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PubMed1991

A preliminary trial of fluoxetine in refractory borderline patients.

Borderline personality disorder is characterized by many of the symptoms associated with serotonin dysregulation, including affective lability, suicidal behaviors, and impulsive aggression. These provide an ideal clinical model for studying the treatment of these serious symptom presentations. The recent development of selective serotonin reuptake inhibitors such as fluoxetine makes it possible to study the role of serotonin in the etiology of affective and behavioral dyscontrol in borderline personality disorder. In this preliminary medication trial, 5 borderline personality disorder patients with severe symptoms resistant to phenelzine and neuroleptics were treated openly with fluoxetine 20 to 40 mg for 8 weeks, with weekly ratings of symptoms. The findings from this work suggested efficacy for fluoxetine in treating the depressive and impulsive symptoms of refractory patients with borderline personality disorder.

Adult↗
PubMed1990

Treatment of borderline patients: a pragmatic approach.

Outlined in the preceding sections are what one could call the ABCDs of treating borderline patients. A = analytically informed psychotherapy; B = behavior therapy; C = cognitive therapy; and D = drug therapy. Together they add up to "E": eclectic therapy. In this pragmatic approach, the therapist will assess at the outset (1) amenability to exploratory therapy, but also (2) the need for supportive measures, including education, rehabilitation, and expansion of outside interests, (3) indications for behavioral technics (socially alienating habits, handwashing compulsions, phobias), (4) indications for cognitive measures (conflicts or fears resolvable through rational explanation or logical weighing of alternatives), and (5) indications for pharmacotherapy. All these steps involve the careful weighing of biologic/constitutional, psychodynamic, and, where present, posttraumatic factors, as well as personality assets and habitual problem-solving style. This will help assure against overreliance on a technic that does not fit with the patient's personality and against unwise persistence in a technic that is uncongenial or threatening. Patients already in stable life situations who are seeking help because of life crises may respond well to a brief course of therapy. Borderlines in late adolescence or early adult life, if self-destructive and not yet able to form lasting relationships (or to live contentedly without them), usually require sustained treatment over several years, preferably with the same therapist. Appropriate selection of medications, where indicated, should reduce impulsivity, aggressivity, and psychoticism. This, in turn, will facilitate psychotherapeutic work on maladaptive interpersonal patterns, exaggerated "all-or-none" responses to relatively innocuous stimuli, overpersonalized responses to other people's remarks, and so on. Therapists trained in identical methods will evaluate the same patient in somewhat different ways owing to their differences in personality and perception. This may lead to different sets of priorities and suggests different tactics that are still within the realm of therapeutic efficacy. Those trained primarily in one of the "ABCDs" may have equal success, yet via a different route than the one taken by therapists of a different subspecialty. Borderline patients, perhaps two out of five, often drop out of treatment no matter who the therapist. Yet two out of three patients, if followed long enough, eventually have a good result. One therapist's failure will be his colleague's success, and vice versa. Therapists, to maximize the success of their own efforts, need to be sufficiently steeped in at least one theoretical model of psychopathology/psychotherapy so as not to feel "lost" when confronted by the often bewildering dynamics and symptoms of their borderline patients.(ABSTRACT TRUNCATED AT 400 WORDS)

Borderline Personality Disorder↗
PubMed1990

[Diagnosis and treatment of borderline disorders within the scope of inpatient psychiatric care].

Borderline-patients compose a group of severe problem-patients on psychiatric inpatient units. Among other topics this concerns the difficult differential diagnosis, attitudes of demandingness and entitlement, feelings of depressive despair, acting out and impulsive behavior. Using a process oriented diagnostical approach which includes the behavior of the patient on the unit and the analysis of the therapeutic interaction, the borderline disorder is differentiated from the psychoses on the one side and the neuroses on the other. The specific treatment problems of borderline-patients are dealt with under the headings of regression, splitting, projective identification and acting out. The counter-transference problems of treatment teams are taken under special consideration. The last part of the article deals with treatment goals and therapeutic strategies in the psychiatric inpatient treatment of borderline patients and discusses possible modalities of adjunctive treatment.

Borderline Personality Disorder↗
PubMed1990

Borderline personality disorder in primary care.

