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.     

Borderline personality disorder features predict negative outcomes 2 years later

In a sample of 351 young adults, the authors assessed whether borderline personality disorder (BPD) features prospectively predicted negative outcomes (poorer academic achievement and social maladjustment) over the subsequent 2 years, over and above gender and both Axis I and Axis II psychopathology. Borderline traits were significantly related to these outcomes, with impulsivity and affective instability the most highly associated. The present findings suggest that the impulsivity and affective instability associated with BPD leads to impairment in relating well with others, in meeting social role obligations, and in academic or occupational achievement. Therefore, these may be especially important features to target in interventions for BPD.     

Borderline personality disorder features and utilization of treatment over two years

This study assessed the relationship between borderline personality disorder (BPD) features and treatment utilization over a 2-year time period. Participants included 349 18-year-old nonclinical young adults, approximately one-half of whom endorsed significant borderline features. The laboratory phase of the study involved the administration of self-report and interview-based assessments of BPD psychopathology at Wave 1, as well as interviews targeting Axis I psychopathology and treatment utilization history at Wave 2 (2 years later). Results indicated that borderline features prospectively predicted utilization of psychopharmacological treatment above and beyond what was accounted for by gender, lifetime Axis I psychopathology, and nonBPD Axis II psychopathology. The borderline feature most strongly associated with treatment utilization was affective instability.     

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.     

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.     

Borderline personality features predict alcohol use problems

This study assessed the relation between BPD features and problems associated with alcohol use 2 years later in young adults. Approximately 5,000 nonclinical young adults were screened for BPD features, and two cohorts of participants completed the laboratory phase of the study at Time 1 (total N = 421) and then again 2 years later at Time 2 (total N = 356). Measures included self-report and interview-based assessments of personality disorders, psychopathology in biological parents, Axis I psychopathology, and alcohol use problems. BPD features were found to significantly predict alcohol use problems 2 years later after controlling for parents' substance use disorders, Axis I psycho-pathology (including alcohol abuse/dependence), and non-BPD personality disorders. In addition, the BPD subscale that assesses impulsivity was found to be significantly associated with alcohol use problems once all predictors were entered into the model.     

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.     

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.     

Prospective prediction of nonsuicidal self-injury: a 1-year longitudinal study in young adults

Nonsuicidal self-injury (NSSI) has become a significant public health problem. Although numerous studies have examined cross-sectional psychological correlates of NSSI, there has been little research examining predictors of NSSI over time. The present study examined cross-sectional and longitudinal correlates of NSSI in 81 young adult self-injurers (M age = 19, 74.1% female, 51.9% Caucasian), 51 of whom were followed up 1 year later. At baseline, participants completed self-report measures of NSSI, Axis-I disorders, borderline personality disorder (BPD), and impulsivity, as well as an implicit measure of NSSI attitudes and identity. One year later, participants completed a Timeline Followback Method whereby they indicated their engagement in NSSI over the previous 12 months. Analyses replicated many known cross-sectional correlates of NSSI, including symptoms of several Axis-I disorders and BPD. However, many of these same variables failed to predict the course of NSSI over the 1-year follow-up. The only variables to prospectively predict NSSI were past NSSI (i.e., frequency, methods, and recency of NSSI), participants’ behavioral forecast of their engagement in future NSSI, and BPD features. Findings suggest that many cross-sectional correlates of NSSI may not be useful for predicting subsequent NSSI. Instead, NSSI severity and BPD features appear to best predict continued engagement in NSSI.     

Adolescent Disruptive Behavior and Borderline Personality Disorder Symptoms in Young Adult Men

Very few studies have prospective information, especially regarding males, on the prediction of Borderline Personality Disorder (BPD) in adulthood from psychiatric disorders in childhood. Certain childhood disorders, however, have notably similar features in common with BPD. In particular, the affective dysfunction, hostility and interpersonal conflict of Oppositional Defiant Disorder (ODD) and the impulsivity of Attention Deficit Hyperactivity Disorder (ADHD) in particular may be indicative of an early developmental path towards BPD. The present study uses longitudinal data from a clinical sample of 177 boys, initially between the ages of 7 and 12, who were followed up annually to age 18, and who were reassessed at age 24 (n = 142). The study examines the prediction from repeated childhood measures of psychopathology measured annually through adolescence to BPD symptoms assessed at age 24, accounting for the effects of covariates including substance use, other personality disorders at age 24 and harsh physical punishment. The prevalence of BPD in this sample was consistent with other population estimates. Attention Deficit Hyperactivity Disorder (ADHD) and ODD were the only child psychiatric disorders to predict BPD symptoms, and the oppositional behavioral dimension of ODD was particularly predictive of BPD. These results indicate possible developmental links between early psychiatric disorders and BPD.     

