Attachment and borderline personality disorder

The author outlines his concept of reflective function or mentalization, which is defined as the capacity to think about mental states in oneself and in others. He presents evidence to suggest that the capacity for reflective awareness in a child's caregiver increases the likelihood of the child's secure attachment, which in turn facilitates the development of mentalization in the child. He proposes that a secure attachment relationship offers the child a chance to explore the mind of the caregiver, and in this way to learn about minds; he formulates this model of the birth of the psychological self as a variation on the Cartesian cogito: "My caregiver thinks of me as thinking and therefore I exist as a thinker." This model is then applied to provide insight into some personality-disordered individuals who were victims of childhood abuse. The author proposes (1) that individuals who experience early trauma may defensively inhibit their capacity to mentalize to avoid having to think about their caregiver's wish to harm them; and (2) that some characteristics of severe borderline personality disorder may be rooted in developmental pathology associated with this inhibition. He offers evidence for and some qualifications of this model, and argues that the therapeutic effect of psychoanalysis depends on its capacity to activate patients' ability to evolve an awareness of mental states and thus find meaning in their own and other people's behavior.     

Comparing borderline definitions: DSM-III borderline and schizotypal personality disorders

Compared the two types of borderline disorder formally defined by DSM-III, borderline personality disorder and schizotypal personality disorder, at the diagnostic category and individual criterion level. Unlike previous research in this area, which has focused on inpatient and outpatient populations, the sample was a psychometrically defined, nonpatient sample including Ss meeting DSM-III criteria for each disorder. The results indicated that the two diagnostic categories each define a type of borderline with distinctive combinations of features. Perceptual and cognitive distortion, however, seem to be present in both and define an area of overlap between the two disorders. The implications of these findings for the revision of the SPD diagnostic criteria in DSM-III-R are discussed, and the theoretical separation of two subtypes of borderline personality is affirmed.     

Emotional granularity and borderline personality disorder

This study examined the affective dysregulation component of borderline personality disorder (BPD) from an emotional granularity perspective, which refers to the specificity in which one represents emotions. Forty-six female participants meeting criteria for BPD and 51 female control participants without BPD and Axis I pathology completed tasks that assessed the degree to which participants incorporated information about valence (pleasant-unpleasant) and arousal (calm-activated) in their semantic/conceptual representations of emotions and in using labels to represent emotional reactions. As hypothesized, participants with BPD emphasized valence more and arousal less than control participants did when using emotion terms to label their emotional reactions. Implications and future research directions are discussed.     

Interpersonal patterns in borderline personality disorder

Research has shown that a disturbed capacity to relate to others is a key feature of borderline personality disorder (BPD; e.g., Bender & Skodol, 2007; Gunderson, 2007). However, few attempts have been made to determine if and how this disturbance translates into identifiable core interpersonal patterns. This study investigated the relationship patterns of 68 patients presenting with BPD. Vignettes of interpersonal interactions spontaneously reported by participants were rated using the Core Conflictual Relationship Theme (CCRT; Luborsky & Crits-Christoph, 1990) method. Results of a factor analysis revealed six patterns of interactions: (1) interactions involving the ego ideal; (2) dependent-depressive interactions; (3) receptive interactions; (4) passive-submissive interactions; (5) successful interactions; and (6) sadomasochistic interactions. The clinical implications of these findings are discussed.     

Metarepresentative functions in borderline personality disorder

Many authors consider that patients suffering from Borderline Personality Disorder (BPD) are hampered in their ability to metarepresent, which is the correct ascribing of states of mind to oneself and to others and the reflecting thereon. Although the ability to mentalize is generally described as being uniform, various authors pinpoint problems which appear to be of a diverse psychological nature. Some describe difficulties in identifying emotions or a shortfall in their regulation, others identify a lack of integration between representations of self and those of others, and yet others focus on the failure to distinguish between fantasy and reality. In the present research all sessions during the first year of therapy of four patients suffering from BPD were tape-recorded and transcribed, and then analyzed using the Metacognition Assessment Scale (MAS), which is designed for the evaluation of the ability to metarepresent in clinical reports. The results support the hypothesis that there is a metarepresentation impairment in BPD but that it is more selective than was thought until now. In particular, such patients maintain their ability to identify internal states, whereas they are impaired in the integration of representations of self and others and in the differentiation between fantasy and reality.     

