The Role of Incest in Developmental Theory and Treatment of Women Diagnosed with Borderline Personality Disorder

The incidence of incest in the histories of women diagnosed with borderline personality disorder (BPD) has been noted recently by a number of clinicians (e.g., Barnard & Hirsch, 1985; Herman, Perry, & van der Kolk, 1989). However, the experience of child sexual abuse is virtually ignored in the developmental theory of the borderline syndrome. This paper presents a critical review of theoretical and clinical literature on child sexual abuse and BPD to explore three major goals: to describe the overlapping clinical picture of adult female survivors of incest and of women diagnosed with BPD, to examine the ways in which mother-blaming in psychoanalytic thought has contributed to the neglect of this experience in borderline clients, and to integrate treatment strategies from the child sexual abuse literature, traditional object relations theory, and feminist clinical theory.     

Examining the relationship between emotion regulation deficits and borderline personality disorder features: A daily diary study

This study used a six-day daily diary methodology to precisely specify the nature of emotion regulation deficits associated with borderline personality disorder (BPD) features. Three possibilities were explored: that BPD features are associated with (1) the overall underuse of emotion regulation strategies; (2) the overuse of dysfunctional and the underuse of functional strategies; and (3) the lower perceived effectiveness of emotion regulation strategies. One hundred and fifty-four undergraduate participants completed self-report measures of BPD feature severity, and then reported their daily negative emotional intensity, whether or not they used various emotion regulation strategies, and whether or not the strategies that they used were effective across a six-day period. Higher BPD features were associated with (a) higher total frequency use of emotion regulation strategies; (b) higher frequency use of dysfunctional and functional emotion regulation strategies; and (c) less self-reported effectiveness of functional strategies. BPD features may be characterized by increased attempts to regulate emotions, without corresponding increases in perceived effectiveness.     

Dialectical Behavior Therapy: An Emotion-Focused Treatment for Borderline Personality Disorder

Dialectical Behavior Therapy (DBT) is a cognitive-behavioral treatment for borderline personality disorder (BPD) that is based on the theory that emotion dysregulation is the core feature of BPD. This article focuses on aspects of DBT theory and techniques that specifically address emotion. The dialectical and biosocial theories that underlie DBT are reviewed with an emphasis on how each relates to emotional experiencing in BPD. Selected treatment strategies that address emotion dysregulation and their hypothesized mechanisms of change are also described. Relevant research findings are incorporated throughout to provide an empirical foundation for the DBT theories and strategies that are discussed.     

Children At-Risk for Borderline Personality Disorder

Adult patients who have been diagnosed with borderline personality disorder (BPD) have provided valuable information about events and family dynamics that are frequently associated with BPD. Clinicians who work with children are frequently aware of family or individual characteristics that may put a child at risk for developing BPD. Such situations frequently involve attachment issues with the child's caregivers and can include sexual abuse, divorce, alcoholism/substance use, illness/ death, and neglect. Child characteristics such as learning difficulties and temperament may also predict BPD. Yet, many children are resilient and seemingly unaffected by these events or situations, especially when early intervention may prevent development of BPD.     

Development and validation of the Minnesota borderline personality disorder scale

Although large epidemiological data sets can inform research on the etiology and development of borderline personality disorder (BPD), they rarely include BPD measures. In some cases, however, proxy measures can be constructed using instruments already in these data sets. In this study, the authors developed and validated a self-report measure of BPD from the Multidimensional Personality Questionnaire (MPQ). Items for the new instrument-the Minnesota BPD scale (MBPD) -were identified and refined using three large samples: undergraduates, community adolescent twins, and urban substance users. The authors determined the construct validity of the MBPD scale by examining its association with (a) diagnosed BPD, (b) questionnaire-reported BPD symptoms, and (c) clinical variables associated with BPD: suicidality, trauma, disinhibition, internalizing distress, and substance use. The authors also tested the MBPD scale in two prison inmate samples. Across samples, the MBPD scores correlated with BPD indices and external criteria and showed incremental validity above measures of negative affect, thus supporting its construct validity as a measure of BPD.     

The STEPPS Group Treatment Program for Outpatients with Borderline Personality Disorder

The authors describe a new cognitive-behavioral systems-based group treatment for outpatients diagnosed with borderline personality disorder (BPD). The program is identified by the acronym STEPPS, which stands for Systems Training for Emotional Predictability and Problem Solving. The STEPPS program was developed to address the cognitive distortions and behavioral dyscontrol typical of clients with BPD, and combines this with skills training and a systems component. The latter involves clients with BPD and those in their system including family members, significant others, and health care professionals. The program is fully manualized, and involves 20 two-hour weekly group meetings; specific goals (or lessons) are identified for each session. Preliminary data from the US and the Netherlands have shown that the group achieves high levels of acceptance from clients and therapists and that the model may be effective in helping to relieve the symptoms associated with BPD. Work is now underway to confirm the effectiveness of the model through a randomized controlled trial.     

