Childhood antisocial behaviors as predictors of psychotic symptoms and DSM-III-R borderline criteria among inpatients with borderline personality disorder.

Structured clinical interviews of 107 female inpatients diagnosed with borderline personality disorder (BPD) were used to determine whether antisocial personality disorder (APD) diagnostic criteria evident prior to age 15 could be used to predict current Axis I and Axis II psychopathology. Diagnostic information was gathered using the Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II) and the Structured Clinical Interview for DSM-III-R-Patient Version (SCID-P). Childhood APD criteria were subjected to principal-components analysis, and three factors--rule-breaking, assault, and sadism--emerged. The severity of the childhood APD criteria was related to psychotic symptoms, as well as to the unstable relationships and labile affect BPD criteria and the current overall severity of BPD criteria. Sadism predicted psychotic symptoms and BPD severity, while rule-breaking predicted unstable relationships and BPD severity. Childhood APD severity also had a larger effect on BPD severity than on psychotic symptoms. Possible explanations for these findings are explored and discussed.     

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.     

Borderline personality disorder symptoms as predictors of 4-year romantic relationship dysfunction in young women: addressing issues of specificity

The relationships between romantic relationship dysfunction and symptoms of borderline personality disorder (BPD), other personality disorders, and depression were examined prospectively in a community sample of 142 late adolescent women. Although BPD symptoms predicted 4-year romantic dysfunction (romantic chronic stress, conflicts, partner satisfaction, abuse, and unwanted pregnancy), the associations were not unique to BPD. Instead, relationship dysfunction was better predicted by a cumulative index of non-BPD Axis II pathology. Depression did not predict outcomes uniquely when Axis II symptoms were included, except in the case of unplanned pregnancy. The results suggest that although BPD is associated with relationship dysfunction, the effect is a more general phenomenon applying rather broadly to Axis II pathology. The results also highlight the importance of subclinical psychopathology in the construction of early intimate relationships.     

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

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

Borderline personality disorder features and utilization of treatment over two years

This study assessed the relationship between borderline personality disorder (BPD) features and treatment utilization over a 2-year time period. Participants included 349 18-year-old nonclinical young adults, approximately one-half of whom endorsed significant borderline features. The laboratory phase of the study involved the administration of self-report and interview-based assessments of BPD psychopathology at Wave 1, as well as interviews targeting Axis I psychopathology and treatment utilization history at Wave 2 (2 years later). Results indicated that borderline features prospectively predicted utilization of psychopharmacological treatment above and beyond what was accounted for by gender, lifetime Axis I psychopathology, and nonBPD Axis II psychopathology. The borderline feature most strongly associated with treatment utilization was affective instability.     

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.     

Gender differences in a clinical sample of patients with borderline personality disorder

The aim of the study was to investigate gender differences and similarities in patients with borderline personality disorder (BPD) with respect to Axis I comorbidity, Axis II comorbidity, general psychopathology (Symptom Checklist 90-Revised), and dimensional personality traits (NEO-Personality-Inventory Revised [NEO-PI-R] and the Dimensional Assessment of Personality Profile Basic questionnaire [DAPP-BQ]). Fifty-seven men and 114 women with BPD were included in the study. Regarding Axis I and II disorders in an exploratory analysis, men with BPD more often fulfilled the diagnostic criteria for binge eating disorder, antisocial personality disorder, narcissistic personality disorder, and conduct disorder in childhood, whereas women had higher frequencies of bulimia nervosa, posttraumatic stress disorder, and panic disorder with agoraphobia. After correcting for multiple tests, only the gender differences in narcissistic and antisocial personality disorder remained significant. In the SCL-90-R profile, no significant gender differences could be identified. In the exploratory analysis of the dimensional personality traits, women showed higher rates on the NEO-PI-R main factors (Neuroticism and Agreeableness) compared to men. In the DAPP-BQ profile, men reached higher sores on the main factor, Dissocial Behavior. When correcting for multiple tests, gender differences still existed for Neuroticism and Dissocial Behavior. Our results argue for gender differences in Axis I and II comorbidity and dimensional personality traits in BPD. However, in general, more similarities than differences were shown in this study.     