Social networks in borderline personality disorder

The interpersonal dysfunction that characterizes borderline personality disorder (BPD) has generally been studied using broad global measures, leading to a lack of precision. We report on a novel methodology using social network analysis (SNA) to quantify interactions with others in the patient's social world. We assessed the social networks of 22 clinical patients, diagnosed with either BPD (N = 11) or no personality disorder (No PD; N = 11). The social networks of patients with BPD contained a greater number of former romantic partners, and a greater number of relationships that had been terminated. Mixed model analyses found that the No PD group reported higher levels of positive relationships (e.g., trust, social support) with more central members of their social networks, whereas the BPD group did not discriminate among members of their networks. Results suggest deficits in social cognition for positive relations, but not for negative relations such as interpersonal conflict.     

Five-factor measure of borderline personality traits

This study provides psychometric data for a new self-report measure of borderline personality traits from the perspective of the Five-factor model (FFM) of general personality. Subscales were constructed in an undergraduate sample (n = 109) to assess maladaptive variants of 12 FFM traits (e.g., Affective Dysregulation as a maladaptive variant of FFM Vulnerability). On the basis of data from a second undergraduate sample (n = 111), the Five Factor Borderline Inventory (FFBI) subscales were shown to have good internal consistency, convergent, discriminant, and incremental validity. These psychometric results were replicated in a clinical sample of female residents at a substance abuse treatment facility (n = 94).     

Homogeneous group therapy of borderline personality disorder

The authors maintained a time-limited, diagnostically homogeneous psychotherapy group of borderline patients for one year. The group progressed through prototypical stages of group development, but each phase was marked by variations of the aggressive drive and defenses against aggression that are characteristic of this disorder. The group provided a well-suited forum for the exploration of suicidal and homicidal impulses and the development of an observing ego. Despite the limits on generalizability from this group, it appears that group psychotherapy can be a valuable adjunctive modality for some borderline patients.Paper presented at the American Psychiatric Association Conference, Montreal, May, 1988.     

A taxometric study of borderline personality disorder

Taxometric methodology was used to determine whether borderline personality disorder (BPD) represents a taxon that is categorically distinct from normal personality or whether it falls on a dimensional continuum with normality. Two taxometric procedures were used with a sample of 1,389 outpatients assessed for BPD symptoms by semistructured interview. The procedures indicated that BPD does not represent a latent category. Implications are drawn for the conceptualization and etiology of BPD, and for the categorical versus dimensional status of personality disorders in general.     

Dimensional personality profiles of borderline personality disorder in comparison with other personality disorders and healthy controls

The present study examined the sensitivity and clinical specificity of dimensional personality profiles associated with borderline personality disorder (BPD) by comparing three groups of patients: (a) patients with BPD according to DSM-IV criteria (n = 31); (b) patients with other DSM-IV PD (n = 31); and (c) general population controls (n = 31). All three samples were matched for age and gender and the two patient samples were matched for chronicity and depressive symptoms. All patients were given the Six-Factor Test measuring the five-factor model of personality (FFM), the Temperament and Character Inventory (TCI), and the Dimensional Assessment of Personality Pathology (DAPP). Nonparametric statistics were applied to analyze the data (Mann-Whitney-U-tests for group comparisons; Spearman's coefficients for correlational analyses). Neuroticism (FFM), Self-Directedness (TCI), and Emotional Dysregulation (DAPP) were identified as general markers of personality pathology, which were significantly interrelated in all three samples. BPD patients also showed a specific profile compared with other PD patients with lower scores on Agreeableness (FFM), higher scores on Novelty Seeking and Self-Transcendence (TCI), and higher scores on the DAPP higher-order dimensions of Emotional Dysregulation, Dissocial Behavior, and Inhibitedness. Results support the assumption that BPD can be characterized by dimensional approaches with sufficient sensitivity in comparison with healthy controls and specificity in comparison with other PD patients.     

Subtyping borderline personality disorder by suicidal behavior

Course and outcome of Borderline Personality Disorder (BPD) are favorable for the vast majority of patients; however, up to 10% die by suicide. This discrepancy begs the question of whether there is a high lethality subtype in BPD, defined by recurrent suicidal behavior and increasing attempt lethality over time. In a prospective, longitudinal study, we sought predictors of high lethality among repeat attempters, and defined clinical subtypes by applying trajectory analysis to consecutive lethality scores. Criteria-defined subjects with BPD were assessed using standardized instruments and followed longitudinally. Suicidal behavior was assessed on the Columbia Suicide History, Lethality Rating Scale, and Suicide Intent Scale. Variables discriminating single and repeat attempters were entered into logistic regression models to define predictors of high and low lethality attempts. Trajectory analysis using three attempt and five attempt models identified discrete patterns of Lethality Rating Scale scores. A high lethality trajectory was associated with inpatient recruitment, and poor psychosocial function, a low lethality trajectory with greater Negativism, Substance Use Disorders, Histrionic and/or Narcissistic PD co-morbidity. Illness severity, older age, and poor psychosocial function are characteristics of a poor prognosis subtype related to suicidal behavior.     