Comorbid attention-deficit/hyperactivity disorder in borderline patients defines an impulsive subtype of borderline personality disorder

In order to examine the impulsive profile of a BPD sample with comorbid ADHD, adult patients who met criteria for BPD were assessed for ADHD with the CAADID and the WURS. A high rate of ADHD in the BPD sample was found, with sixty-nine (38.1%) BPD patients diagnosed as having comorbid adult ADHD. BPD-ADHD group had higher rates of general substance use disorder (59.4% vs. 38.4%), antisocial personality disorder (7.2% vs. 0.9%) and obsessive-compulsive personality disorder (21.7% vs. 6.3%). The BPD group without comorbid adult ADHD showed a higher rate of mood disorders (62.5% vs. 37.7%), panic disorders (54.5% vs. 23.1%) and benzodiazepine abuse (18.8% vs. 5.8%). Only in BPD patients without ADHD was comorbid avoidant personality disorder found. BPD patients could be distinguished in two clear subgroups related to the adult ADHD comorbidity. BPD-ADHD patients showed a more homogeneous and impulsive profile while BPD without ADHD comorbidity had more anxiety and depressive disorders.     

Discriminant validity of the ZKPQ in a sample meeting BPD diagnosis vs. normal-range controls

Widiger and Simonsen (2005) state that given the limitations of the categorical model of Personality Disorders classification proposals are to be expected for dimensional classifications. The purpose of this paper is to test the alternative five factorial model (AFFM) of personality in a sample with PDs. Subjects were administered the ZKPQ to test the discriminant capacity of the AFFM in classifying subjects diagnosed with BPD (n = 74) vs normal-range controls (n = 148) paired by age and sex, and identifying sensitive and/or specific dimensions that can be of help in diagnosing BPD. The results showed that high scores on N-Anx and Imp-SS, and low scores on Act are prognostic factors for being diagnosed with BPD. Likewise, this model correctly classified 88% of subjects with a kappa index of 0.73. The AFFM of personality appears to have a substantial power for predicting SCID-II interview-based BPD diagnosis.     

Refining the borderline personality disorder phenotype through finite mixture modeling: implications for classification

Borderline personality disorder (BPD) is characterized by considerable heterogeneity. Prior approaches to resolving heterogeneity in BPD pathology have used factor and cluster analytic as well as latent class analysis strategies. These prior studies have been atheoretical in nature, but provide an initial empirical corpus for further sub-typing efforts in BPD. A model-based taxonomy for BPD that is supported by evidence from an advanced statistical methodology would enhance investigations of BPD etiology, pathophysiology, and treatment. This study applied finite mixture modeling analysis, in a model-guided fashion, to selected dimensions of pathology within a group of well-characterized BPD patients to determine if latent groups are harbored within the disorder. Subjects with BPD (N = 90) were examined on a variety of model-relevant psychopathology dimensions. We applied finite mixture modeling to these dimensions. We then evaluated the validity of the obtained solution by reference to a variety of external measures not included in the initial mixture modeling. Three phenotypically distinct groups reside within the overall BPD category. Group-1 is characterized by low levels of antisocial, paranoid, and aggressive features. Group-2 is characterized by elevated paranoid features, whereas Group-3 is characterized by elevated antisocial and aggressive features. External correlates reveal a pattern of differences consistent with the validity of this proposed grouping structure. A theory-guided finite mixture modeling analysis supports a parsing of the BPD category into three subgroups. This proposed BPD taxonomy represents an approach to reducing heterogeneity observed among BPD patients and it may prove useful in studies seeking to understand etiologic and pathophysiologic factors as well as treatment response in BPD.     

Experiential Avoidance and Emotion Regulation in Borderline Personality Disorder

Many of the severe behavioral difficulties observed among persons with BPD (e.g., self-harm, suicidal behaviors) have been conceptualized as attempts to avoid or escape unwanted emotional experiences. As such, experiential avoidance likely plays a prominent role in the difficulties faced by persons with BPD. Individuals with BPD have demonstrated heightened levels of experiential avoidance in several studies. Several key features of BPD may contribute to experiential avoidance among persons with BPD, including a vulnerability to negative or distressing emotions, difficulty regulating emotions, and distress intolerance. Some research also suggests that a vulnerability to negative emotions among persons with BPD may be partly due to the use of experiential avoidance strategies to cope with emotional experiences. Within this paper, we review the literature on experiential avoidance and possible mechanisms underlying experiential avoidance among persons with BPD, and discuss the research and clinical implications of this literature.     

