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PubMed2003

The management of affect storms in the psychoanalytic psychotherapy of borderline patients.

Affect storms are a frequent complication in the psychoanalytic approach to borderline patients. The descriptive, psychodynamic, and structural characteristics of these storms are explored, and the verbal, nonverbal, and countertransference manifestations that permit the formulation of interpretations under such conditions are described, as are the interventions required to maintain the treatment frame as a precondition for an analytic approach. The principal theoretical formulations regarding the affect pathology of borderline patients are reviewed and related to a proposed interpretive approach. An apparently opposite development, the utter absence of emotional developments in the sessions, is examined, and its defensive function of avoiding affect storms is explored. Clinical case material illustrates the proposed approach to these storms, and clinical evidence is given to support the approach, which centers on systematic analysis of the primitive internalized object relations of these patients in the transference, the use of countertransference analysis without countertransference communication to the patient, and the repeated restoration of technical neutrality in the service of protecting the treatment frame.

Acute Disease↗

PubMed1988

Fantasy or structural defect? The borderline dilemma as viewed from analysis of an experience of nonhumanness.

The experience of nonhumanness, a crucial aspect of the phenomenal self of borderline states, is studied in two cases to test assumptions concerning the application of the classic ego-psychological or object-relations and self-psychological models. Are these experiences to be seen as fantasy and treated as manifest content, with dynamically active unconscious conflict and meaning, requiring interpretation, or as a developmental arrest in which structural disturbances are ameliorated through clarifying and empathic interventions? The first case is of a patient with a neurotic depression and hysterical and obsessional character traits, treated in a classic psychoanalysis. Even though dyadic oral and anal fantasies were strongly in evidence, the ego was well integrated. The second case is of a severe borderline patient who showed depressive panic and agoraphobia. Her major ego disturbances, poorly integrated and differentiated self- and object representations, and primitive defenses prevented effective psychoanalytically oriented treatment. Interventions were used to consolidate self-representations, internalize tension-regulating structures, promote adaptive ego functions and reality testing. These clarifications were necessary to move the patient to where she could tolerate facing unconscious dynamic conflicts. Only at that point could repression be lifted, memory emerge, and interpretation be utilized.

Adult↗

PubMed2005

Lamotrigine treatment of aggression in female borderline-patients: a randomized, double-blind, placebo-controlled study.

Anger and aggression are typical in borderline patients. The goal of this study was to compare the efficacy of lamotrigine versus placebo in the treatment of aggression in women meeting the criteria for borderline personality disorder (BPD). We conducted a randomized, double-blind, placebo-controlled study of lamotrigine in 24 female subjects meeting Structured Clinical Interview for DSM-IV (SCID) criteria for BPD. The subjects were randomly assigned in a 2: 1 manner ratio to lamotrigine (n = 18) or placebo (n = 9). Treatment duration was 8 weeks. Primary outcome measures were self-reported changes on the anger scales of the Trait Anger Expression Inventory (STAXI). In comparison with the placebo group, and according to the intention-to-treat principle, highly significant (p < 0.01) changes on four STAXI scales (State-Anger, Trait-Anger, Anger-Out, Anger-Control) were observed in those subjects treated with lamotrigine after 8 weeks. The only exception (p < 0.05) was found on the Anger-In scale, where a difference of only 8.5% (p < 0.2) was found. All the patients tolerated lamotrigine relatively well. Lamotrigine appears to be a safe and effective agent in the treatment of anger in women with criteria-defined BPD as defined by SCID criteria. It did not produce any clinically significant effect on body weight.

Adult↗

PubMed2001

Frequency of borderline personality disorder in a sample of French high school students.

OBJECTIVE: To estimate the frequency of borderline personality disorder (BPD) in French high school students. METHOD: A random sample of high school students (n = 1363) ranging in age from 13 to 20 years agreed to complete a questionnaire, the Screening Test for Comorbid Personality Disorders (STCPD); 107 of them volunteered to be interviewed. We assessed this group using the Revised Diagnostic Interview for Borderlines (DIB-R). We conducted a regression analysis to determine a cut-off for BPD diagnosis with the STCPD. RESULTS: We estimated the overall frequency of BPD to be 10% for boys and 18% for girls. After a peak of frequency at age 14 years for both sexes, the frequency increased significantly again in late adolescence. CONCLUSION: This study found a high frequency of BPD in French adolescents, which adds to questions regarding the validity of diagnosing this disorder in adolescents.

Adolescent↗

PubMed2004

The boundary between borderline personality disorder and bipolar disorder: current concepts and challenges.

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.

Bipolar Disorder↗

PubMed2006

The neuropsychological correlates of borderline personality disorder and suicidal behaviour.

