Frontal lobe dysfunctions in borderline personality disorder? Neuropsychological findings

This study aims to determine whether specific neuropsychological performance impairments in borderline patients can be objectified and whether these findings indicate frontal dysfunctions. Twenty-three patients with borderline personality disorder and 23 normal controls were examined using a neuropsychological test battery to assess intelligence, attentiveness, proneness to interference, learning and memory, as well as planning and problem solving. All subjects filled out standardized questionnaires to assess aggressiveness and impulsiveness in the context of these cognitive performance areas. The neuropsychological test results of the borderline patients were comparable to those of the controls. Although there were no indications of frontal dysfunction of cognitive information processing, inverse correlations were found between the severity of borderline-related personality traits regarding impulsiveness and various areas of cognitive performance. Borderline personality patients show no indications of frontal cognitive dysfunction. Further research is needed to clarify the relationship between impulsiveness and cognitive information processing in borderline personality disorder, including a dimensional approach to personality and personality disorder.     

Is avoidant personality disorder more than just social avoidance?

Although social avoidance is a defining feature of avoidant personality disorder (APD), some theorists posit that APD is characterized by a broader pattern of avoidance that extends beyond social situations. This paper describes a series of four studies that examined the different types of nonsocial avoidance hypothesized to characterize APD in three undergraduate student samples and a clinical sample of adults with APD. Overall, the findings revealed low to moderate associations between APD and emotional and novelty avoidance, as well as avoidance of various nonsocial events. The results provide support for contemporary models of APD.     

Should self-defeating personality disorder be revisited in the DSM?

Self-defeating personality disorder (SDPD) was proposed for consideration in the DSM-III-R, but was eventually removed from the manual because of the lack of evidence to support its validity. Yet, after DSM-IV was published, some studies suggested that SDPD may be a viable diagnosis. The purpose of this study was to evaluate SDPD's viability as a diagnostic category. Consequently, SDPD's internal consistency, comorbidity with other Axis I and II disorders, association with psychosocial impairment, and its ability to predict overall impairment in past, current, and global levels of functioning beyond other personality disorder symptomatology was assessed in 1,200 psychiatric evaluated with the Structured Clinical Interview for DSM-IV Personality (Pfohl, Blum, & Zimmerman, 1997). Cronbach's alpha for SDPD criteria was 0.61, and item-total correlations ranged between 0.22-0.38. There was substantial comorbidity of SDPD with depressive, avoidant, and borderline personality disorders, as well as major depression and anxiety disorders. The SDPD group did not significantly differ from psychiatric controls on multiple measures of psychosocial impairment, global functioning, and suicidality. SDPD did not meaningfully add to the prediction of impairment above and beyond other measures of Axis II pathology. It is concluded that the data do not support the reliability, validity, and utility of the SDPD diagnosis.     

Is personality disorder inherited? An overview of the evidence

Genetic factors appear to be of considerable importance in determining normal variation in personality. This is suggested by family, twin, and adoption studies as well as by indirect findings based on animal and psychophysiological studies. In contrast, there is consistent evidence that the contribution of shared family environment is minimal. Despite difficulties in defining personality disorder, it appears that many types of personality disorder, in particular schizotypal personality disorder and antisocial personality disorder/criminality, are also influenced genetically. The genetic transmission of normal personality traits and disorder is most easily explained by the contribution of multiple genes of small effect rather than by single-gene inheritance. Recent advances in molecular genetics have led to the localization of genes of minor effect for some traits. This raises the possibility of detecting a molecular basis of traits and disorders such as personality and personality disorder.Anita Thapar is supported by a Research Training Fellowship from the Medical Research Council.     

Are personality disorder criteria ethnically biased? A card-sort analysis

On the basis of methodology used in previous research on sex criterion bias, this study examined ethnicity criterion bias of personality disorders (PDs) defined in the Diagnostic and Statistical Manual of Mental Disorders (3rd ed., Rev.) and included examination of sex as well as ethnicity. A card-sort analysis using undergraduate college students as sorters indicated that criteria for all of the PDs were applied disproportionately by ethnicity, resulting in particular ethnic groups receiving diagnoses for specific PDs. Criteria were sorted systematically such that diagnoses of antisocial and paranoid PDs were assigned to African Americans, schizoid PD was assigned to Asian Americans, and schizotypal PD was assigned to Native Americans. All other PDs were assigned to European Americans, whereas none of the criteria were sorted resulting in any PD diagnosis being applied to Latinos. Implications for clinicians, methodological considerations, and recommendations for future research are discussed.     

Does obsessive-compulsive personality disorder belong within the obsessive-compulsive spectrum?

It has been proposed that certain Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Axis I disorders share overlapping clinical features, genetic contributions, and treatment response and fall within an "obsessive-compulsive" spectrum. Obsessive-compulsive personality disorder (OCPD) resembles obsessive-compulsive disorder (OCD) and other spectrum disorders in terms of phenomenology, comorbidity, neurocognition, and treatment response. This article critically examines the nosological profile of OCPD with special reference to OCD and related disorders. By viewing OCPD as a candidate member of the obsessive-compulsive spectrum, we gain a fresh approach to understanding its neurobiology, etiology, and potential treatments.     