Dialectical Behavior Therapy for Managing Interpersonal Relationships

Dialectical Behavior Therapy (DBT) is a treatment designed for individuals having borderline personality disorder (BPD), patients having binge eating disorder, co-morbid substance dependence and BPD, and depressed older adults. This paper aims to explore the use of DBT and to ascertain the status of DBT education in treating difficulties in handling interpersonal relationships among clients seeking counseling and psychotherapy. The skills training mode can be employed for teaching skills to solve relationship problems. Validation and acceptance strategies can lessen rejection sensitivity and negative feelings that make interpersonal situations chaotic. Black and white thinking can be resolved by finding a middle path through acceptance and change. This paper suggests the possible utility of DBT for enhancing psychological well-being in clients.     

Affect and alcohol use: an ecological momentary assessment study of outpatients with borderline personality disorder

Alcohol use may be viewed as an attempt (albeit maladaptive) to regulate negative emotional states. We examined associations between both negative and positive affects and alcohol use in outpatient women diagnosed with borderline personality disorder (BPD; n=74), a prototype of emotional dysregulation, as well as a psychiatric control group of women with current depressive disorder (major depressive disorder/dysthymic disorder [MDD\DYS]; n=50). Participants completed randomly prompted reports of mood and alcohol use up to six times a day over a 28-day period using electronic diaries. Mean levels of either positive or negative affects did not distinguish between drinkers and nondrinkers in either diagnostic group. However, levels of both negative and positive affects were positively associated with alcohol use at the momentary level in BPD drinkers. More robust findings were obtained with respect to within-person affective variability, which was related to alcohol use in multiple ways. BPD drinkers showed higher within-person variability for most negative affects than BPD nondrinkers; MDD\DYS drinkers in general showed less within-person variability than MDD\DYS nondrinkers for negative affects. Multilevel lagged analyses for BPD drinkers indicated that alcohol use was positively related to variability in all affects, concurrently, but fewer significant effects of affect variability on the next day's drinking or significant effects of alcohol use on the next day's affect variability were observed. Among MDD\DYS drinkers, we observed more significant associations between affect variability on next day's alcohol use and of alcohol use on next day's affect variability. We discuss theoretical and methodological issues relevant to these findings as well as implications for future research.     

Temperamental and environmental risk factors for borderline personality disorder among inner-city substance users in residential treatment

Borderline Personality Disorder (BPD) is widely considered the result of biological vulnerability and environmental adversity. Despite growing evidence for the role of several temperamental and environmental risk factors in the development of BPD, the unique contribution of each to the development of this disorder remains unclear. Furthermore, the extent to which these factors are associated with BPD among underserved and diverse populations is unknown. The current study examined the temperamental and environmental factors uniquely associated with BPD among a sample of 93 inner-city individuals receiving residential substance use treatment. Results indicate that BPD was associated with higher impulsivity and emotional instability/vulnerability, lower well-being, and several interpersonal manifestations of positive and negative temperament (i.e., greater alienation and lower achievement and social closeness). BPD was also associated with several forms of childhood maltreatment, including emotional and physical abuse and neglect. However, only emotional instability or vulnerability, impulsivity, and emotional abuse emerged as unique predictors of BPD status.     

Assumptions in borderline personality disorder: specificity, stability and relationship with etiological factors.

The specificity and stability of a set of assumptions hypothesized to be characteristic of Borderline Personality Disorder (BPD) was investigated. BPD patients (n = 16) were compared to cluster-C personality disorder patients (n = 12) and to normal controls (n = 15). All subjects were female and diagnosed with SCID-I and -II. Subjects rated a short version of the Personality Disorder Beliefs Questionnaire (PDBQ), with six sets of 20 assumptions each, hypothesized to be characteristic of avoidant, dependent, obsessive-compulsive, paranoid, histrionic and borderline personality disorder. The BPD assumptions (Cronbach alpha = 0.95) proved to be the most specific to BPD patients. Subjects rated the shortened PDBQ again after viewing an emotional video fragment one week later. Despite increased negative emotions, the PDBQ ratings remained relatively stable. Confirming the cognitive hypothesis, regression analyses indicated that the BPD assumptions mediate the relationship between self-reported etiological factors from childhood (sexual abuse and emotional/physical abuse) and BPD pathology assessed with the SCID-II. It is suggested that a set of assumptions is characteristic of BPD, and is relatively stable despite the instability of the behaviour of people diagnosed as having BPD.     

