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.     

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.     

Zanarini Rating Scale for Borderline Personality Disorder (ZAN-BPD): a continuous measure of DSM-IV borderline psychopathology

The purpose of this study was to assess the psychometric properties of the Zanarini Rating Scale for Borderline Personality Disorder (ZAN-BPD), the first clinician-administered scale for the assessment of change in DSM-IV borderline psychopathology. The questions for the measure were adapted from the BPD module of the Diagnostic Interview for DSM-IV Personality Disorders (DIPD-IV) to reflect a 1-week time frame and each of the nine criteria for BPD is rated on a five-point anchored rating scale of 0 to 4, yielding a total score of 0 to 36. Two diagnostic interviews that assess the presence of BPD were administered to 200 nonpsychotic patients: the BPD module of the DIPD-IV and the Revised Diagnostic Interview for Borderlines (DIB-R). The ZAN-BPD was also administered, blind to diagnostic information. In addition, each patient filled out a self-report measure of general psychopathology that is often used in borderline treatment studies, the Symptom Checklist 90 (SCL-90). The convergent validity of the ZAN-BPD and relevant scales of the SCL-90 and the DIB-R was assessed and found to be highly significant. The discriminant validity of the various scores of the ZAN-BPD was also found to be highly significant, easily discriminating the 139 patients who met the DSM-IV criteria for BPD from the 61 patients who did not. In addition, internal consistency of the ZAN-BPD was found to be high (Cronbach's alpha=0.85). The interrater reliability of the ZAN-BPD was assessed using 32 conjoint interviews, while same day test-retest reliability was assessed in a separate sample of 40 patients. All reliability raters were blind to all previously collected information concerning each subject. All intraclass correlations were in the good to excellent range. Finally, the sensitivity of the ZAN-BPD to change was assessed using a third sample of 41 patients who were reinterviewed by a blind rater 7 to 10 days after the ZAN-BPD was first administered. The SCL-90 was also readministered at this time. The correlations between difference scores of the ZAN-BPD and difference scores of the SCL-90 were found to be significant, indicating that the ZAN-BPD measures change in a clinically meaningful manner. Taken together, the results of this study suggest that the ZAN-BPD is a promising clinician-administered scale for the assessment of change in borderline psychopathology over time.     

A preliminary, randomized trial of psychoeducation for women with borderline personality disorder

The main objective of this study was to determine whether being taught the latest information concerning borderline personality disorder (BPD) leads to a decline in core BPD symptoms and an improvement in psychosocial functioning. Fifty-five late adolescent women participated in a rigorous diagnostic assessment and 50 met DIB-R and DSM-IV criteria for BPD. All 50 were informed that they met criteria for BPD. Then 30 were randomized to a psychoeducation workshop that took place within a week of diagnostic disclosure. The other 20 were assigned to a waitlist and participated in the workshop at the end of this 12-week study. The two primary outcome measures were readministered each week of the trial: the Zanarini Rating Scale for DSM-IV Borderline Personality Disorder (ZAN-BPD) and the Sheehan Disability Scale (SDS). Immediate psychoeducation concerning the BPD diagnosis was associated with a significantly greater decline in general impulsivity and the storminess of close relationships. However, it did not result in significantly improved psychosocial functioning. Taken together, the results of this study suggest that informing patients about BPD soon after diagnostic disclosure may help to alleviate the severity of two of the core elements of borderline psychopathology-general impulsivity and unstable relationships. They also suggest that such instruction may prove to be a useful and cost-efficient form of pre-treatment.     

Hypervigilance in patients with borderline personality disorder: specificity, automaticity, and predictors

According to cognitive theory, an important factor in borderline personality disorder (BPD) is hypervigilance. The aim of the present study was to test whether BPD patients show schema-related biases, and to explore relations with childhood trauma, schemas, and BPD symptoms. Sixteen BPD patients were compared with 18 patients with a cluster C personality disorder, 16 patients with an axis I disorder, and 16 normal controls. An emotional Stroop task was applied with schema-related and unrelated, negative and positive, supra- and subliminal person-related stimuli. BPD patients showed hypervigilance for both negative and positive cues, but were specifically biased towards schema-related negative cues. Predictors were BPD schemas, childhood sexual traumas, and BPD anxiety symptoms. Both BPD and axis I disorder patients showed a trend for a bias for negative schema-related subliminal stimuli. More attention to hypervigilance in BPD is recommended for clinical practice.     

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.     

The Collaborative Longitudinal Personality Disorders Study: reliability of axis I and II diagnoses

Both the interrater and test-retest-retest reliability of axis I and axis II disorders were assessed using the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) and the Diagnostic Interview for DSM-IV Personality Disorders (DIPD-IV). Fair-good median interrater kappa (.40-.75) were found for all axis II disorders diagnosed five times or more, except antisocial personality disorder (1.0). All of the test-retest kappa for axis II disorders, except for narcissistic personality disorder (1.0) and paranoid personality disorder (.39), were also found to be fair-good. Interrater and test-retest dimensional reliability figures for axis II were generally higher than those for their categorical counterparts; most were in the excellent range (> .75). In terms of axis I, excellent median interrater kappa were found for six of the 10 disorders diagnosed five times or more, whereas fair-good median interrater kappa were found for the other four axis I disorders. In general, test-retest reliability figures for axis I disorders were somewhat lower than the interrater reliability figures. Three test-retest kappa were in the excellent range, six were in the fair-good range, and one (for dysthymia) was in the poor range (.35). Taken together, the results of this study suggest that both axis I and axis II disorders can be diagnosed reliably when using appropriate semistructured interviews. They also suggest that the reliability of axis II disorders is roughly equivalent to that reliability found for most axis I disorders.     