Management of borderline patients requires skills that are at the heart of successful continuity of care. These skills include alliance-building, educating patients about their symptoms, referral, encouraging communication and cooperation in the health care team, utilizing community resources to sustain one's own professional development, and foreseeing and preventing morbidity. As trying as it may be to have a borderline patient in a practice, and as slow as progress with the patient may be, successful management of such patients will add poise, confidence, and maturity to the exercise of these invaluable primary care skills. More clinical and empirical discussion of borderline personality disorder is needed in the family practice literature. Probably no other professional is more likely to see such patients. The informed, motivated family physician, with the help of a supportive multidisciplinary team, can make invaluable contributions to reducing morbidity in borderline patients and can help avoid misunderstanding, frustration, and exhaustion in the health care team of the patient with this challenging disorder.

Borderline Personality Disorder↗
PubMed1989

[The practical significance of the concept of borderline disorders].

There is not agreement on borderline disorders. The authors support the view that borderline disorders are related to other classified mental disorders, i.e. that they are their abortive forms. There is a continuous transition between abortive and non-abortive forms of those classified mental disorders which are the basis of non-specific manifestations of borderline mental disorders. The authors feel that is of practical importance to differente a small circle of abortive forms which resemble various non-psychotic disorders where an axial disposition is assumed but where, contrary to recognized abortive forms (e.g. pseudoneurotic schizophrenia or hysteriform depression), they cannot be identified at a psychopathological level. The diagnosis of a borderline disorder corresponding to this narrow basic circle of abortive forms makes it possible to avoid inadequately founded diagnoses of psychosis or an authoritative refusal of the diagnosis of psychosis, and it makes the doctor search for symptoms of latent axial disposition.

Borderline Personality Disorder↗
PubMed1987

The relationship of borderline personality disorder to the affective disorders.

The proposition that Borderline Personality Disorders (BPDs) are atypical forms of affective disorder is reviewed in the light of pharmacological, outcome and clinical studies. The case can be summarized briefly as follows: that the basic underlying cause of borderline symptomatology is an effective disorder; that mood disturbance, which is viewed as primarily biological, is more important than developmental experience and life events in maintaining borderline personality features; that therapies aimed at treating the mood disorder should therefore be expected to relieve the personality disorder. However, the pharmacological studies suggest that antidepressant medications have been largely ineffective in treating well defined BPD, except in the presence of coexisting depressive disorder. Indeed low dose antipsychotics have a demonstrated efficacy in the treatment of BPD, which does not strengthen the case for an affective etiology. Follow-up studies of BPDs suggest that dramatic characterological features seen at the time of index hospitalization tend to recede by the time patients are in their 30s, that major affective disorders fail to emerge over time, and that long-term marginal functioning derives from long-term maladaptive patterns across a variety of areas. Clinical studies suggest that 20-60 per cent of patients with BPD have a concomitant depressive disorder. Conversely the prevalence of personality disorders in depressions varies with depressive category, with considerably higher incidence of personality disturbance found in non-endogenous depression. The high rate of coexistence of these two disorders does not imply causality or primacy, in the sense that it is the affective disorder which brings out and causes the personality disorder. The review concludes that the assertion that BPD represents atypical affective disorder begs the possibility that it is precisely in having borderline features that they are atypical, and hence distinct.

Affective Disorders, Psychotic↗
PubMed1988

Psychotic character versus borderline.

The clinical syndrome designated by the diagnostic term borderline, exists. However, the diagnosis borderline as such gives no clue about the clinical or psychodynamic feature in this syndrome. Furthermore, the use of the concept borderline by its very vagueness and diffuseness deprives us of a means of understanding these conditions clinically and dynamically. It thereby makes it more difficult to treat these patients with appropriate understanding. I therefore believe it should be abandoned. The diagnosis psychotic character has previously been proposed by the author for this syndrome. It relates more appropriately to the clinical and psychodynamic features and is more consonant with an understanding of the syndrome. The diagnosis suggests, among other frames of reference, the underlying psychotic process which typifies these patients. It provides frames of reference which facilitate understanding these conditions psychodynamically and genetically. Out of this understanding a more meaningful therapeutic approach may evolve. We therefore feel that the term and concept borderline should be abandoned.

Adult↗
PubMed1985

A critical examination of empirical studies of the diagnosis of borderline disorders in adults.