Suicide Attempts in Major Depressed Patients with Personality Disorder

Suicide attempters who met criteria for borderline personality disorder (BPD) comorbid with major depressive disorder (MDD) were compared to both suicide attempters suffering from MDD alone and to attempters with comorbid MDD and other personality disorders (PD). Participants were 239 (158 patients with comorbid PD and 81 patients with MDD without comorbidity) inpatients consecutively admitted after a suicide attempt made in the last 24 hours. Suicide attempters with comorbid MDD and BPD had more frequent previous suicide attempts and were more likely to have a history of aggressive behaviors and alcohol and drug use disorders compared with patients suffering from MDD without Axis II comorbidity.     

Relationships of borderline features to parental mental illness, childhood abuse, Axis I disorder, and current functioning

Although a number of studies have investigated single, putative etiological factors for borderline personality disorder (BPD), few studies have assessed the relations between multiple etiological factors and borderline features within the same study. Borderline features, parental psychopathology, childhood physical and sexual abuse, lifetime Axis I disorder, and current functioning were assessed in 65 nonclinical participants, a portion of which exhibited significant BPD features. Multivariate models were tested and results indicated that parental mental illness and lifetime Axis I disorder were significant and unique predictors of borderline scores. Borderline features accounted for significant variance in current functioning beyond what was accounted for by other predictors; borderline scores mediated the relations between lifetime Axis I disorder and current functioning.     

Borderline personality disorder features predict negative outcomes 2 years later

In a sample of 351 young adults, the authors assessed whether borderline personality disorder (BPD) features prospectively predicted negative outcomes (poorer academic achievement and social maladjustment) over the subsequent 2 years, over and above gender and both Axis I and Axis II psychopathology. Borderline traits were significantly related to these outcomes, with impulsivity and affective instability the most highly associated. The present findings suggest that the impulsivity and affective instability associated with BPD leads to impairment in relating well with others, in meeting social role obligations, and in academic or occupational achievement. Therefore, these may be especially important features to target in interventions for BPD.     

Prevalence of personality disorders among bulimics,nonbulimic binge eaters,and normal controls

We examined the comorbidity of bulimia and personality pathology among college women. Subjects included women (n=23) meeting DSM-III-R criteria for bulimia nervosa (bulimics), women (n=23) who reported binge eating but did not fulfill the criteria for bulimia nervosa (binge eaters), and women (n=23) who did not binge eat (normals). The subjects completed an assessment battery consisting of the Personality Disorders Examination and the SCID as well as the Beck Depression Inventory, the Rosenberg Self-Esteem Index, and measures of impulsivity and self-defeating tendencies. Fourteen of 23 bulimics (61%) met criterion for a personality disorder using DSM-III-R Axis II criteria. In comparison, 3 of 23 (13%) binge eaters and 1 of 23 (4%) normal subjects received an Axis II diagnosis. Borderline and self-defeating diagnoses were the predominant personality disorders in 96% of the bulimics exhibiting clinically significant personality pathology. Bulimics also exhibited significantly more depression, impulsivity, and self-defeating behavior and lower self-esteem than binge eaters and normals. The findings are discussed within a conceptual framework that posits an interaction between personality pathology and restrained eating.     

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.     

A family study of outpatients with borderline personality disorder and no history of mood disorder

While several studies have examined psychiatric disorders in the relatives of individuals with borderline personality disorder, many of these studies have not employed a family study methodology and suffer from other methodological shortcomings. Thus, the conclusions from family data addressing the validity of borderline personality disorder, its relation to other conditions, and its distinction from mood disorders, continue to be debated. The present investigation employed a family study design with direct interviews with relatives, structured diagnostic interviews with both probands and relatives, and blind assessment of relatives. Rates of psychiatric disorders were examined in 563 relatives of outpatients with mood disorders (n = 119), 54 relatives of outpatients with borderline personality disorder and no history of mood disorder (n = 11), and 229 relatives of never psychiatrically ill controls (n = 45). Results indicate increased rates of mood disorders and personality disorders in the relatives of borderline probands compared with never psychiatrically ill controls. Familial aggregation of psychiatric disorders was generally similar for borderline personality and the mood disorder comparison group. The results suggest there may be common etiological factors between borderline personality disorder and mood disorders.     

