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The authors detail their investigation into the positive relationship between borderline personality and multiple personality and present their finding that although borderline personality disorder is very prevalent in patients with multiple personality disorder, it is not universal and is a separate and distinct disorder.
A discussion of "Notes on the Potential Differentiation of Borderline Conditions," by W.W. Meissner, M.D. Through psychotherapy, borderline personalities can develop a mature level of emotional autonomy. Their fundamental psychopathology involves annihilation anxiety consequent on inadequacy and instability of holding-soothing introjects. Psychological corollaries of this deficit render them unable to effect the internalization of real caring relationships that is necessary for development of effective holding introjects. Ideally, psychotherapy proceeds in three phases. Phase I is devoted to amelioration of the pathological impediments to using relationships with the therapist and others as resources for a holding-soothing form of emotional security. The outcome is development of a relatively stable idealized self-object transference in terms of holding-soothing, along with formation of relatively stable idealized holding-soothing introjects. Phase II of treatment involves optimal disillusionment in relation to idealization of the therapist as holding-soother; this results in gradual acceptance of the realistic use of external objects along with modification of holding-soothing introjects to correspond more nearly with reality. Stable autonomy in the area of self-security is fully attained in Phase III, in which the relationship with the therapist provides the context for the patient's developing capacities by means of identification to care for, esteem, love, and trust himself or herself. Psychotherapy of narcissistic issues is also important, but special precautions must be observed.
Borderline personality disorder is a significantly disabling disturbance often arising in adolescents or young adults. In the absence of demonstrated effective treatments in this population, this open prospective study evaluated the effect of low dose (3 mg per day) flupenthixol in 13 rigorously diagnosed adolescents with borderline personality disorder. Therapeutic outcome over eight weeks of treatment assessed across measures of impulsivity, depression/dysphoria, general psychopathology and global functioning showed significant improvement in all spheres. These findings suggest that low dose flupenthixol may have a role to play in the short-term treatment of this population.
The author gives in this paper an overview of current psychodynamic psychotherapy of patients with Borderline personality organization. Parallel to his own concept different treatment strategies by Adler, Volkan and Searles within the psychoanalytic framework are discussed. Finally recent developments of his own group are described. Emphasis lies on structuring the psychodynamic psychotherapeutic process of Borderline patients according to the developmental level the patient presents in each session and to treat symptoms belonging to so-called earlier levels (e.g primitive aggression, psychotic or paranoid transferences) before working through of more advanced conflicts.
The comorbidity of personality discorders and eating discorders is an important topic of theoretical and empirical investigation in the field of eating disorders. There is disagreement both concerning the extent of such comorbidity and it's clinical implications for the development and conduct of treatments. After a critical review of the literature up to 12/1994, we report on the results of a standard screening for borderline personality disorder (BPD) with the Diagnostic Interview for Borderlines--Revised (DIB-R) administered by trained and reliable raters in a consecutive sample of 172 first attenders of a regional eating disorders clinic (anorexia, restrictive type [DSM-IV 307.1]: n = 31, anorexia, binge eating/purging type [DSM-IV 307.1]: n = 29, bulimia nervosa [DSM-IV 307.51]: n = 80, eating disorder NOS [DSM-IV 307.50]: n = 32). 8.8% of all eating disordered patients (n = 172) and 10.0% of patients fulfilling the criteria for either anorexia or bulimia (n = 140) met the criteria of a BPD (DIB-R score > or = 8). There were no significant differences between the anorectic and bulimic subgroups. BPD-patients did not differ from the non-BPD patients in the extent or type of their eating disorder. These results differ substantially from those reported in (mostly) smaller and more selected samples. Their nosological and clinical implications are discussed.
Patients with borderline personality disorder present a clinical challenge, largely because of their chronic suicidality. Long-term outcome research shows that about 10 per cent of borderline patients will eventually complete suicide, but that is difficult to predict which patients are at highest risk. There is no evidence at present that treatment prevents suicide. Clinical recommendations are made, suggesting that suicide prevention should not be the major priority of therapy of these patients.