Is hospitalization useful for suicidal patients with borderline personality disorder?

This article examines the value of hospitalization for chronically suicidal patients with borderline personality disorder (BPD). One in 10 of these patients will eventually complete suicide. However, this outcome is not readily predictable. Hospitalization is of unproven value for suicide prevention and can often produce negative effects. Day treatment is an evidence-based alternative to full admission. Chronic suicidality can best be managed in an outpatient setting.     

Psychiatric literacy: Lay beliefs of obsessive–compulsive personality disorder

This study examined the lay perceptions of the nature, aetiology and treatment of obsessive–compulsive personality disorder (OCPD). An opportunistic, predominantly British, sample of 342 participants completed a 22-item questionnaire on the treatments and causes of OCPD. Factor analysis revealed various constructs about aetiology, including a genetic/biological basis, problems with adaptation, parenting problems and issues of co-morbidity. Similarly, the ratings of the statements about efficacious cures factored into beliefs about psychoanalysis, cognitive behaviour therapy, self-help methods and the possibility of spontaneous remission. Theories of cause and treatment were modestly and significantly correlated. The findings highlight the necessity of greater mental health awareness and the importance of counselling and education in order to increase successful treatment and self- help-seeking of OCPD patients. Limitations of the study are considered.     

Do DSM-5 personality disorder proposals meet criteria for clinical utility?

The Work Group for the DSM-5 personality disorders has submitted their proposal to the professional community. In this paper, we consider the proposal in light of its ability to meet criteria for clinical utility as proposed by First and colleagues (2004). While the Work Group's proposal has addressed some of these concerns, we conclude that there remain several unanswered problems with how the proposal will improve the clinical utility of personality disorders section of the DSM-5. Though these concerns can be addressed to some extent in the field trials, it is incumbent upon the Work Group and clinical researchers to attend carefully to these issues so that shortcomings of previous diagnostic manuals are not repeated in the future.     

Facial expression recognition ability among women with borderline personality disorder: implications for emotion regulation?

This study examined recognition of facial expressions of emotion among women diagnosed with borderline personality disorder (BPD; n = 21), compared to a group of women with histories of childhood sexual abuse with no current or prior diagnosis of BPD (n = 21) and a group of women with no history of sexual abuse or BPD (n = 20). Facial recognition was assessed by a slide set developed by Ekman and Matsumoto (Japanese and Caucasian Facial Expressions of Emotion and Neutral Faces, 1992), expanded and improved from previous slide sets, and utilized a coding system that allowed for free responses rather than the more typical fixed-response format. Results indicated that borderline individuals were primarily accurate perceivers of others' emotions and showed a tendency toward heightened sensitivity on recognition of fear, specifically. Results are discussed in terms of emotional appraisal ability and emotion dysregulation among individuals with BPD.     

Heterogeneity of borderline personality disorder: do the number of criteria met make a difference?

Many studies have compared the demographic and clinical characteristics of patients with and without borderline personality disorder (BPD), but there is limited knowledge on differences within the population of borderline patients. One potential index of heterogeneity is disorder severity. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we examined whether the severity of borderline personality disorder, as measured by the number of criteria present, is associated with co-morbidity of Axis I and Axis II diagnoses, as well as demographic factors and psychosocial functioning. Two thousand three hundred psychiatric outpatients were interviewed with the Structured Interview for DSM-IV Personality (SIDP-IV). Approximately ten percent (n = 237) of the patients were diagnosed with BPD, and they were divided into four groups based on the number of DSM-IV criteria met, 5 (n = 89), 6 (n = 70), 7 (n = 46), and 8 or 9 (n = 32). There were greater rates of drug use disorders and comorbid Axis II disorders, as well as a greater number of suicidal gestures, in patients meeting seven or more BPD criteria. There were no significant differences between the groups in the number and specific rates of other co-morbid Axis I disorders, other measures of psychosocial functioning, or demographic correlates. Sub-typing of borderline patients by the number of criteria met provides a limited explanation for heterogeneity within BPD patients.     

Does personality disorder co-morbidity impact treatment outcome for patients with major depression? A multi-level analysis

In literature, there exists disagreement regarding the impact of comorbid personality disorder(s) (PD[s]) on treatment outcome for patients with major depressive disorder (MDD). The aim of this paper was to investigate whether statistical heterogeneity and inter-dependency are potential moderators of the effect of co-morbid PDs on outcome for patients with MDD. Clinician-rated MADRS scores and DSM-IV Axis II personality disorder diagnoses were obtained from 562 outpatients with MDD who received 6 months of combined psycho- and pharmacotherapy. Single-level regression showed significantly worse treatment outcome among patients with co-morbid PD, as compared to patients with no PD. After controlling for statistical heterogeneity and interdependency, treatment outcome was no longer significantly worse for patients with co-morbid PD. In conclusion, heteroscedasticity and inter-dependency should be considered as potentially compelling explanations for inconsistencies in findings on treatment outcome for depressed patients with co-morbid PDs.     

