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PubMed2003

Borderline personality disorder and the search for meaning: an attachment perspective.

OBJECTIVE: To explore the links between the attachment theory-derived concept of disorganized attachment, and the psychiatric diagnosis of borderline personality disorder (BPD). METHOD: Literature search for characteristics of disorganized attachment. Clinical case material from psychotherapeutic work with patients suffering from BPD. RESULTS: Disorganized attachment can be understood in terms of an approach-avoidance dilemma for infants for whom stressed or traumatized/traumatizing caregivers are simultaneously a source of threat and a secure base. Interpersonal relationships in BPD including those with caregivers is similarly seen in terms of an approach-avoidance dilemma, which manifests itself in disturbed transference/countertransference interactions between therapists and BPD sufferers. Borderline personality disorder sufferers lack meaning in their lives because they are unable to play 'language games' with their potential intimates, resorting to actions rather than words to express feelings. CONCLUSIONS: Possible ways of handling these phenomena are suggested, based on Main's (1995) notion of 'meta-cognitive monitoring', in the hope of re-instating meaning and more stable self-structures, in these patients' lives.

Borderline Personality Disorder↗
PubMedDate not supplied

Borderline personality disorder and the chronic headache patient: review and management recommendations.

BACKGROUND: Physicians and psychologists who treat headache not infrequently encounter patients with borderline personality disorder (BPD). BPD patients frequently suffer from headache, and often pose special problems in treatment. Few guidelines exist for the management of the BPD headache patient. OBJECTIVES: To provide an overview of current concepts on BPD, including comorbidity, psychopathophysiology, and treatment. To provide an explicit framework for managing borderline behavior in patients with chronic headache. METHODS: A literature review combined with clinical observations from the tertiary treatment of intractable headache in outpatient and inpatient settings. RESULTS: BPD is found in almost 2% of the general population, with increased prevalence in patients with comorbid psychopathology and substance abuse. Severe headaches and migraine appear to be more prevalent in patients with BPD than the general population. A reported history of abuse is common, but must be interpreted with caution. Recent research has found reduced hippocampal volume in women patients with BPD; hypometabolism in the premotor, prefrontal, and anterior cingulate cortex, as well as the thalamic, caudate, and lenticular nuclei; and serotonergic dysfunction. Opioid medications may have an adverse influence on certain clinical features of BPD. Some patients show at least short-term improvement in dissociative behavior when given opioid antagonists. Treatment should combine appropriate pharmacotherapy with ongoing psychotherapy. Early identification of BPD is likely to improve the course of treatment. Treatment often requires explicit contracts, consistent limit-setting, confrontation, and communication between different treating professionals to avoid "splitting." The recognition and management of the doctor's own countertransference is important to successful management. Noncompliant patients may need to be terminated from treatment. CONCLUSIONS: Specific management guidelines and the use of explicit treatment contracts can help sustain patients in treatment, reduce the risk of medication abuse, and minimize distress in the treating professional. Headaches and other symptoms in patients with BPD can be successfully managed over the course of a long-term relationship with clearly defined limits.

Borderline Personality Disorder↗
PubMedDate not supplied

A 27-year follow-up of patients with borderline personality disorder.

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.

Borderline Personality Disorder↗
PubMedDate not supplied

The impact of borderline personality disorder on post-traumatic stress in the community: a study of health status, health utilization, and functioning.

This study examines impairment and health status and resource utilization among individuals with and without borderline personality disorder (BPD), all of whom had post-traumatic stress symptoms (PTSS). Using data from the community-based Piedmont Health Survey, 150 adult respondents who had experienced clinically significant PTSS during their life were identified. The Diagnostic Interview Schedule (DIS) Borderline Index was used to distinguish a subset of respondents who met criteria for BPD. Compared with adults with PTSS (n = 135), individuals with PTSS and BPD (PTSS-BPD) (n = 15) exhibited impaired health status and greater utilization of mental health services and psychotropic medications, as well as more functional impairment based on social, occupational, and early adverse life-event measures. Individuals with comorbid PTSS and BPD demonstrate greater overall impairment and usage of health care resources.