The rejection-rage contingency in borderline personality disorder

Though long-standing clinical observation reflected in the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.) suggests that the rage characteristic of borderline personality disorder (BPD) often appears in response to perceived rejection, the role of perceived rejection in triggering rage in BPD has never been empirically tested. Extending basic personality research on rejection sensitivity to a clinical sample, a priming-pronunciation experiment and a 21-day experience-sampling diary examined the contingent relationship between perceived rejection and rage in participants diagnosed with BPD compared with healthy controls. Despite the differences in these 2 assessment methods, the indices of rejection-contingent rage that they both produced were elevated in the BPD group and were strongly interrelated. They provide corroborating evidence that reactions to perceived rejection significantly explain the rage seen in BPD.     

Interpersonal evaluation bias in borderline personality disorder

Background

The cognitive theory of personality disorders hypothesizes that the emotional dysregulation and interpersonal problems in individuals with borderline personality disorder (BPD) are, at least partially, caused by dysfunctional cognitive schemas. These schemas lead to biased evaluation of environmental and interpersonal stimuli.

Method

This study examined the interpersonal evaluations of individuals with BPD, depressive and healthy control participants with the thin-slice judgments paradigm. Participants were asked to evaluate six persons in six film clips, which showed these persons for 10 s, during which these persons entered a room and took a seat. Interpersonal style of the BPD group was investigated with the Inventory of Interpersonal Problems (IIP-C) questionnaire.

Results

Individuals with BPD judged the persons as being more negative and aggressive and less positive than the healthy participants, and more aggressive than the depressive individuals. In addition, individuals with BPD reported more extreme interpersonal behavior relative to the controls.

Conclusions

The findings indicate an aggressivistic evaluation bias and elevated levels of interpersonal problems in individuals with BPD as suggested in the cognitive theory.     

Suicide, suicide litigation, and borderline personality disorder

In the category of malpractice liability affecting mental health practitioners of all disciplines, malpractice based on suicide is the leading claim by a significant margin. Our discussion here will be organized in two sections. First, we consider the theory, practice, and psychology of malpractice litigation itself in relation to suicide. Second, we describe how those basic principles apply to patients with borderline personality disorder.     

MCMI-II borderline personality disorder in anorexia and bulimia nervosa

The aim of the present study is to explore the MCMI-II personality style and MCMI-II possible disorder of borderline personality (BPD) in various groups of women. 93 patients-31 anorexia nervosa restricting subtype (ANr), 31 anorexia nervosa binge-eating/purging subtype (ANp), and 31 bulimia nervosa purging subtype (BNp); 31 women at high risk for eating disorder or symptomatic control group (S-CG) and 31 without known pathology or not symptomatic control group (NS-CG)-completed the Spanish version of the MCMI-II. The results revealed: (1) clinically significant borderline personality traits [74>Base Rate (BR) <85]: 16.1% ANr, 12.9% ANp, and 45.2% BNp versus 3.2% of the S-CG and none of the NS-CG; (2) possible disorder (BR>84): 29% ANr, 41.9% ANp and 29% BNp. According to the MCM-II, women with BNp displayed more BPD traits than possible disorder (though these were more severe). However, the probability of a possible disorder was higher in ANp (more disorders than traits).     

Positive affective and cognitive states in borderline personality disorder

The aim of the current study was to compliment previous studies identifying negative states present in borderline personality disorder (BPD) by investigating the presence of positive affective and cognitive states. Ninety-six patients with criteria-defined borderline personality disorder and 24 axis II comparison participants completed the Positive Affect Scale, a 50-item self-report measure designed to assess positive states thought to be characteristic of and discriminating for BPD. Seventeen positive states (4 affective, 10 cognitive, and 3 mixed) were found to be significantly more common among axis II comparison participants than borderline patients. Twelve of these states were common to both borderline patients and axis II comparison participants. Furthermore, four positive states, when co-occurring together, were particularly strongly associated with borderline personality disorder (three negatively and one positively): (a) Fond of myself, (b) That things around me are real, (c) That I've forgiven others, and (d) Assertive. Finally, the overall mean score on the PAS significantly distinguished patients with borderline personality disorder from axis II comparison participants. Taken together, these results suggest that borderline patients are far less likely to report experiencing positive states of an affective, cognitive, and mixed nature than axis II comparison participants. They also suggest that being assertive is a positive state particularly discriminating for borderline personality disorder.