Validation of the UPPS impulsive behaviour scale: a four‐factor model of impulsivity

The current study attempts to clarify the multi‐faceted nature of impulsivity through the use of the four‐factor UPPS Impulsive Behaviour scale. In order to build the nomological network surrounding this scale, the UPPS was administered to individuals with borderline personality disorder (BPD), pathological gamblers (PG), alcohol abusers (divided into two groups based on the presence of antisocial features), and a control group. Several of the UPPS scales (e.g. Urgency, lack of Premeditation, and Sensation Seeking) differentiated the BPD, PG, and alcohol abusers with antisocial features from a group of non‐antisocial alcohol abusers and a control group. Overall, the UPPS scales accounted for between 7% (pathological gambling) and 64% (borderline personality disorder features) of the overall variance in the psychopathology measures. Individual UPPS scales also made unique contributions to several of these disorders, which may provide insight into which of these personality traits may predispose individuals to behave in maladaptive or problematic ways. The results provide support for the differentiation of impulsivity‐related constructs into the current four‐factor model. Copyright © 2005 John Wiley & Sons, Ltd.     

Relationship between cumulative BMI and symptomatic, psychosocial, and medical outcomes in patients with borderline personality disorder

We examined the relationship between cumulative body mass index (BMI) and symptomatic, psychosocial, and medical outcomes in patients with borderline personality disorder (BPD). Two hundred female borderline patients were weighed and measured during their index admission. They were subsequently interviewed at six-, eight-, and 10-year intervals. Over 10 years of prospective follow-up, increases in cumulative BMI were significantly associated with self-mutilation and dissociation (but not suicide attempts). Increases in cumulative BMI were also significantly associated with having no life partner, a poor work or school history, being on disability, being rated with a GAF score in the fair or poor range, and having a low income. In addition, increases in BMI were related to having two or more other medical conditions and using costly forms of health care. Increases in cumulative BMI may be a marker for adverse symptomatic, functional, and medical outcomes in patients with BPD.     

Impulsivity and emotion dysregulation in Borderline Personality Disorder

This study examined the association of borderline personality disorder (BPD) and negative emotional states with impulsivity in the laboratory. Undergraduate participants who were high in BPD features (high-BPD; n = 39) and controls who were low in BPD features (low-BPD; n = 56) completed measures of negative emotional state before a laboratory measure of impulsivity--a passive avoidance learning task. Controlling for psychopathology, high-BPD participants committed a greater number of impulsive responses than did low-BPD participants. Negative emotional state moderated the effect of BPD on impulsive responses. High-BPD participants who were in a negative emotional state committed fewer impulsive responses than high-BPD participants who were low in negative emotional state. Fear, nervousness, and shame negatively correlated with impulsivity among high-BPD participants but not among low-BPD participants. In addition, high-BPD participants reported greater emotion dysregulation in a variety of domains, compared with low-BPD participants.     

An open clinical trial of cognitive therapy for borderline personality disorder

Although borderline personality disorder (BPD) is a major public health concern, psychotherapeutic trials have been limited. The present uncontrolled clinical trial examines whether cognitive therapy for BPD is associated with significant improvement on measures of psychopathology. A total of 32 patients with BPD, who also reported suicide ideation or who engaged in self-injury behavior, received weekly cognitive therapy sessions over a 1-year period as described by Layden et al. (1993). The results revealed significant and clinically important decreases on measures of suicide ideation, hopelessness, depression, number of borderline symptoms and dysfunctional beliefs at termination and 18-month assessment interviews. Implications for further research with this difficult-to-treat patient population are discussed.     

Psychopathology, childhood trauma, and personality traits in patients with borderline personality disorder and their sisters

The aim of this study was to document and compare adverse childhood experiences, and personality profiles in women with borderline personality disorder (BPD) and their sisters, and to determine how these factors impact current psychopathology. Fifty-six patients with BPD and their sisters were compared on measures assessing psychopathology, personality traits, and childhood adversities. Most sisters showed little evidence of psychopathology. Both groups reported dysfunctional parent-child relationships and a high prevalence of childhood trauma. Subjects with BPD reported experiencing more emotional abuse and intrafamilial sexual abuse, but more similarities than differences between probands and sisters were found. In multilevel analyses, personality traits of affective instability and impulsivity predicted DIB-R scores and SCL-90-R scores, above and beyond trauma. There were few relationships between childhood adversities and other measures of psychopathology. Sensitivity to adverse experiences, as reflected in the development of psychopathology, appears to be influenced by personality trait profiles.     

