Reasons for suicide attempts and nonsuicidal self-injury in women with borderline personality disorder

Self-reported reasons for suicide attempts and nonsuicidal self-injury were examined using the Parasuicide History Interview within a sample of chronically suicidal women meeting criteria for borderline personality disorder (N = 75). Overall, reasons given for suicide attempts differed from reasons for nonsuicidal self-injury. Nonsuicidal acts were more often reported as intended to express anger, punish oneself, generate normal feelings, and distract oneself, whereas suicide attempts were more often reported as intended to make others better off. Almost all participants reported that both types of parasuicide were intended to relieve negative emotions. It is likely that suicidal and nonsuicidal parasuicide have multiple intents and functions.     

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.     

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.     

Prospective predictors of suicide attempts in borderline personality disorder at one, two, and two-to-five year follow-up

Efforts to identify reliable predictors of suicidal behavior in Borderline Personality Disorder have been confounded by the marked dimensional heterogeneity of the disorder, frequent comorbidity with other high risk disorders, debilitating social and vocational consequences of BPD over time. Using survival analyses, we assessed the predictive association between risk factors in each of these symptom domains and suicide attempts in BPD subjects followed for 12 months, 18-24 months and 2-5 years. The suicide attempt rate was 19% in the first year, 24.8% through the second year. The risk of suicidal behavior among 137 BPD subjects completing the first 12 months was increased by comorbid MDD and poor social adjustment. Outpatient treatment decreased short-term risk. Among 133 subjects completing 18-24 months in the study, the relative risk of a suicide attempt was increased by hospitalization (prior to any attempt), and poor social adjustment. Among 122 subjects followed for 2-5 years, increased risk was associated with hospitalization and medication visits (prior to any attempt), an attempt in the first year, and a low GAS score at baseline. Long term risk was decreased by "any outpatient treatment." Predictors of suicidal behavior in BPD change over time. MDD has a short-term effect on suicide risk, while poor social adjustment may increase risk throughout each follow-up interval. Assessing and supporting family, work, and social relationships may decrease suicidal behavior in BPD, and should be a principal focus of long-term treatment.     

Recent life events, social adjustment, and suicide attempts in patients with major depression and borderline personality disorder

This study investigated the impact of recent life events and social adjustment on suicide attempter status in 34 patients with major depression, 24 patients with borderline personality disorder, and 22 patients with co-morbid major depression and borderline personality disorder. Suicide attempters reported more recent life events and scored lower on a measure of social adjustment in their families and overall social adjustment, compared with non-attempters. Borderline disordered and borderline or depressed patients were more likely to have attempted suicide than patients with major depression only. Recent life events did not predict attempter status. Lower social adjustment in the immediate family and lower overall social adjustment were predictive of suicide attempter classification, regardless of diagnosis. Borderline disordered patients low on overall social adjustment were over 16 times more likely to have attempted suicide than patients diagnosed with major depression only. Recent life events may elevate suicide risk in groups already at high risk for suicide completion, whereas high levels of social adjustment may be protective against stress-related suicidal behavior.     

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.     

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.     

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.     

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.     

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.     

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.     

Screening for borderline personality disorder in outpatient youth

Young people with borderline personality disorder (BPD) commonly seek help but often go unrecognized. Screening offers a means of identifying individuals for more detailed assessment for early intervention and for research. AIMS: This study compared the McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD), Borderline Personality Questionnaire (BPQ), the BPD items from the International Personality Disorder Examination Screening Questionnaire and the BPD items from the Structured Clinical Interview for DSM-IV Axis II disorders (SCID-II) Personality Questionnaire. METHOD: 101 outpatient youth (aged 15-25 years) completed the screening measures and were interviewed, blind to screening status, with the SCID-II BPD module. The screening measures were readministered two weeks later to assess test-retest reliability. RESULTS: All four instruments performed similarly but the BPQ had the best mix of characteristics, with moderate sensitivity (0.68), the highest specificity (0.90), high negative predictive value (0.91) and moderate positive predictive value (0.65). Compared to the other three instruments, the BPQ had the highest overall diagnostic accuracy (0.85), a substantially higher kappa (0.57) with the criterion diagnosis, the highest test-retest reliability (ICC = 0.92) and the highest internal consistency (alpha = 0.92). The only clear difference to emerge in the Receiver Operator Curve (ROC) analysis was that the BPQ significantly outperformed the MSI (p = 0.05). CONCLUSION: Screening for BPD in out-patient youth is feasible but is not a replacement for clinical diagnosis.     

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.     

Assessment of dysfunctional beliefs in borderline personality disorder

This study had two aims: to test the hypothesis that borderline personality disorder (BPD) patients hold numerous dysfunctional beliefs associated with a variety of Axis II disorders, and to construct a BPD belief scale which captures these beliefs. Beliefs were measured using the Personality Belief Questionnaire (PBQ) which is designed to assess beliefs associated with various personality disorders, although not specifically BPD. Eighty-four BPD patients and 204 patients with other personality disorders (OPD) were randomly split into two study samples. Fourteen PBQ items were found to discriminate BPD from OPD patients in both samples. These items came from the PBQ Dependent, Paranoid, Avoidant, and Histrionic scales and reflect themes of dependency, helplessness, distrust, fears of rejection/abandonment/losing emotional control, and extreme attention-seeking behavior. A BPD beliefs scale constructed from these items showed good internal consistency and diagnostic validity among the 288 study patients. The scale may be used to assist in diagnosis and cognitive therapy of BPD.     

High-lethality status in patients with borderline personality disorder

Recurrent suicidal behaviors in patients with Borderline Personality Disorder (BPD) are often considered communicative gestures; however, 10% complete suicide. This study seeks to identify risk factors for suicide within a BPD sample by comparing patients with High- and Low-Lethality attempts. BPD attempters (n = 113) were assessed on demographic, diagnostic, and personality variables: clinical symptoms, suicidal behaviors; childhood, family, and treatment histories; social adjustment; and recent life events. Forty-four High-Lethality attempters, defined by a score of 4 or more on Beck's Medical Lethality Scale, were compared to 69 Low-Lethality attempters. Discriminating variables were entered in a multivariate logistic regression model to define predictors of High-Lethality status. High-Lethality attempters were older, with children, less education, and lower socioeconomic class (SES) than Low-Lethality attempters. They were more likely to have Major Depressive Disorder (MDD), co-morbid Antisocial Personality Disorder (ASPD), and family histories of substance abuse. They reported greater intent to die, more lifetime attempts, hospitalizations, and time in the hospital. High-Lethality status was best predicted by low SES, co-morbid ASPD, extensive treatment histories, and greater intent to die. These characteristics resemble profiles of patients who complete suicide, are not specific for BPD, and do not include impulsivity, aggression, or severity of BPD criteria.     

Disturbed sense of identity in borderline personality disorder

Traditionally, personal identity is considered to be important for psychological health and adaptive functioning. Identity diffusion and other more severe forms of disturbance associated with personal identity are regarded as being essential parts of the borderline personality disorder. Moreover, disturbances in identity are seen as being part of the dynamic background for many of the symptoms and maladaptive behaviors found in borderline patients. It is argued, that the development of personal identity is intimately related to, and indeed dependent on, elements of modern culture, with significant cultural changes having affected the conditions under which human identity develops. Therefore, the identity diffusion seen in patients with borderline disorders must be understood in relation to not only the individual patient's personal history and inner structures but also contemporary late modern culture and social organization.