OBJECTIVE: In subjects with borderline personality disorder (BPD), compared with subjects who attempted suicide, to review neuropsychological (NP) function that may predispose to suicidal behaviour along a continuum of high and low lethality. METHOD: We undertook electronic searches of MEDLINE, PsycINFO, EMBASE, Biosos Reviews, and Cinhal. The searches were restricted to English-language publications from 1985 onward. The search terms borderline personality disorder, suicide, suicide attempt, self-harm behaviour, neuropsychological, executive function (EF), neurocognitive, and neuropsychological function produced 29 neuropsychology studies involving BPD and 7 neuropsychology studies of suicide attempters, regardless of psychiatric diagnosis. RESULTS: Of the BPD studies, 83% found NP impairment in one or more cognitive domains, irrespective of depression, involving specific or generalized deficits linked to the dorsolateral prefrontal and orbitofrontal regions. The functions most frequently reported (in 71% to 86% of BPD studies) are response-inhibitory processes affecting executive function performance that requires speeded attention and visuomotor skills. Decision making and visual memory impairment are also most frequently affected; 60% to 67% of BPD studies report attentional impairment, verbal memory impairment, and visuospatial organizational impairment. Least affected processes in BPD appear to involve spatial working memory, planning, and possibly, IQ. The similarities in NP deficits found in BPD and suicide-attempt studies involve decision making and Trails performances. BPD studies, however, reflect more frequent impairment on the Stroop Test and Wisconsin Card Sort Test performance than the suicide-attempt studies, whereas verbal fluency appears to be more frequently impaired in those attempting suicide. CONCLUSIONS: Impaired EF and disinhibitory processes, as indicated by verbal fluency, Trails, and Stroop performance, primarily associated with dorsolateral prefrontal cortical regions may represent a dominant executive pathway to suicide attempt. A primary motivational inhibitory pathway involving conflictual, affective, and reflexive decision-making processes associated with orbitofrontal brain regions, in combination with significant cognitive rigidity, may influence the repetitive expression of self-harm or low-lethality suicidal behaviour. The hypothesis of a specific trait-like cognitive vulnerability for suicidal behaviour involving dysregulatory, disinhibiting pathways awaits confirmation.

Attention↗

PubMed1982

The existence of the borderline diagnosis: studies on diagnostic validity.

The author discusses the validity of the borderline concept in terms of the recent empirical research. Five phases of exploration are reviewed; namely, clinical descriptions, laboratory studies, delineation from other disorders, follow-up studies, and family studies. These data are related to the current status of the diagnosis for clinical practice and to areas warranting further research. The conclusions reached show initial support for the validity of the borderline diagnosis. Descriptively, the literature tends to characterize these patients as having impulsivity, heightened affect, mild psychotic reactions and disturbed close relationships. Speculation about possible etiologies is felt to be premature and the identification of meaningful subgroups of patients within this syndrome is not yet possible. Further research using the objective scales in well-defined samples is felt to be required, as are family and prospective follow-up studies.

Borderline Personality Disorder↗

PubMed1984

Analysis of emotional status during the hospital treatment of a borderline patient.

This single case study illustrates a methodology for identifying recurrent pathological emotional states in a hospitalized, borderline patient. Parallel therapeutic inputs are delineated and examined in terms of patient-specific responses. The results indicate that ratings of nursing notes recorded across three periods of hospitalization can reliably isolate the patient's most salient and debilitating emotional states. State-specific therapeutic interventions are extracted and their effectiveness noted. The analyses illustrate clinical phenomena which are congruent with what is known about borderline symptomatology. In addition, the study locates therapeutic errors which often occur when working with difficult patients.

Adult↗

PubMed1988

Characteristics of borderline personality disorder: a Canadian study.

This study presents data on a Canadian sample of inpatients with the diagnosis of Borderline Personality Disorder (BPD). Inpatients with BPD were compared to inpatients with borderline traits. The results indicate that the BPD inpatients have a chronic severe disorder, which onsets in adolescence, and are likely to have suffered early deprivation or abuse.

Adult↗

PubMed1988

Time-limited, group psychotherapy for borderline patients.

Preparation for treatment, group process and time boundaries are presented as components of a treatment model designed to respond to specific problems inherent in the nature of borderline personality disorder. A pilot study of the proposed treatment model is underway and one case illustration from this study is described to illustrate the adaptation to this treatment of a borderline patient with an extensive prior history of individual treatment.

Adaptation, Psychological↗

PubMed1989

Predictors of suicide in borderline personality disorder.

One hundred patients with borderline personality disorder who were followed for a mean of 15 years were compared with 14 borderline patients who committed suicide. The most significant predictors of completed suicide were previous attempts and higher education.

Borderline Personality Disorder↗

PubMed1990

A comparison of borderline and schizophrenic patients for childhood life events and parent-child relationships.

Fifteen patients with DSM-III diagnoses of borderline personality disorder and 14 schizophrenics were administered two questionnaires by an interviewer blind to the diagnoses. The questionnaires were the Childhood Life Events and Family Characteristics Questionnaire and the Parental Bonding Instrument. A scale to monitor denial was also included. Borderlines, when compared with schizophrenics, reported having significantly more childhood sexual and physical abuse, more early separation from their mothers, more paternal criminality, and also more paternal overprotection and less maternal care. When compared with normal population data, they received significantly less care and were significantly more overprotected by both parents.