Adult↗
PubMedDate not supplied

Predictors of outcome in a 27-year follow-up of patients with borderline personality disorder.

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 Global Assessment of Functioning (GAF), the Symptom Check List-90 (SCL-90), and the Social Adjustment Scale (SAS-SR). Subjects were also administered two self-report measures of childhood experience: the Parental Bonding Index (PBI) and the Developmental Experiences Questionnaire (DEQ). DIB-R scores and GAF scores at 15 years were significant predictors of all these measures of long-term outcome. In contrast, reports of parenting quality and of childhood abuse or trauma had no relationship to outcome.

Borderline Personality Disorder↗
PubMedDate not supplied

STEPPS: a cognitive-behavioral systems-based group treatment for outpatients with borderline personality disorder--a preliminary report.

We describe a new cognitive-behavioral systems-based group treatment for persons with borderline personality disorder (BPD). The program is called STEPPS, an acronym for Systems Training for Emotional Predictability and Problem Solving. Briefly, the program combines cognitive-behavioral techniques and skills training with a systems component. The latter involves patients with BPD and persons in their system (e.g., family members, significant others, health care professionals). The program involves 20 two-hour weekly group meetings with two facilitators, is manual-based, and has specific goals to accomplish each week. Here, we review the background and development of the program, and present preliminary efficacy data from a subset of patients which suggest that patients experience improvement in BPD and mood-related symptoms. Survey results suggest moderate to high levels of satisfaction for the treatment from patients and therapists. A new scale, the Borderline Evaluation of Severity Over Time (BEST), developed to measure severity and change in persons with BPD, is described. We propose to conduct additional research to further validate the efficacy of STEPPS.

Adolescent↗
PubMedDate not supplied

Borderline personality disorder in major depression: symptomatology, temperament, character, differential drug response, and 6-month outcome.

Among 183 depressed patients participating in a randomized long-term treatment trial of fluoxetine and nortriptyline, 30 patients had borderline personality disorder (BPD), 53 had other personality disorders (OPD), and 100 had no personality disorders (NPD). The borderline depressed patients had earlier age of onset of their depressions, more chronic depressions, more alcohol and cannabis comorbidity, and were more likely to have histories of suicide attempts and of self-mutilation. On self-report, patients with BPD and OPD reported more phobic symptoms, greater interpersonal sensitivity, and more paranoid ideation. Uniquely, BPD patients were more angry than OPD patients. BPD patients had high novelty seeking, high harm avoidance, low self-directedness, and low cooperativeness. Depressed patients with BPD did poorly in the short term if treated with nortriptyline rather than fluoxetine. After 6 months, those with BPD had a favorable outcome in regard to depressive symptoms, social adjustment, and even improvement in the character measure of self-directedness. Those with the poorest outcome were those with OPD.

Adult↗
PubMed2001

[Examination of body concept of female patients with borderline personality disorder].

The operationalized diagnosis of borderline personality disorder (BPD) by DSM-IV and ICD-10 (research criteria) is meanwhile considered as valid and reliable. A disturbed or inappropriate body image within the group of borderline patients is not assessed by these instruments. Using the "Frankfurter Körperkonzeptskalen" [6], we compared the body concept of 47 female patients with BPD with a group of patients with the diagnosis of Bulimia nervosa and with a representative sample of healthy subjects. We found highly significant differences between patients with BPD and the clinical controls as well as to the norm group. Neither dissociative symptoms nor sexual child abuse correlate with the extent of the negative body concept. Correlations between self-concept (Giessen-Test) and body concept as well as clinical implications of these findings are discussed.

Adult↗
PubMed2001

[Symptom-focussed drug therapy in borderline personality disorder].