A study was undertaken to evaluate the efficacy of multidrug therapy as per WHO recommendation in 50 fresh cases (46 males and 4 females) suffering from borderline tuberculoid leprosy. All were given multidrug therapy consisting of rifampicin 600 mg once a month and dapsone 100 mg daily for 6 months. At the end of 6 months all were evaluated clinically and histopathological examinations of the lesions were studied. The lesions were still active in 60% of patients clinically; 32% cases receiving multidrug therapy had shown marked improvement. Histologically lymphocytic infiltration in skin still persisted in all the slides examined and nerve infiltration was still present in 68% of cases at the end of 6 months after receiving multidrug therapy. The study shows that treatment with multidrug regimen for 6 months may not be sufficient to treat borderline tuberculoid leprosy cases.
This article focuses on the emotionality of the individual diagnosed as "borderline." There may be no clinical condition characterized by so wide a range of affective expression. The author points out that both Kernberg and Kohut view this cohort from the standpoint of drive theory, in which all emotion is traced to drive forces gone awry. Viewed from the perspective of affect theory, it becomes possible to explain this otherwise puzzling cluster of symptoms as the expression of and defenses against the painful emotion of shame. The very concept of a "borderline" illness may prove to be a construction made necessary by previous misunderstanding of shame psychology, and the symptoms themselves perhaps an artifact of a wider, societal misunderstanding of shame.
The interest in the psychopharmacological treatment of the borderline personality disorder (BPS) has been steadily increased in the last years. There isn't, however, any investigation, which has proved the existence of a specific "Anti-Borderline-Drug" yet. There are, however, identifiable drug-responsive syndromes. The description by Coccaro and Karoussi (1991) of a syndrome of affective instability (abnormalities in the brain's adrenergic and cholinergic systems, respond to carbamazepine and lithium), transient psychotic phenomena (abnormalities in the central dopaminergic systems, respond to low-dose neuroleptics) and impulsive, aggressive behaviour (abnormalities in the central serotonergic systems, respond to serotonergic agents) seems to be very promising in this regard.
The authors provide the data on the etiological role played by higher aliphatic amines of the fatty series in the development of borderline neuropsychic disorders. The dopamine system was shown to play the leading part in their genesis. Activation of that system goes in parallel with disorders in immune and neuromediator homeostasis. Leukopenia, lymphocytosis, inhibition of T system immunity, a rise of the B lymphocyte count, beta-lysine, expression, of acetylcholine, dopamine, noradrenaline, adrenaline, histamine, serotonin, GABA, opiate and benzodiazepine receptors by immunocompetent cells were revealed. It has been demonstrated that the changes in the count of rosette-forming cells immune to neuromediators reflect the disease development and can be used as objective criteria for the diagnosis and treatment policy for borderline neuropsychic disorders caused by higher aliphatic amines of the fatty series.
We studied the cytokine profiles and cellular compositions in the lesions of borderline lepromatous (BL) and borderline tuberculoid (BT) leprosy patients in order to ascertain the immunological distinctions between these two groups. Using a modified, reliable, noninvasive, suction-induced blister technique to sample lesions, we determined that CD4+ T cells predominated in BT lesions; whereas CD8+ T cells predominated in BL lesions. However, the numbers of CD8+ per mm2 surface area of the lesion did not differ significantly between the two patient groups. In BT lesions, the elevation in the number of CD4+ cells was paralleled by the levels of soluble interleukin-2 (IL-2) receptor and soluble CD4 in the lesions. The CD4+:CD8+ ratio was 16:1 in BT lesions and 0.36:1 in BL lesions, although this ratio in the peripheral blood was similar in both groups. In addition, cells expressing the CD8 molecule dominated in the TCR-gamma delta subpopulation. The cytokine profiles in the lesions were not as distinctly different between BL and BT patients as were the cellular compositions. However, trends observed included elevated concentrations of IL-6 in BL lesions and elevated TNF-alpha levels in BT lesions.
A patient with cutaneous sarcoidosis is presented. The patient was diagnosed initially as borderline tuberculoid leprosy downgrading to borderline lepromatous leprosy and received a full 2 years of World Health Organization multibacillary drug treatment (MDT). Bilateral hilar lymphadenopathy on chest X-ray and cutaneous anergy manifested by negative Mantoux, candidin and trichophytin skin tests suggested the diagnosis of sarcoidosis. Histopathology confirmed this diagnosis. The subcutaneous nodule seen in this patient is a rare type of cutaneous sarcoidosis.