Adolescent↗

PubMed1991

The dexamethasone suppression test in borderlines: is it useful?

The relationship between borderline personality disorders (BPD) and major depressive disorder (MDD) continues to be controversial. A reliable biological marker for depressed BPD patients would not only support the diagnosis but could also help in predicting treatment outcome. A large sample of psychiatric patients was screened and data on the Dexamethasone Suppression Test (DST) were obtained for 67 patients who met the criteria for BPD by scoring 7 or greater on the Diagnostic Interview for Borderlines. The DST was positive in 23.9% of the cases. Fifty cases of BPD also met the Research Diagnostic Criteria for MDD. The DST was positive in 26.0%. Of the 50 patients with MDD, 34 also met the criteria for endogenous depression. Only 17.6% of this subgroup had positive results on the DST. The low sensitivity and specificity of the DST for depression in BPD patients suggests that the DST is not a useful test in differentiating BPD patients with MDD from those without MDD. The possible reasons for the DST not being useful in this population are discussed. These findings raises further questions about the nature of the depression suffered by BPD patients.

Adolescent↗

PubMed1992

A critical review of the role of childhood sexual abuse in the etiology of borderline personality disorder.

A number of recent reports have indicated that there is a high incidence of sexual abuse during childhood among patients with borderline personality disorder. Although these findings are important, a simple association between abuse and the disorder is an oversimplification. Community studies of the long term effects of abuse indicate that the parameters of abuse are crucial to the patient's outcome. In addition, correlations have been found between sexual abuse during childhood and factors related to the family environment. A multifactorial model of the etiology of borderline personality disorder is proposed in which biological vulnerability, psychological factors and social influences are considered along with their interactions.

Adolescent↗

PubMed1992

Social risk factors for borderline personality disorder: a review and hypothesis.

A number of behaviours associated with borderline personality disorder (including attempted suicide, suicide, substance abuse, and antisocial behaviour) are on the increase among the young. The common factor in these disorders is impulsiveness. Evidence is reviewed suggesting that social disintegration reduces the threshold of impulsive behaviours. It is proposed that this is the mechanism through which social risk factors effect the prevalence and morbidity of borderline personality. A number of ways of testing this hypothesis are suggested.

Borderline Personality Disorder↗

PubMed1994

Severity as a diagnostic dimension of borderline personality disorder.

The purpose of this study was to identify diagnostic and severity subgroups within a cohort of patients with borderline personality disorder (BPD). Of 171 patients clinically diagnosed with BPD, 132 were Diagnostic Interview for Borderlines (DIB) positive. Through a process of random selection, 41 of the DIB positive subjects were also interviewed with the revised version of the DIB (DIBR) and approximately one half with two semi-structured research interviews, the Schedule for Affective Disorders (SADS) and the Personality Disorder Examination (PDE). All subjects completed four self-report measures of problematic behaviours, symptoms and social adaptation. The analyses included examination of: 1. the correspondence of the BPD diagnosis across the DIB, the DIBR and the PDE; 2. the association between DIBR scoring levels and scores on measures of symptoms and behavioural status; and 3. the co-occurrence of BPD with Axis I and other Axis II disorders. Correlations and analyses of variance between both the DIB and DIBR scoring levels and the scores on the four symptom and behavioural measures showed that the scoring levels (DIB 7 to 10; DIBR 8 to 10) could be used to distinguish three subgroups of BPD. The three groups differed in terms of concordance for BPD with the PDE and in terms of patterns of overlap with DSM-III-R, Axis I and other Axis II disorders. This study shows that BPD subgroups can be located on a continuum of symptomatic and behavioural severity and that each subgroup has a specific pattern of overlap with Axis I and other Axis II disorders.

Adolescent↗

PubMed1995

The five-factor model of personality in borderline and nonborderline personality disorders.

OBJECTIVE: The purpose of this study was to examine to what extent the phenomena associated with a diagnosis of borderline personality disorder (BPD) can be described by the five-factor model of personality. METHOD: The sample consisted of female patients with BPD (n = 29) and a control group with a mixture of nonborderline personality disorders (n = 30). All subjects were given the NEO-PI-R. RESULTS: Borderline patients differed from community norms on all five factors, and were particularly high on Neuroticism, and particularly low on Agreeableness. The scores on the five factors did not differ significantly between the 2 clinical groups. Two facets of the conscientiousness scale (competence and deliberation) were significantly lower in the BPD group. CONCLUSIONS: Dimensional profiles only partially account for the clinical symptomatology seen in formally diagnosed cases of BPD.

Adult↗

PubMed2004

Recognizing and treating uncommon behavioral and emotional disorders in children and adolescents who have been severely maltreated: borderline personality disorder.

This article explores the characteristics of borderline personality disorder, a disorder that may occur with relative frequency in adolescents who have been severely maltreated. Behaviors indicating the possibility of borderline personality disorder existing are reviewed, as are comorbid disorders. Suggestions for treatment for the adolescent and his or her family are explored.

Adolescent↗