Development and first results of the Borderline Personality Inventory: a self-report instrument for assessing borderline personality organization.

This article reports the development of a short 53-item true-false self-report instrument, the Borderline Personality Inventory (BPI). The BPI is based on Kernberg's (1984) concept of borderline personality organization. However, the diagnostic criteria are compatible with both the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) and Gunderson's (Gunderson & Kolb, 1978) concept of borderline personality disorder (BPD). The BPI contains scales for assessing identity diffusion, primitive defense mechanisms, and reality testing. Another scale refers to the fear of closeness. The construction of the scales is based on the results of a factor analysis. As a result of several studies, a cutoff score is proposed to make the diagnosis of a BPD. Thus, the BPI combines dimensional and categorical models of BPD. The BPI was tested in several studies. According to the results, internal consistency and retest reliability are satisfactory (Cronbach's alpha = .68-.91, rtt = .73-.89). Results for sensitivity are .85 to .89, and results for specificity .78 to .89. The BPI identifies borderline patients in high agreement with Kernberg's criteria of borderline personality organization, Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev.; American Psychiatric Association, 1987) criteria of BPD and Gunderson's criteria of BPD. The BPI is recommended as a screening instrument for borderline personality organization and BPD and for dimensional research of borderline features in Axis I and Axis II disorders.     

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.     

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

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

Childhood abuse in Chinese patients with borderline personality disorder

This study examined (1) the relative prevalence of childhood abuse and other pathological childhood experiences in China reported by outpatients with borderline personality disorder (BPD), with other personality disorders, and without personality disorders; and, (2) whether the primary predictors of BPD in North America are associated with the development of BPD in China. The childhood experiences of 203 outpatients with BPD, 109 outpatients with other personality disorders, and 70 outpatients without Axis II diagnoses were assessed with the Chinese version of the Childhood Experience of Care and Abuse Questionnaire (CECA.Q). Patients with BPD reported significantly more physical, emotional, and sexual abuse than either comparison group. Four types of childhood experiences were significant predictors of BPD: maternal neglect, paternal antipathy, sexual abuse, and maternal physical abuse. The findings suggest that maternal physical abuse is as strong a predictor of BPD in China as sexual abuse, a finding not replicated in North America.     

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.     

The nature of borderline personality disorder: multiple dimensions, multiple symptoms, but one category

Borderline personality disorder (BPD) is a multidimensional syndrome that is not rooted in a single diathesis. Each of its features (affective instability, impulsivity, unstable relationships, and cognitive defects) reflects different diatheses. BPD differs from other Axis II disorders in its high level of symptoms, but is not a variant of an Axis I disorder and is difficult to describe through dimensional traits. This review suggests that BPD needs to be diagnosed with a narrower set of criteria that cover all of its domains. In the long run, the disorder will need to be redefined on the basis of its etiology and pathogenesis.     

Expressed emotion attitudes and individual psychopathology among the relatives of bipolar patients

This study investigated the relationships between expressed emotion (EE) and individual psychopathology among 82 biological and non-biological relatives of 66 patients with bipolar I disorder. Relatives' psychopathology was assessed via the Structured Clinical Interview for DSM-III-R, Patient Version (SCID-P) and the General Behavior Inventory (GBI), a self-report measure of lifetime subsyndromal mood disturbances. We hypothesized that relatives who held high-EE critical, hostile, and/or overinvolved attitudes toward their bipolar family member, as measured via the Camberwell Family Interview, would be more likely to have DSM-III-R Axis I diagnoses on the SCID, as well as more mood and temperamental disturbances on the GBI, than those who held low-EE attitudes. The findings did not support a significant relationship between overall EE status and psychopathology in family members. However, relatives without significant Axis I pathology scored significantly higher than those with Axis I pathology on one measure of EE, emotional overinvolvement. The findings are discussed with reference to explanations for the genesis of high-EE attitudes.