Abstracts for Personality Disorders

Given space limitations and varying reprint permission policies, not all of the influentual publications the editors considered reprinting in this issue could be included. This section contains abstracts from additional articles the editors deemed well worth reviewing.

Functional Impairment in Patients With Schizotypal, Borderline, Avoidant, or Obsessive-Compulsive Personality Disorder

Skodol AE, Gunderson JG, McGlashan TH, Dyck IR, Stout RL, Bender DS, Grilo CM, Shea MT, Zanarini MC, Morey LC, Sanislow CA, Oldham JM

American Journal of Psychiatry 2002; 159:276–283

Objective: The purpose of this study was to compare psychosocial functioning in patients with schizotypal, borderline, avoidant, or obsessive-compulsive personality disorder and patients with major depressive disorder and no personality disorder. Method: Patients (N=668) were recruited by the four clinical sites of the Collaborative Longitudinal Personality Disorders Study. The carefully diagnosed study groups were compared on an array of domains of psychosocial functioning, as measured by the Longitudinal Interval Follow-Up Evaluation–Baseline Version and the Social Adjustment Scale. Results: Patients with schizotypal personality disorder and borderline personality disorder were found to have significantly more impairment at work, in social relationships, and at leisure than patients with obsessive-compulsive personality disorder or major depressive disorder; patients with avoidant personality disorder were intermediate. These differences were found across assessment modalities and remained significant after covarying for demographic differences and comorbid axis I psychopathology. Conclusions: Personality disorders are a significant source of psychiatric morbidity, accounting for more impairment in functioning than major depressive disorder alone.

A Twin Study of Personality Disorders

Torgersen S, Lygren S, Oien PA, Skre I, Onstad S, Edvardsen J, Tambs K, Kringlen E

Comprehensive Psychiatry 2000; 41:416–425

No twin study has previously investigated the whole range of personality disorders (PDs) recorded by interviews. Based on twin and patient registries, 92 monozygotic (MZ) and 129 dizygotic (DZ) twin pairs were interviewed with the Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II). Observed prevalence rates from a normal population study of more than 2,000 individuals were used in combination with data from the present study to generate statistics assumed to be valid for a normal twin population, and these statistics were used for structural equation modeling. The best-fitting models had a heritability of .60 for PDs generally, .37 for the eccentric (A) cluster, .60 for the emotional (B) cluster, and .62 for the fearful (C) cluster. Among the specific PDs, the heritability appeared to be .79 for narcissistic, .78 for obsessive-compulsive, .69 for borderline, .67 for histrionic, .61 for schizotypal, .57 for dependent, .54 for self-defeating, .29 for schizoid, .28 for paranoid, and .28 for avoidant PDs. The best-fitting models never included shared-in-families environmental effects. However, a model with only shared familial and unique environmental effects could not be ruled out for dependent PD. Shared familial environmental effects may also influence the development of any PD and borderline PD. Passive-aggressive PD did not seem to be affected by genes or family environment at all. The low occurrence of antisocial PD in the twin sample precluded any model for this disorder. PDs seem to be more strongly influenced by genetic effects than almost any axis I disorder, and more than most broad personality dimensions. However, we observed a large variation in heritability among the different PDs, probably partly because of a moderate sample size and low prevalence of the specific disorders.

History of Childhood Attention Deficit/Hyperactivity Disorder Symptoms and Borderline Personality Disorder: A Controlled Study

Fossati A, Novella L, Donati D, Donini M, Maffei C

Comprehensive Psychiatry 2002; 43:369–377

To evaluate the association between history of childhood attention deficit/hyperactivity disorder (ADHD) symptoms and the diagnosis of borderline personality disorder (BPD) in adulthood, the Wender Utah Rating Scale (WURS) was administered to 42 consecutively admitted BPD subjects, 94 consecutively admitted controls with any cluster B personality disorder (PD) diagnosis other than BPD, 38 consecutively admitted controls with any cluster A or cluster C PD diagnosis but no cluster B PD diagnosis, and 69 consecutively admitted controls with no PD diagnosis. A fourth control group was composed by 201 nonclinical volunteers. According to Dunn-Bonferroni contrasts, BPD subjects showed a significantly higher mean WURS total score compared to all control groups (minimum t = 7.93, maximum t = 11.63, all Ps <.001). These contrasts remained significant even controlling for potential confounders such as antisocial personality disorder (ASPD) diagnosis, gender, inpatient status, and axis I diagnoses. The results of this study seem to support the hypothesis of an association between history of childhood ADHD symptoms and adult BPD diagnosis. [Copyright 2002, Elsevier Science (USA). All rights reserved.]