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.     

Factors associated with Borderline pathology in school-age children

The Diagnostic Interview for Borderlines as revised (DIB-R) for use with children and chart review was completed using the records of 54 children, ages 6 to 12 years, who had been admitted to a public psychiatric hospital. Based on the results of the DIB-R, the children were grouped as borderline and nonborderline. The two groups were then compared with regard to 52 independent variables which have historically been associated with the borderline diagnosis. Stepwise logistic regression was used to identify the cluster of diagnostic and independent variables which best discriminated the borderline subjects. Self-destructive behavior, irritable affect, anhedonia, and an externalizing disorder diagnosis at the time of admission accounted for 95.4% of the borderline children. These findings are in contrast to previous studies which have found an assortment of neuropsychological and/or neurological deficits and stressed the importance of a tendency toward psychotic regression on psychological testing as discriminative variables. The authors underscore the idea that borderline pathology may represent a spectrum of disorders and the need for a more specific psychiatric nosology in describing and diagnosing these children.     

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.     

The impact of borderline personality disorder on process group outcome among women with posttraumatic stress disorder related to childhood abuse.

The outcome of a 12-week interpersonal process group therapy for women with postraumatic Stress Disorder (PTSD) related to childhood sexual abuse with and without borderline personality disorder (BPD) was assessed by comparing three naturally occurring treatment conditions: groups that did not have any members with borderline personality disorder (BPD-) (n = 18), groups in which at least one member carried the diagnosis (BPD+)(n = 16), and a 12-week waitlist (WL) (n = 15). PTSD, anger, depression, and other symptoms were significantly reduced in the BPD- groups. However, the BPD+ and WL conditions did not show any pre- to posttreatment improvements. Furthermore, the BPD+ condition showed a significant worsening on measures of anger. Analyses within the BPD+ condition indicated that women with and without the diagnosis experienced equal posttreatment increases in anger problems. These latter results suggest the presence of an anger "contagion" effect. That is, women without BPD did well in the BPD- groups but showed increased anger similar to the BPD+ women when treated in groups with them. Implications for client-treatment matching considerations in PTSD group therapy are discussed.     

Comparing the Personality Disorder Interview for DSM–IV (PDI–IV) and SCID–II Borderline Personality Disorder Scales: An Item–Response Theory Analysis

One-hundred sixty-nine psychiatric outpatients and 171undergraduate students were assessed with the Personality Disorder Interview–IV (PDI–IV; Widiger, Mangine, Corbitt, Ellis, & Thomas, 1995) and the Structured Clinical Interview for DSM–IV Axis II disorders (SCID–II; First, Gibbon, Spitzer, Williams, & Benjamin, 1997) for borderline personality disorder (BPD). Eighty individuals met PDI–IV BPD criteria, whereas 34 met SCID–II BPD criteria. Dimensional ratings of both measures were highly intercorrelated (rs = .78, .75), and item-level interrater reliability fell in the good to excellent range. An item–response theory analysis was performed to investigate whether properties of the items from each interview could help understand these differences. The limited agreement seemed to be explained by differences in the response options across the two interviews. We found that suicidal behavior was among the most discriminating criteria on both instruments, whereas dissociation and difficulty controlling anger had the 2 lowest alpha parameter values. Finally, those meeting BPD criteria on both interviews had higher levels of anxiety, depression, and more impairments in object relations than those meeting criteria on just the PDI–IV. These findings suggest that the choice of measure has a notable effect on the obtained diagnostic prevalence and the level of BPD severity that is detected.     

Heightened subjective experience of depression in borderline personality disorder

Despite the frequent comorbidity of major depression and borderline personality disorder (BPD), limited research has examined what effect this comorbidity has on the severity, course, and presentation of depression. The purpose of this study was to examine whether the severity of major depressive disorder (MDD) in the context of comorbid borderline personality disorder (BPD) differs from MDD when comorbid BPD is not present and to determine whether different measures of depression yield convergent findings. Sixty patients diagnosed with DSM-IV MDD participated in this study. Twenty-nine were diagnosed with DSM-IV BPD, while the remaining 31 had no Axis II diagnosis. Depression was evaluated with both clinician (Hamilton Rating Scale for Depression) and self-report (Beck Depression Inventory) ratings. While the two groups were rated as similarly depressed by clinicians on the overall rating and the factor scores, the MDD/BPD group reported more severe depressive symptoms on the self-report measure. This difference was significant even after controlling for clinician-rated severity. Gender interacted with diagnosis, males in the BPD group showed the largest discrepancies between clinician ratings and self-reports. Posthoc analyses of HDRS factors with the BDI showed that the clinicianrated cognitive disturbance and retardation factors were correlated with self-rated severity overall. Within subgroups, only the retardation factor was correlated with the BDI. Our results suggest that while depressed individuals with and without BPD may be rated as similarly depressed when assessed with objective rating methods, the subjective experience of the depression may be rated as more intense or severe by patients with comorbid BPD. The mechanism underlying this effect remains unknown, and requires further research.     