Studies of the long term outcome of borderline personality disorder have shown that, although most patients improve with time, there is a high rate of suicide associated with this disorder. In the absence of clinical trials which could demonstrate the long term effects of treatment, the management of the borderline patient must take into account the chronicity of the disorder. A wide range of treatment options are reviewed, all of which could be included in a model emphasizing continuous availability and intermittent active intervention.
The major focus of the non pharmacological treatment of borderline personality disorders is rapidly shifting from long term, psychodynamically oriented therapies to highly structured and explicitly operationalized cognitive-behavioural treatment models. The goal of these models is changing targeted maladaptive coping behaviour. This paper examines possible limiting factors to Linehan's model of dialectical behaviour therapy, based on the implications of self-definition-seeking behaviour which is commonly observed in these patients. The extent to which borderline patients' self-definition-seeking behaviour is exaggerated and unremitting in a therapeutic context identifies the primacy of these individuals' striving for self-cohesion. If this need is unrecognized and treatment strategies which address it are not incorporated, the success of cognitive-behavioural treatment models can be unnecessarily (and sometimes severely) compromised. A solution to this problem may lie in the integration of therapeutic principles derived from self-psychology. An outline of this theoretical model and its application in brief therapy on increasing self-cohesion are presented.
The existence of an "organic" subgroup of borderline personality disorder (BPD) has been postulated. This report is of a case-controlled, chart-review study of BPD. The control sample consisted of patients with a variety of psychiatric diagnoses. The study found that 81% of the patients with BPD and 22% of the control patients had a history of brain injury, either developmental (44%), acquired (58%) or both. Furthermore, there was a positive correlation between the summed number of developmental and acquired brain injuries and the score on the retro-Diagnostic Interview for Borderline. A pilot neuropsychological study showed that seven of nine subjects with BPD had evidence of frontal system dysfunction. These results help to support the hypothesized existence of an organic BPD subgroup.
The author characterizes so called "borderline-children" on the basis of 190 case-studies referring to the results of a survey of some 100 child therapists and 40 child psychiatrists. "Borderline-children" show severe psycho-social strain and traumatic experiences and can be characterized by discrepant development, narcissistic pathology, aggressively and impulsiveness, clinging relationships as well as contact problems with children of the same age. The therapy aims at helping children to continue their development at a level appropriate to their age. Due to anxieties and hectic acting out, the therapy has to set distinct boundaries from the very beginning. Regression has to be curbed, archaic fantasies are to be copied with at a metaphorical level by play therapy and not interpreted by the therapist so that dissociated conscious matter is bridged. Usually the social environment has to be integrated into the treatment. In some cases. residential treatment and pharmacotherapy are necessary.
Previous research has tentatively identified a large subgroup of patients with borderline personality disorder (BPD) with histories of developmental or acquired brain insults. Similarly, these studies have demonstrated a possible biological correlation between the severity of BPD and the number of previous brain insults. The possibility of frontal system cognitive dysfunction in BPD has been raised. This single-blind, case-control study of BPD showed that 13 of 24 subjects with BPD had suffered a brain insult. Correlations between neurodevelopmental/acquired brain injury score and the diagnostic interview for borderline (DIB) score (r = 0.47), and between frontal system cognitive functioning and DIB score (r = -0.37) were seen. Neurocognitive testing and comparison with a cohort of subjects with traumatic brain injury (TBI) showed a pattern of similar cognitive functioning between the 2 groups, with the only differences on individual tests being in the direction of worse functioning in the group with BPD on 2 tasks. These results support the hypotheses described above. The main limitation reflects the low numbers of subjects.
A number of studies have indicated that selective serotonin reuptake inhibitors (SSRIs) are effective in reducing the symptomatology accompanying borderline personality disorder (BPD). The SSRIs have proven efficacious in reducing self-injury, suicidality, affective instability, rage, impulsivity, psychosis, and obsessionality. Fluoxetine and sertraline have been shown to be effective in clinical trials, although no single SSRI has emerged as the treatment of choice. Individuals failing one SSRI often respond to another. The data presented in this article indicate that venlafaxine is effective in treating borderline personality disorder (BPD) as an initial intervention and may benefit many individuals for whom fluoxetine or sertraline treatment has failed.