The diagnosis of borderline disorders poses complex problems of a semantic and methodological nature. The various diagnostic criteria sets published are examined and compared. Gunderson's borderline personality disorder and the DSM-III schizotypal and borderline disorders are recommended, as used with the structured interviews developed for them. Problems concerning the relationship of borderline disorders to the major psychoses, the importance of brief psychotic experiences, diagnostic efficiency of items, and various cut-off levels of criteria are discussed in detail, and proposals for further research are pointed out.

Borderline Personality Disorder↗
PubMedDate not supplied

Analytically oriented psychotherapy in schizotypal and borderline patients: at the border of treatability.

Analytically oriented psychotherapy (AOP) has been considered the treatment of choice for borderline patients and a useful technique in the treatment of schizotypal patients. There are many exceptions, however, in addition to a number of borderline and schizotypal patients who are just barely amenable to this modality: they are at the border of treatability by AOP. Limitations relating to time, cost, and the availability of therapists trained in this discipline render it important to delineate the factors which conduce either to the success or failure of AOP. From the author's clinical impressions about borderline and schizotypal patients at the border of treatability by AOP, a number of such factors emerge. On the positive side: likeableness, autoplastic defenses, high motivation, psychological-mindedness, genuine concern, good moral sense, self-discipline, and low impulsivity. Negative factors include, beside the opposites to the aforementioned, vengefulness and parental abusiveness or exploitation. A scale for measuring the balance between these positive and negative factors is proposed. Its use may, it is hoped, improve forecast, during initial consultation, as to which borderline and schizotypal patients will respond favorably to AOP.

Adult↗
PubMed1985

Parental qualities as perceived by borderline personality disorders.

This study explores the contribution of parental qualities to the borderline personality disorder. The Parental Bonding Inventory is used to compare four parental qualities (caring mother, caring father, overprotective father, and overprotective mother) across three groups (borderline personality disorders, assorted psychiatric controls and normal controls). The major finding was that the borderline patients perceived their parents to be significantly less caring and more overprotective than both the psychiatric control or nonclinical control groups. This study was verified previous reports that patients diagnosed with an affective illness (in either the borderline group or psychiatric control group) reported no significant differences on the inventory. Pinpointing parental characteristics which antecede mental disorders may be an important first step in devising primary preventive interventions for adult disorders.

Adult↗
PubMed1984

Dexamethasone suppression test and Axis I diagnoses of inpatients with DSM-III borderline personality disorder.

To determine the relationship of Axis I diagnoses to the DSM-III diagnosis of borderline personality disorder, 100 consecutive admissions to an inpatient service were studied. Of the 27 patients labeled borderline, 14 were given an Axis I diagnosis of major depression (unipolar) compared with 8 of 73 nonborderlines; 73% (19 of 26) of all borderlines tested but only 46% (18 of 39) of nonborderlines had a positive DST (p less than .05). Few borderline patients received concomitant nonaffective diagnoses, and even fewer were given bipolar or schizoaffective diagnoses.

Adolescent↗
PubMed1983

Borderline personality disorder: symptomatology and MMPI characteristics.

Using the Schedule for Interviewing Borderlines and the MMPI, 20 subjects diagnosed as borderline and/or schizotypal personality disorder were examined to determine 1) whether having one diagnosis affected the likelihood of having the other, 2) the amount of diagnostic overlap between the two diagnoses, and 3) whether different MMPI profiles could be found. The results indicated some overlap but also some differentiation between the borderline and schizotypal disorders. The modest overlap in diagnostic criteria was consistent with other studies and justifies the continued separation of the two diagnoses. The MMPI may be used as an initial screen to identify persons who warrant further evaluation for a borderline personality disorder but would not be appropriate as a screen for a schizotypal personality disorder.

Adult↗
PubMedDate not supplied

Some comments on the treatment of the borderline personality.