Overgeneral autobiographical memory predicts higher prospective levels of depressive symptoms and intrusions in borderline patients

Overgeneral memory (OGM), the tendency to retrieve categories of events from autobiographical memory instead of single events, is found to be a reliable predictor for future mood disturbances and post-traumatic symptom severity. Patients with borderline personality disorder (BPD) often report co-morbid episodes of major depressive disorder (MDD) and post-traumatic stress disorder (PTSD). Therefore, we investigated whether OGM would predict depression severity and (post-traumatic) stress symptoms in BPD patients. At admission (N?=?54) and at six-month follow-up (N?≥?31), BPD patients completed the Structured Clinical Interview for DSM-IV Disorders, the Assessment of DSM-IV Personality Disorders, the Autobiographical Memory Test, the Beck Depression Inventory—2nd edition (BDI-II), and the Impact of Event Scale. OGM at baseline predicted (a) higher levels of depressive symptoms at follow-up and (b) more intrusions related to a stressful event over and above baseline levels of borderline symptoms, depressive symptoms, and intrusions, respectively. No association was found between memory specificity and event-related avoidance at follow-up. Despite previous findings suggesting that OGM in BPD is less robust than in MDD and PTSD, our results suggest that memory specificity in BPD patients may have some relevance for the course of depressive and stress symptomatology in BPD.     

Psychometric Evaluation of the Borderline Personality Disorder Severity Index-IV-Adolescent Version and Parent Version

The Borderline Personality Disorder Severity Index-IV-adolescent and parent versions (BPDSI-IV-ado/p) are DSM-IV based semi-structured interviews for the assessment of the severity of symptoms of borderline personality disorder (BPD) in adolescents. The present study evaluates the psychometric properties of the BPDSI-IV-ado/p. The interviews were administered to 122 adolescents, aged 14-19 years and their parents/caretakers who were referred to mental health centres for emotion regulation problems, and to 45 healthy controls. The interrater reliability and internal consistency of all nine subscales (following the nine BPD symptoms in DSM-IV) proved to be good to excellent. Discriminant, concurrent, and construct validity were satisfactory. Cut-off scores that optimize sensitivity and specificity were derived. Informant agreement between adolescents and parents/caretakers was modest. The results of this study suggest that the BPDSI-IV adolescent and parent versions are valid and reliable instruments for the assessment of BPD symptom severity in adolescents.     

Impulsivity: core aspect of borderline personality disorder

This prospective follow-up study addresses whether impulsivity versus other aspects of borderline personality disorder (BPD) are (1) stable over a 7-year follow-up period; (2) able to predict the persistence versus remittance of BPD over 7 years of follow-up, and (3) more predictive of the level of borderline psychopathology on follow-up than other aspects of the disorder. When the cohort was assembled, 88 of 130 subjects scored seven or higher on the Diagnostic Interview for Borderlines (DIB), indicating a definite diagnosis of BPD. The cohort was reassessed at 2 and 7 years after the index admission. At the 7-year follow up, 81(62.3%) of the original cohort were re-examined, two (1.6%) were deceased, six (4.6%) suicided, 36 (27.7%) refused to participate and five (3.8%) could not be located. The results indicated that the initial impulse action subscale score was highly correlated with the 7-year follow-up score (r = 0.53). Using a stepwise multiple regression technique, the impulse action subscale score from the DIB best predicted borderline psychopathology at the 7-year follow up, with an r2 of 0.24, F = 24.84, p < 0.001. This prospective study of subjects with BPD indicates that impulsivity is stable over time and highly predictive of borderline psychopathology over 7 years follow up. These results suggest the treatment of impulsivity may impact the course of BPD.     

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.     

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.     

Interpersonal Assessment of Borderline Personality Disorder: Preliminary Findings

We examined the reliability and validity of scores on an interpersonal measure of borderline personality disorder (BPD). Ratings on the Interpersonal Measure of Borderline Personality Disorder (IM–B) were based on nonverbal behaviors and interpersonal interactions occurring during clinical interviews with 276 adults. Scores on the IM–B exhibited good reliability. IM–B scores also displayed expected patterns of associations with scores on other measures of BPD, as well as with scores on measures of affective dysfunction, interpersonal pathology, and behavioral impairment associated with BPD, including indexes of maladaptive emotion regulation, interpersonal sensitivity, and self-harm. The pattern of associations for IM–B scores was quite similar to what would be expected for a dimensional measure of BPD symptoms. Scores on the IM–B were also associated with symptoms of disorders generally comorbid with BPD. Finally, IM–B scores contributed incrementally to the prediction of interpersonal dysfunction and suicidal ideation and behavior. Discussion focuses on implications for the assessment of BPD.