Attentional Mechanisms of Borderline Personality Disorder

Posner MI, Rothbart MK, Vizueta N, Levy KN, Evans DE, Thomas KM, Clarkin JF

Proceedings of the National Academy of Sciences of the United States of America 2002; 99:16366–16370

We consider whether disruption of a specific neural circuit related to self-regulation is an underlying biological deficit in borderline personality disorder (BPD). Because patients with BPD exhibit a poor ability to regulate negative affect, we hypothesized that brain mechanisms thought to be involved in such self-regulation would function abnormally even in situations that seem remote from the symptoms exhibited by these patients. To test this idea, we compared the efficiency of attentional networks in BPD patients with controls who were matched to the patients in having very low self-reported effortful control and very high negative emotionality and controls who were average in these two temperamental dimensions. We found that the patients exhibited significantly greater difficulty in their ability to resolve conflict among stimulus dimensions in a purely cognitive task than did average controls but displayed no deficit in overall reaction time, errors, or other attentional networks. The temperamentally matched group did not differ significantly from either group. A significant correlation was found between measures of the ability to control conflict in the reaction-time task and self-reported effortful control.

An Open Clinical Trial of Cognitive Therapy for Borderline Personality Disorder

Brown GK, Newman CF, Charlesworth SE, Crits-Christoph P, Beck AT

Journal of Personality Disorders 2004; 18:257–271

Although borderline personality disorder (BPD) is a major public health concern, psychotherapeutic trials have been limited. The present uncontrolled clinical trial examines whether cognitive therapy for BPD is associated with significant improvement on measures of psychopathology. A total of 32 patients with BPD, who also reported suicide ideation or who engaged in self-injury behavior, received weekly cognitive therapy sessions over a 1-year period as described by Layden et al. (1993). The results revealed significant and clinically important decreases on measures of suicide ideation, hopelessness, depression, number of borderline symptoms and dysfunctional beliefs at termination and 18-month assessment interviews. Implications for further research with this difficult-to-treat patient population are discussed.

Dialectical Behavior Therapy of Borderline Patients With and Without Substance Use Problems: Implementation and Long-Term Effects

van den Bosch LM, Verheul R, Schippers GM, van den Brink W

Addictive Behaviors 2002; 27:911–923

Objective: The aim of this article is to examine whether standard Dialectical Behavior Therapy (DBT) (1) can be successfully implemented in a mixed population of borderline patients with or without comorbid substance abuse (SA), (2) is equally efficacious in reducing borderline symptomatology among those with and those without comorbid SA, and (3) is efficacious in reducing the severity of the substance use problems. Method: The implementation of DBT is examined qualitatively. The impact of comorbid SA on its efficacy, as well as on its efficacy in terms of reducing SA, is investigated in a randomized clinical trial comparing DBT with treatment-as-usual (TAU) in 58 female borderline patients with (n = 31) and without (n = 27) SA. Results: Standard DBT can be applied in a group of borderline patients with and without comorbid SA. Major implementation problems did not occur. DBT resulted in greater reductions of severe borderline symptoms than TAU, and this effect was not modified by the presence of comorbid SA. Standard DBT, as it was delivered in our study, however, had no effect on SA problems. Conclusions: Standard DBT can be effectively applied with borderline patients with comorbid SA problems, as well as those without. Standard DBT, however, is not more efficacious than TAU in reducing substance use problems. We propose that, rather than developing separate treatment programs for dual diagnosis patients, DBT should be “multitargeted.” This means that therapists ought to be trained in addressing a range of severe manifestations of personality pathology in the impulse control spectrum, including suicidal and self-damaging behaviors, binge eating, and SA.

Two-Year Stability and Change of Schizotypal, Borderline, Avoidant, and Obsessive-Compulsive Personality Disorders

Grilo CM, Sanislow CA, Gunderson JG, Pagano ME, Yen S, Zanarini MC, Shea MT, Skodol AE, Stout RL, Morey LC, McGlashan TH

Journal of Consulting and Clinical Psychology 2004; 72:767–775

The authors examined the stability of schizotypal (STPD), borderline (BPD), avoidant (AVPD) and obsessive-compulsive (OCPD) personality disorders (PDs) over 2 years of prospective multiwave follow-up. Six hundred thirty-three participants recruited at 4 collaborating sites who met criteria for 1 or more of the 4 PDs or for major depressive disorder (MOD) without PD were assessed with semistructured interviews at baseline, 6, 12, and 24 months. Lifetable survival analyses revealed that the PD groups had slower time to remission than the MDD group. Categorically, PD remission rates range from 50% (AVPD) to 61% (STPD) for dropping below diagnostic threshold on a blind 24-month reassessment but range from 23% (STPD) to 38% (OCPD) for a more stringent definition of improvement. Dimensionally, these findings suggest that PDs may be characterized by maladaptive trait constellations that are stable in their structure (individual differences) but can change in severity or expression over time.

A 27-Year Follow-Up of Patients With Borderline Personality Disorder

Paris J, Zweig-Frank H

Comprehensive Psychiatry 2001; 42:482–487

Sixty-four patients with borderline personality disorder (BPD) were followed up for a mean of 27 years. Outcome was assessed using the Diagnostic Interview for Borderlines, Revised (DIB-R); the Schedule for DSM-III-R Diagnosis (SCID); Global Assessment of Functioning (GAF); the Symptom Check List-90 (SCL-90); and the Social Adjustment Scale (SAS-SR). Most patients showed significant improvement as compared to a previous 15-year follow-up, with only five currently meeting criteria for BPD. Mean GAF score was 63.3, mean SCL-90 raw score was 0.7, and mean SAS-SR score was 2.0. Fourteen subjects met SCID criteria for dysthymia, and this subgroup had a significantly poorer outcome on all measures. The total percentage of suicides from the original cohort has reached 10.3%, with 18.2% of all patients now deceased.

