagnosis of borderline personality disorder and who are treated by cotherapists utilizing object relations theory. Interpretations of phenomena shown by borderline patients—splitting, projective identification and denial—are illustrated. How cotherapy lends itself to the recognition and management of the problems these patients bring to group psychotherapy is illustrated.Hope Aspell assisted in the editing of this paper.     

The BPQ: a scale for the assessment of borderline personality based on DSM-IV criteria

The aim of the study was to develop a self-report measure that assesses borderline personality traits as defined by DSM-IV criteria, including separate subscales for each criterion. A sample of normal subjects from community colleges in the midwestern region of the United States was used to develop the scale. The psychometric properties of the scale were examined using an additional United States sample and student samples from England and Australia. The scale was compared with existing measures of borderline and schizotypal personality. Evidence for the internal consistency and convergent and divergent validity of the new scale is presented. The results of several analyses of variance comparing males and females in the three national groups are reported. A Principal Components Analysis of the subscales suggested either a single factor or two correlated factors. Oblique rotation yielded a structure that distinguished identity/interpersonal and impulsivity borderline personality traits. It is concluded that the new scale provides a useful tool for clinicians and researchers interested in screening for borderline personality traits in both general and clinical populations. Suggestions for further research are indicated.     

Differential impairment as an indicator of sex bias in DSM-IV criteria for four personality disorders

The aim of the present study was to investigate the possibility of sex bias in the diagnostic criteria for borderline, schizotypal, avoidant, and obsessive-compulsive personality disorders. A clinical sample of 668 individuals was evaluated for personality disorder criteria using a semistructured interview, and areas of functional impairment were assessed with both self-report and semistructured interview. The authors used a regression model of bias to identify bias as differences in slopes or intercepts between men and women in the relationship between each diagnostic criterion and level of impairment. The results suggest that most of the diagnostic criteria examined do not seem to display sex bias. However, those criteria that displayed evidence of bias came largely from the borderline diagnosis.     

Psychological Test Signs of Borderline Personality Disorder: A Review of the Empirical Literature

Recent empirical work aimed at identifying test signs of borderline personality disorder is reviewed. The review focuses on commonly employed clinical tests, including the Wechsler Adult Intelligence Scale (WAIS), the Rorschach, and the Minnesota Multiphasic Personality Inventory (MMPI). Possible test signs reconsidered in relation to their sensitivity to and specificity for the diagnosis and in relation to the criteria of DSM-III, which define the disorder. Although consistent patterns of potentially useful test signs have begun to appear, methodological difficulties have hampered any subsequent development of clinically useful indices. Greater attention to sample size and its composition and definition as well as demonstrations of adequate reliability and predictive utility are required for further development of these signs.     

A randomized controlled trial of cognitive behavior therapy for borderline personality disorder: rationale for trial, method, and description of sample

This paper describes the rationale for a randomized controlled trial, comparing cognitive behavior therapy in addition to treatment as usual with treatment as usual alone, for borderline personality disorder. Previous pioneering randomized controlled trials of psychotherapies have suffered from methodological weaknesses and have not always been reported clearly to allow adequate evaluation of either the individual study or comparisons across studies to be undertaken. We report on the recruitment and randomization, design, and conduct of an ongoing randomized controlled trial of one hundred and six patients with borderline personality disorder. Primary and secondary hypotheses and their planned analyses are stated. The baseline characteristics of 106 patients meeting diagnostic criteria for borderline personality disorder are described.     

Age-related differences in individual DSM criteria for borderline personality disorder

This study examined age-related effects of individual DSM criteria for borderline personality disorder (BPD) and symptoms of depression and anxiety in three groups: patients diagnosed with BPD, another personality disorder, or no personality disorder. The goal was to determine if distinctive age effects emerged within the BPD group. This mixed clinical and community sample (N = 380) ranged from 20-50 years old. Each participant was assessed for symptoms of axis I and II psychopathology. We found significant interactions for personality disorder group x age for the suicidal behavior and impulsivity criteria that reflected distinctive changes in the BPD group. The BPD group reported significantly more anxious and depressive symptoms. However, no main effect for age or personality disorder x age interaction emerged with symptoms. These results demonstrate that older individuals with BPD report less impulsivity and fewer suicidal behaviors, although symptoms of distress persist.     

How stable are borderline diagnoses?

Borderline diagnostic terms are still being routinely and rather unreliably made in many centers. In the present sample of probands with various borderline states other diagnoses from the entire spectrum of psychiatric disorders, especially schizophrenia, were also found. Thus, in those cases with multiple admissions, a borderline diagnosis demonstrated only little stability over time. There was a strong tendency for borderline cases towards a diagnosis of schizophrenia and vice versa. Indeed, probands, with both borderline and schizophrenic diagnoses had no clear-cut course characteristics. It is suggested that the criteria of DSM-III for borderline personality disturbance be provisionally used for research purposes.     

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.     

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.     

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.     

Humor styles and borderline personality

The present study examined the phenotypic, genetic, and environmental correlations between four humor styles (affiliative, self-enhancing, aggressive, and self-defeating) and four dimensions of borderline personality disorder (affective instability, identity disturbance, negative relationships, self-harm) as well as a total borderline personality disorder score. Participants were 574 same-sex Australian adult twin pairs. At the phenotypic level, the two adaptive humor style dimensions (affiliative and self-enhancing) were found to correlate negatively with borderline personality and the two maladaptive humor style dimensions (aggressive and self-defeating) were found to have positive correlations with borderline personality. Bivariate genetic analyses demonstrated significant genetic, common environment, and unique environmental correlations. These results indicate that a large component of the phenotypic association between borderline personality disorder and humor style arises from the influence of shared familial and environmental factors associated with both phenotypes.     

A comparison of interview and self-report methods for the assessment of borderline personality disorder criteria

Interview methods are widely regarded as the standard for the diagnosis of borderline personality disorder (BPD), whereas self-report methods are considered a time-efficient alternative. However, the relative validity of these methods has not been sufficiently tested. The current study used data from the Collaborative Longitudinal Personality disorder Study to compare diagnostic base rates and the relative validity of interview and self-report methods for assessing functional outcome in BPD. Although self-report yielded higher base rates of criteria endorsement, results did not support the common assumption that diagnostic interviews are more valid than self-reports, but instead indicated the combined use of these methods optimally identifies BPD criteria.