Inter-rater and test-retest reliability of the Revised Diagnostic Interview for Borderlines

The baseline inter-rater reliability, test-retest reliability, follow-up inter-rater reliability, and follow-up longitudinal reliability (interrater reliability between generations of raters) of borderline symptoms and the diagnosis of borderline personality disorder (BPD) were assessed using the Revised Diagnostic Interview for Borderlines (DIB-R). Excellent kappa s (> .75) were found in each of these reliability substudies for the diagnosis of BPD itself. Excellent kappa s were also found in each of the three inter-rater reliability substudies for the vast majority of borderline symptoms assessed by the DIB-R. Test-retest reliability for these symptoms was somewhat lower but still very good. More specifically, one-third of the BPD symptoms assessed had a kappa in the excellent range and the remaining two-thirds had a kappa in the fair-good range (.57-.73). The dimensional reliability of BPD symptom areas was somewhat higher than for categorical measures of the subsyndromal phenomenology of BPD. More specifically, all five dimensional measures of borderline psychopathology had intraclass correlation coefficients in the excellent range for all four reliability substudies. Taken together, the results of this study suggest that both the borderline diagnosis and the symptoms of BPD can be diagnosed reliably when using the DIB-R. They also suggest that excellent reliability, once achieved, can be maintained over time for both the syndromal and subsyndromal phenomenology of BPD.     

Borderline personality disorder from the perspective of general personality functioning

The authors extended previous work on the hypothesis that borderline personality disorder (BPD) can be understood as a maladaptive variant of personality traits included within the 5-factor model (FFM) of personality. In each of 3 samples, an empirically derived prototypic FFM borderline profile was correlated with individuals' FFM profiles to yield a similarity score, an FFM borderline index. Results across all samples indicated that the FFM borderline index correlated as highly with existing borderline measures as they correlated with one another, and the FFM borderline index correlated as highly with measures of dysfunction, history of childhood abuse, and parental psychopathology as did traditional measures of BPD. Findings support the hypothesis that BPD is a maladaptive variant of FFM personality traits.     

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.     

Predicting self-damaging and suicidal behaviors in female borderline patients: reasons for living, coping, and depressive personality disorder.

The aims of this study are to examine (1) whether reasons for living predict self-damaging and suicidal behaviors, (2) the associations of reasons for living with coping strategies and depressive personality disorder (PD), and (3) the unique predictive validity of reasons for living in a multivariate predictor model. Reasons for living (RFL), coping strategies, and depressive personality disorder were measured at baseline in 38 patients who met DSM-IV criteria for borderline personality disorder (BPD). Frequency of self-damaging and suicidal behaviors in the 6-month period following baseline was measured prospectively at 3- and 6-month follow-ups. The RFL has only one subscale that predicts parasuicidal behaviors (i.e. Survival and Coping Beliefs [SCB]). Participants who scored low on this subscale were 6.8 times more likely to exhibit self-damaging and suicidal behaviors in the follow-up period than their high-scoring counter-parts. However, SCB was substantially correlated with the coping strategies "reassuring thoughts," "active coping," and "palliative reaction pattern," as well as with depressive personality traits. In a multivariate model, the predictive power of SCB appeared to be accounted for by reassuring thoughts and depressive PD. Coping scales might be preferable over the RFL as a predictor of self-damaging and suicidal behaviors in borderline patients.     

Dysfunctional beliefs and psychopathology in Borderline Personality Disorder

This study examined the factor structure of the Borderline Personality Disorder subscale of the Personality Beliefs Questionnaire (PBQ-BPD; Butler, Brown, Beck, & Grisham, 2002), and the relationships between the emergent factors and psychopathology. The sample comprised 184 patients diagnosed with borderline personality disorder (BPD). Exploratory factor analysis yielded three factors relating respectively to dependency, distrust, and the belief that one should act preemptively to avoid threat. Although the three factors were significantly associated with depression, only dependency and distrust significantly correlated with hopelessness. Distrust was the sole factor that correlated significantly with suicide ideation. These findings support the dimensional structure of the PBQ-BPD. Given its multidimensional structure, the scale can be used as a measure of belief profiles associated with BPD and as an aid to conceptualizing beliefs underlying a range of psychopathology associated with patients with BPD.