Amygdala Hyperreactivity in Borderline Personality Disorder: Implications for Emotional Dysregulation

Donegan NH, Sanislow CA, Blumberg HP, Fulbright RK, Lacadie C, Skudlarski P, Gore JC, Olson IR, McGlashan TH, Wexler BE

Biological Psychiatry 2003; 54:1284–1293

Background: Disturbed interpersonal relations and emotional dysregulation are fundamental aspects of borderline personality disorder (BPD). The amygdala plays important roles in modulating vigilance and generating negative emotional states and is often abnormally reactive in disorders of mood and emotion. The aim of this study was to assess amygdala reactivity in BPD patients relative to normal control subjects. We hypothesized that amygdala hyperreactivity contributes to hypervigilance, emotional dysregulation, and disturbed interpersonal relations in BPD. Methods: Using functional magnetic resonance imaging, we examined neural responses to 20-sec blocks of neutral, happy, sad, and fearful facial expression (or a fixation point) in 15 BPD and 15 normal control subjects. The DSM IV-diagnosed BPD patients and the normal control subjects were assessed by a clinical research team in a medical school psychiatry department. Results: Borderline patients showed significantly greater left amygdala activation to the facial expressions of emotion (vs. a fixation point) compared with normal control subjects. Post-scan debriefing revealed that some borderline patients had difficulty disambiguating neutral faces or found them threatening. Conclusions: Pictures of human emotional expressions elicit robust differences in amygdala activation levels in borderline patients, compared with normal control subjects, and can be used as probes to study the neuropathophysiologic basis of borderline personality disorder.

Hyperresponsiveness of Hypothalamic-Pituitary-Adrenal Axis to Combined Dexamethasone/Corticotropin-Releasing Hormone Challenge in Female Borderline Personality Disorder Subjects With a History of Sustained Childhood Abuse

Rinne T, de Kloet ER, Wouters L, Goekoop JG, DeRijk RH, van den Brink W

Biological Psychiatry 2002; 52:1102–1112

Background: High coincidence of childhood abuse, major depressive disorder (MDD), and posttraumatic stress disorder (PTSD) has been reported in patients with borderline personality disorder (BPD). Animals exposed to early trauma show increased stress-induced hypothalamic-pituitary-adrenal (HPA) axis activity due to an enhanced corticotropin-releasing hormone (CRH) drive and glucocorticoid feedback resistance. In humans, PTSD and MDD are associated with decreased and increased resistance to glucocorticoid feedback, respectively, which might reflect persistent changes in neuroendocrine sequelae following childhood abuse. Methods: We investigated the relationship between childhood abuse and HPA axis function using a combined dexamethasone/CRH (DEX/CRH) test in 39 BPD patients with (n = 24) and without (n = 15) sustained childhood abuse and comorbid PTSD (n = 12) or MDD (n = 11) and 11 healthy control subjects. Results: Chronically abused BPD patients had a significantly enhanced corticotropin (ACTH) and cortisol response to the DEX/CRH challenge compared with nonabused subjects. Comorbid PTSD significantly attenuated the ACTH response. Conclusions: Hyperresponsiveness of the HPA axis in chronically abused BPD subjects might be due to the enhanced central drive to pituitary ACTH release. Sustained childhood abuse rather than BPD, MDD, or PTSD pathology accounts for this effect. Possibly due to an enhanced efficacy of HPA suppression by dexamethasone, PTSD attenuates the ACTH response to DEX/CRH.

The Boundary Between Borderline Personality Disorder and Bipolar Disorder: Current Concepts and Challenges

Magill CA

Canadian Journal of Psychiatry 2004; 49:551–556

Objective: The boundary between borderline personality disorder (BPD) and bipolar disorder (BD) is a controversial subject. Clinically, it can be difficult to diagnose patients who present with both affective instability and impulsivity. This paper reviews concepts and challenges related to the overlap of these disorders. Methods: A Medline search was conducted, using the key words borderline personality disorder, bipolar disorder, affective disorder, and personality disorder. Reference lists from articles generated were also used. Publications from the last 20 years were considered. Results: Studies demonstrate a greater cooccurrence between these 2 disorders than between BPD and other Axis I disorders or between BD and other Axis II disorders. Some authors suggest that many patients diagnosed with BPD are better described as having BD, that the bipolar classification is too narrow, or that BPD should be considered a variant of affective disorders. Others present evidence supporting BPD as a valid construct. Hypotheses about the relation between the 2 disorders and suggestions for clinical practice are offered. Conclusions: There appears to be sufficient evidence to consider BPD to be a valid diagnosis. Both disorders apply to heterogeneous populations, and their characteristics require further clarification. In diagnostically challenging situations, careful consideration of a patient’s longitudinal history is essential. Future research will be important to ensure that our diagnostic classifications reflect clinically useful entities.