Borderline Personality Disorder (BPD) is a common and serious psychiatric illness. Psychopathological symptoms often are heterogenous and difficult to influence. Psychotherapy stands in the core of treatment efforts. However, during the treatment of these patients often situations occur that make the use of drug treatment necessary. Symptoms such as depression, impulsivity, or dissociation can be difficult to deal with in this population. There appears to be no treatment of choice for the disorder as a whole. Reviews so far have organized the literature by groups of pharmacological agents. In this review we give an overview over psychopathological symptoms in BPD, i.e. depression, affective dysregulation, aggression, impulsivity, dissociation, self-injuries, suicidality, psychotic symptoms, anxiety, obsessions and compulsions, and sleep disturbance. Effectivity of different drugs in influencing these symptoms is presented and significances of findings are used to assess the relevance of these findings. We conclude that certain symptoms such as depression or impulsivity can be successfully treated. Serotonin reuptake inhibitors play a decisive role in pharmacological treatment of Borderline Personality Disorder. Finally, recommendations for effective drug treatment of BPD symptoms are presented. Comorbid depression should be treated with Selective Serotonin Reuptake Inhibitors. These substances could also be shown to be effective in the treatment of impulsive and aggressive behavior. Intermittent psychotic symptoms are a target for atypical neuroleptics. Benzodiazepines are no longer viewed to be useful in the treatment of BPD.

Borderline Personality Disorder↗
PubMed2003

[Differential diagnosis of psychotic symptoms in adolescents and young adults with borderline personality disorder].

OBJECTIVE: This paper reviews findings and problems of differential diagnosis between Borderline personality disorders and schizophrenic illness in adolescents and young adults with psychotic symptoms. METHOD: Therefore relevant especially psychodynamically oriented publications were analysed and related to clinical experiences. RESULTS: Differential diagnostic classification of psychotic symptoms in this age group is difficult, especially when disorder criteria are not yet completely met. Differential diagnostic hints which can indicate severe adjustment problems, Borderline personality disorder and schizophrenia as well as specific diagnostic difficulties are presented in this paper. CONCLUSIONS: Well-reasoned differential diagnosis reveals significant findings for treatment options.

Adjustment Disorders↗
PubMed2004

[Borderline personality disorder associated with psychotic symptoms and parietal lobe abnormalities].

OBJECTIVE: We explore a case of a forensic patient with severe personality disorder, borderline type, and additional psychotic symptoms. Furthermore, she showed parietal lobe abnormalities. METHOD: We describe a case report and the relevant theoretical deliberations. CONCLUSIONS: Attempts to categorize patients with severe borderline personality disorder and psychotic symptoms have been made since the beginning of the 20th century. We show that in our patient neuroimaging such as SPECT scan can prove parietal lobe abnormalities. We describe possible links between these findings and her symptoms.

Adult↗
PubMedDate not supplied

[In-patient treatment concept for acute crises of borderline patients on the basis of dialectical-behavioral therapy].

Whereas the Dialectical-Behavioral Therapy (DBT) by Marsha Linehan for chronic suicidal female patients with borderline personality disorder has also been successfully implemented for in-patient treatment, the management of recurrent crisis has continued to be a significant challenge especially for hospitals taking part in the mandatory health coverage. Therefore, we have established an acute, short-term crisis treatment concept for both genders on a locked unit which takes the different circumstances of acute crisis into account. It ought to be used under the conditions of acute psychiatry and at the same time meet psychotherapeutic demands of borderline treatment. The treatment basis is DBT. The treatment focus is to improve stress-tolerance, especially by skills-training, regarding the individual situation and problems at time of admittance. The in-patient treatment should not take more than three weeks. The short-time aim is a fast reintegration in ambulant treatment or motivation for a specific therapy as DBT, middle- and long-time aims are the improvement of the ability to cope with crises and to demand less in-patient care.

Behavior Therapy↗
PubMed1997

[New approaches for understanding borderline personality disorder].