A discussion of "Some Clinical Manifestations of Structural Defects in a Borderline Personality," by Alan Krohn, M. D. Because the borderline patient presents the gamut of symptomatology and therapeutic responses, diagnosis and treatment have been problems since the beginning of psychoanalysis. With her key conceptualization of the "as if" personality, Helene Deutsch, in the 1930s (1942), stimulated the clarification of both the diagnostic and therapeutic problems. The primitive ego defenses were delineated by Klein (1946), and Mahler's studies (1968) of symbiosis, separation, and individuation provided the developmental framework for the growing understanding of these conditions. Since then, many have contributed, none more than Kernberg (1975). He has proposed limiting the term borderline to a relatively specific, more or less stable personality with typical symptom constellations, defensive operations, pathology of internal object relations, and instinctual vicissitudes. These conditions dictate a modification of therapeutic technique practiced by many but formulated by Kernberg, Masterson (1972, 1976), Boyer (1977), and others. Essential to the implementation of this modified technique is the understanding of the defensive operations and the pathology of the internal object relations. Particular emphasis is given to two defensive operations, splitting and projective identification, and to aspects of the other concepts especially pertinent to the therapy of the borderline. The work of Kernberg has been drawn on extensively.

Borderline Personality Disorder↗
PubMed1995

Recognizing borderline personality disorder in the family practice setting.

The first step in the management of borderline personality disorder is making the correct diagnosis. A clinical example illustrates symptoms of a patient with borderline personality disorder in a family practice setting. Major characteristics of borderline personality disorder include severe mood instability, fear of abandonment, chronic boredom, self-injury, unstable interpersonal relationships, "splitting," identity instability and borderline rage. Early diagnosis may help prevent potential management problems and possible doctor-patient conflicts.

Borderline Personality Disorder↗
PubMed1994

Borderline disorders in children and adolescents: the concept, the diagnosis, and the controversies.

The concept of borderline disorders in children and adolescents remains controversial. After reviewing the development of the "borderline" diagnosis, the author discusses the concept of personality disorders in children and clinical features of borderline personality disorder. He also highlights current ideas on the etiology of the disorder, including psychodynamic, developmental, and biological theories, family factors such as the effects of early loss or separation from parents, and physical and sexual abuse. The author concludes by discussing the differences and similarities between posttraumatic stress disorder as a result of sexual abuse and borderline personality disorder in children and adolescents.

Adolescent↗
PubMed1993

Borderline disorder and attachment pathology.

In this paper, the authors investigate the theoretical and empirical association between dysfunctions of the attachment system and borderline personality disorder. Attachment theory focuses on the maintenance of a sense of safety and security through a close personal relationship with a particular person. Based on a biological behavioural system, functional attachment relationships in adulthood rely on experiences and expectations of security within the relationship. These issues are also important to the definition and dynamics of borderline personality disorder. The dimensions and patterns of reciprocal attachment were compared with other scales measuring components of psychopathology and interpersonal relationships. In a sample of 85 female outpatients, only four of the attachment scales--feared loss, secure base, compulsive care-seeking and angry withdrawal--identified patients with high scores on a measure of borderline disorder. Of these four scales, feared loss had the predominant effect. These empirical results support the hypothesized relationship between dysfunctions of the attachment system and borderline disorder.

Adult↗
PubMed1993

The assessment of ego development in borderline personality disorders.

The purpose of the study was to assess levels of ego functioning in a cohort of patients who met the criteria for borderline personality disorder. The Sentence Completion Test (SCT) and the Descriptions of Significant Others (DSO) test were used to measure dimensions of ego maturity. The borderline patients' responses on the SCT were compared with the responses of an outpatient sample of psychiatric patients and with general population norms established for the test. The scores on the SCT for a selected subgroup of five subjects were compared with their scores on the DSO. Contrary to expectation, the responses on the SCT by those with borderline personality disorder did not differ from those for the psychiatric outpatient sample or the general population norms. However the within-group comparisons between the SCT and the DSO for the subgroup of five subjects showed comparable trends between tests. Discussion of the results focuses on the interpretations of the borderline patients' responses to the two tests. Emphasis is placed on the need to distinguish subsets of ego functions, which can be assessed separately using a variety of measurement strategies.

Adolescent↗
PubMed1993

Psychiatric rehabilitation model for borderline personality disorder.

Borderline personality disorder is a prevalent and chronic disorder characterized by significant morbidity and mortality. Limited success with current treatment approaches suggests that new models of treatment are needed. Aspects of the psychiatric rehabilitation model are applied to borderline personality disorder. This model has implications for the diagnosis and management of borderline personality disorder. The diagnosis of borderline personality disorder will be refined by characterizing the disabilities and handicaps that are associated with the disorder. The psychiatric rehabilitation model suggests that services be developed which provide a validating environment, the opportunity to enhance skills and a mechanism to accept input from families.

Borderline Personality Disorder↗