Social skills and sex‐role functioning in borderline personality disorder: relationship to self‐mutilating behavior

This study compared the social skills functioning and sex role affiliation of female inpatients diagnosed with borderline personality disorder who engaged in self‐mutilating behavior (n?=?30) with female patients with borderline personality disorder who did not engage in such behavior (n?=?18). Patients with borderline personality disorder who engaged in self‐mutilating behavior were found to have relatively poorer skills in communicating non‐verbal emotional information to others and in receiving and interpreting such information from others. In terms of sex role orientation, patients who engaged in self‐mutilating behavior were significantly more likely than non‐mutilators to be typed as undifferentiated using the Bem Sex Role Inventory. These participants were less likely to identify with either masculine or feminine sex roles. Patients who did not self‐mutilate were found to be significantly more likely than those who did self‐mutilate to identify with the masculine sex role.     

Where's the beef? Putting personality back into personality assessment

This article attempts to demonstrate the value of using a psychoanalytic theory of personality for psychological testing. This approach has more clinical utility than a solely research-based one. It recasts test data into conceptually related constructs that have internal consistency to each other and are directly relevant to psychotherapeutic treatment. Such theoretical recasting serves an organizing function, an integrative function, a clarification function, and a predictive function for the clinical inference process. Furthermore, a psychoanalytically oriented approach to testing allows for the expansion in sources of data that one considers in the testing situation. Five different sources of data emerge from the testing situation once one refocuses on theoretical constructs rather than test signs. These include test scores, test content, the patient-examiner interaction, patient behavior, and examiner countertransference.     

Can negative attitudes toward patients with borderline personality disorder be changed? The effect of attending a STEPPS workshop

We sought to determine whether negative attitudes toward patients with borderline personality disorder (BPD) can be modified through education. Mental health clinicians attended a 1-day workshop on the Systems Training for Emotional Predictability and Problem Solving (STEPPS) group treatment program for BPD. A questionnaire to assess attitudes towards BPD was given to 271 clinicians before and after the workshop. Following the workshop, clinicians endorsed having significantly greater empathy toward patients with BPD, and having greater awareness of the distress and low self-esteem associated with the disorder. Significant improvement was seen in the clinicians' attitudes toward patients with BPD and their desire to work with them. Clinicians were significantly less likely to express dislike for BPD patients. They also reported feeling more competent in their ability to treat these patients. The study offers preliminary evidence that negative attitudes toward patients with BPD can be modified through education.     

Body image in social anxiety disorder,obsessive–compulsive disorder,and panic disorder

Body dysmorphic disorder falls under the category of obsessive–compulsive and related disorders, yet research has suggested it may also be highly associated with social anxiety disorder. The current study examined body image variables among 68 outpatients with primary obsessive–compulsive disorder (OCD; n = 22), social anxiety disorder (SAD; n = 25), and panic disorder (PD; n = 21). Participants filled out self-report measures of body image disturbance, attitudes toward one's appearance, and anxiety. Body image disturbance and attitudes toward appearance did not significantly differ between the groups. However, SAD symptoms predicted body image disturbance, Appearance Evaluation and Body Areas Satisfaction, and OCD symptoms predicted Appearance Orientation. These findings suggest that SAD and OCD may be associated with different facets of body image. Implications for the treatment of anxiety disorders and for future research are discussed.     

Are the interpersonal and identity disturbances in the borderline personality disorder criteria linked to the traits of affective instability and impulsivity?

This study examines the degree to which two putative biologically influenced personality traits, affective instability and impulsive aggression, are associated with some of the interpersonal and intrapsychic disturbances of borderline personality disorder (BPD) and with choice of defense mechanism. In a sample of 152 personality disorder patients, affective instability and impulsive aggression were measured. Defense mechanisms were assessed in 140 of these patients using the Defensive Style Questionnaire (DSQ). The correlations between the traits of affective instability and impulsive aggression and the eight DSM-III-R criteria for borderline personality disorder and 20 DSQ defenses were examined. Affective instability was significantly correlated with the DSM-III-R criteria of identity disturbance, chronic emptiness or boredom, inappropriate anger, suicidality, and the affective instability criteria. It also was associated with the defenses of splitting, projection, acting out, passive aggression, undoing, and autistic fantasy. Impulsive aggression was related to unstable interpersonal relationships, inappropriate anger and impulsiveness and with the defense of acting out. It was negatively correlated with the defenses of suppression and reaction formation. A number of the interpersonal and experiential disturbances and defense mechanisms that are features of BPD are associated with the traits of affective instability and impulsive aggression among patients with personality disorders.