The concept of Borderline Personality Disorders was developed from North-American psychiatric and psychoanalytic thought. During recent years different contributions on this disorder emerged from several psychological paradigms. Four current trains of research are reviewed: Approaches based upon the five-factor-model of personality, Linehan's behavioristic approach, interpersonal concepts as shown by Benjamin and a self-developed subject-centered approach focussing on the patients' subjective theories of illness. These models converge into a concept which interprets Borderline Personality Disorders as disturbances of personal identity. The patients fail when attempting to overcome the tension between being a person and being a subject in their interpretation of the world and themselves. At the end of the article consequences for therapy are highlighted.

Borderline Personality Disorder↗
PubMed1993

Borderline disorder and post-traumatic stress disorder: an equivalence?

This paper draws attention to various similarities between Borderline Personality Disorder and Post-traumatic Stress Disorder. It is argued that the former may be considered to be an equivalent of the latter, with the difference that the trauma has either undergone repression or, having been suffered before the establishment of speech, has not been registered in verbal form. The criteria for Borderline Personality Disorder are presented in terms of symptoms of failed attachment consistent with early trauma, and various research papers linking these concepts are considered. Other research in infant attachment suggests intergenerational links between disorganised attachment patterns in infancy and parents with unresolved problems with their own parents. Research concerning the biochemical underpinning of emotional responses is quoted to link these conditions more securely, and may offer a conceptual framework in which to understand the need of these patients for a therapeutic milieu in which early developmental needs may be understood.

Arousal↗
PubMed1981

A short-term hospital program preparing borderline and schizophrenic patients for intensive psychotherapy.

This paper explores the role of a short-term hospitalization program in preparing certain borderline and schizophrenic patients for intensive psychotherapy on an outpatient basis. I will begin with a description of the inpatient unit and next discuss some relevant theoretical issues regarding borderline and schizophrenic psychopathology. I will then describe how these issues are dealt with in the evaluation procedure, in individual psychotherapy, and in the milieu therapy provided by our program.

Adolescent↗
PubMed1984

Supportive containment in the hospital care of treatment-resistant borderline adolescents.

Psychotherapeutic treatment of borderline patients is characterized by threats to maintenance of the therapeutic alliance during periods of regression. Hospitalization provides ego support and limits to help sustain the alliance, but for some patients traditional hospital approaches are not adequate. This paper describes a specialized treatment approach for managing treatment-resistant borderline adolescents in a hospital setting. The approach provides supportive containment through a restricted environment and enforcement of patient dependency on treatment staff. Patients gradually gain freedoms as their self-regulation increases. Success rates with this approach are raised to a level comparable to that attained with less difficult patients.

Acting Out↗
PubMed1985

Historical perspectives on the borderline concept: a review and critique.

Considerable confusion and disagreement remains in the psychiatric literature over the meaning of the term borderline. Over the last ten years a veritable explosion of books and articles on the subject have espoused overlapping and at times contradictory ideas on entirely different levels of discourse: biological, genetic, pharmacological, objective-descriptive, ego psychology theory, object relations theory, separation-individuation theory, and so on. Together, they seem both bewildering and irreconcilable. Despite DSM III's efforts to impose conceptual clarity, the situation remains a semantic mess. "Borderline" still means different things to different people and still tends to be a wastebasket diagnosis. No definition has been entirely satisfactory. This article is a preliminary effort at synthesis and explication of how and why psychiatry has arrived at this state of affairs.

Borderline Personality Disorder↗
PubMed1989

Transference and the vicissitudes of medication use by borderline patients.

This paper discusses the psychodynamics of medication use by borderline patients who are involved in ongoing psychotherapy. Particular attention must be paid to the transference reactions that these patients have to the therapist and to the medication, and to countertransference responses as well. Shifts in the transference must be monitored, as rapidly fluctuating views of self and other may hamper borderline patients' abilities to use medication responsibly at certain points in treatment. Case examples are used to illustrate the complexities of the prescribing process in such situations. The implications for prescribing strategies are considered.

Borderline Personality Disorder↗