Time perception, impulsivity, emotionality, and personality in self-harming borderline personality disorder patients

To investigate how time perception may contribute to the symptoms of self-harming Borderline Personality Disorder (BPD) patients, 19 self-harming BPD inpatients and 39 normal controls were given measures of time perception, impulsivity, personality, emotion, and BPD characteristics. A test sensitive to orbitofrontal cortex (OFC) function ("Frontal" Behavior Questionnaire) was also administered, as the OFC has been associated with impulsivity and time perception. BPD patients produced less time than controls, and this correlated with impulsiveness and other characteristics commonly associated with BPD. BPD patients were also less conscientious, extraverted, and open to experience, as well as more impulsive (self-report and behaviorally), emotional, neurotic, and reported more BPD characteristics, compared to controls. The results suggest that some of these core characteristics of BPD may be on a continuum with the normal population and, impulsivity in particular, may be related to time perception deficits (i.e., a faster subjective sense of time). Finally, BPD patients scored higher on the Frontal Behavior Questionnaire, suggesting that some symptoms of the BPD syndrome may be related to problems associated with the OFC. A control spatial working memory task (SWM) revealed that SWM deficits could not explain any of the BPD patients' poor performance. While impulsivity was correlated with time perception across all participants, emotionality, introversion, and lack of openness to experience were not. This suggests that different symptoms of the borderline personality syndrome may be separable, and therefore, related to different cognitive deficits, and potentially to different brain systems. This may have important implications for treatment strategies for BPD.     

High-risk situations associated with parasuicide and drug use in borderline personality disorder

Both parasuicide and drug use continue to be difficult problems to treat in borderline personality disorder (BPD). One useful approach that has not yet been applied to BPD is to develop a taxonomy of triggering situations for these problems. Once these high-risk precipitants are identified, then the behaviors can be targeted with skills training. This model has been applied by Marlatt (1996) with very influential results. To examine high-risk situations for parasuicide and drug use in BPD, the current study examined women with BPD who came to treatment for two different primary problems: parasuicide (N = 75) and drug dependence (N = 47). Participants identified the situation associated with highest risk for relapse in either the parasuicide or drug category. A taxonomy is presented, which divides results into six main categories. Differences between high-risk situations for drugs and parasuicide were also explored. Parasuicide was significantly more likely to be linked to interpersonal problems, whereas drug use was more likely to be preceded by addiction cues (i.e., being near drugs or people who use drugs).     

An investigation of organic factors in the neuropsychological functioning of patients with borderline personality disorder

The hypothesis to be tested in this study was that the cognitive deficits that have been documented in patients with Borderline Personality Disorder (BPD) are largely the consequence of organic insult, either developmental or acquired. Using a cross-sectional design, 80 subjects (males and females) who met the criteria for BPD participated in the study. They completed a battery of neuropsychological tests and a comprehensive interview assessing organic status as well as measures of the potentially confounding factors of current levels of depression and anxiety. It was expected that BPD-patients with a probable history of organic insult would perform significantly worse than would BPD patients without such a history. Analyses of the results provided partial support for the hypothesis. Subjects with both BPD and a history of organic insult were significantly more impaired on several measures including measures of attention than were BPD only subjects. The results suggested that the impaired cognitive performance of persons diagnosed with BPD may, in part, be attributed to organic factors.     

Behavioral activation and the prevention of suicidal behaviors in patients with borderline personality disorder

Clinical approaches in treating and preventing suicidal behaviors in patients with borderline personality disorder (BPD) have received limited attention. To stimulate further work in this area, we present a behavioral activation treatment for depression (BATD; Lejuez, Hopko, & Hopko, 2002) that has shown promising results in treating clinically depressed patients and a theoretical conceptualization for why BATD may prove particularly useful in reducing the frequency of suicide-related behaviors and other symptoms characteristic of patients with BPD. We also present theoretical consistencies between BATD and the well-established intervention of dialectical behavior therapy (DBT; Linehan, 1993), which may allow for their practical integration, and conclude with a case study that illustrates the assimilation of these strategies in the treatment of a patient with BPD.     

Changes in schemas of patients with severe borderline personality disorder: The Oulu BPD study

Borderline personality disorder (BPD) is a relatively common and severe psychiatric disorder that can impair quality of life in many ways. The aim of this study was to determine whether a combined treatment model for BPD patients, utilising major principles from schema‐focused therapy (SFT) and dialectical behavioral therapy (DBT), could be more effective in relieving early maladaptive schemas of BPD patients, compared to treatment as usual (TAU). This study is a part of the Oulu BPD study conducted at mental health care services run by Oulu city social and health care services. The study is a multisite, randomized controlled trial conducted over a one year period, involving two groups of patients with severe BPD: (1) Community Treatment By Experts (CTBE) patients (n = 18) receiving the combined treatment model, and 2) TAU patients (n = 27). The patients' schemas were assessed using the Young Schema Questionnaire (YSQ‐L3a) before and after one year of treatment. The results reveal that CTBE patients who attended the combined treatment model showed a statistically significant reduction in eight out of 18 early maladaptive schemas, while patients receiving treatment as usual did not demonstrate any significant changes in schemas. The cognitive therapeutic treatment model can be applied for clinical use in public mental health settings using existing professionals, and appears to produce positive changes in patients with BPD.     

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.