Borderline personality disorder

Social judgement in borderline personality disorder

Background

Borderline personality disorder (BPD) is a common and serious mental illness, associated with a high risk of suicide and self harm. Those with a diagnosis of BPD often display difficulties with social interaction and struggle to form and maintain interpersonal relationships. Here we investigated the ability of participants with BPD to make social inferences from faces.

Method

20 participants with BPD and 21 healthy controls were shown a series of faces and asked to judge these according to one of six characteristics (age, distinctiveness, attractiveness, intelligence, approachability, trustworthiness). The number and direction of errors made (compared to population norms) were recorded for analysis.

Results

Participants with a diagnosis of BPD displayed significant impairments in making judgements from faces. In particular, the BPD Group judged faces as less approachable and less trustworthy than controls. Furthermore, within the BPD Group there was a correlation between scores on the Childhood Trauma Questionnaire (CTQ) and bias towards judging faces as unapproachable.

Conclusion

Individuals with a diagnosis of BPD have difficulty making appropriate social judgements about others from their faces. Judging more faces as unapproachable and untrustworthy indicates that this group may have a heightened sensitivity to perceiving potential threat, and this should be considered in clinical management and treatment.

Structure of genetic and environmental risk factors for symptoms of DSM-IV borderline personality disorder

IMPORTANCE

Previous studies have indicated that the psychopathological dimensions of borderline personality disorder (BPD) are influenced by a unitary liability factor. However, to our knowledge, the underlying etiological nature of the individual criteria for BPD as defined by the DSM-IV has not been explored.

OBJECTIVE

To determine the structure of genetic and environmental risk factors for the symptoms of BPD.

DESIGN, SETTING, AND PARTICIPANTS

Multivariate twin study with BPD criteria assessed by personal interview within a general community setting. Participants included 2794 young adults from the Norwegian Institute of Public Health Twin Panel.

MAIN OUTCOMES AND MEASURES

The 9 criteria for BPD assessed by the Structured Interview for DSM-IV Personality.

RESULTS

A common pathway model dominated by 1 highly heritable (55%) general BPD factor that strongly influenced all 9 BPD criteria (standardized path coefficients, 0.53-0.79) fit the data best. The model also included 2 additional common liability factors, mainly influencing criteria reflecting the affective and interpersonal dimensions. Both of these were mostly influenced by environmental liability factors (heritability, 29.3% and 2.2%). With 1 exception (criterion 2, unstable and intense relationships), the specific criteria were strongly influenced by environmental factors. Five of the 9 criterion-specific genetic effects were either 0 or negligible.

CONCLUSIONS AND RELEVANCE

These results indicate that most of the genetic effects on the individual BPD criteria derive from 1 highly heritable general BPD factor, whereas the environmental influences were mostly criterion specific.

Shifted intrinsic connectivity of central executive and salience network in borderline personality disorder

Borderline personality disorder (BPD) is characterized by “stable instability” of emotions and behavior and their regulation. This emotional and behavioral instability corresponds with a neurocognitive triple network model of psychopathology, which suggests that aberrant emotional saliency and cognitive control is associated with aberrant interaction across three intrinsic connectivity networks [i.e., the salience network (SN), default mode network (DMN), and central executive network (CEN)]. The objective of the current study was to investigate whether and how such triple network intrinsic functional connectivity (iFC) is changed in patients with BPD. We acquired resting-state functional magnetic resonance imaging (rs-fMRI) data from 14 patients with BPD and 16 healthy controls. High-model order independent component analysis was used to extract spatiotemporal patterns of ongoing, coherent blood-oxygen-level-dependent signal fluctuations from rs-fMRI data. Main outcome measures were iFC within networks (intra-iFC) and between networks (i.e., network time course correlation inter-iFC). Aberrant intra-iFC was found in patients’ DMN, SN, and CEN, consistent with previous findings. While patients’ inter-iFC of the CEN was decreased, inter-iFC of the SN was increased. In particular, a balance index reflecting the relationship of CEN- and SN-inter-iFC across networks was strongly shifted from CEN to SN connectivity in patients. Results provide first preliminary evidence for aberrant triple network iFC in BPD. Our data suggest a shift of inter-network iFC from networks involved in cognitive control to those of emotion-related activity in BPD, potentially reflecting the persistent instability of emotion regulation in patients.

Improving services for people with personality disorders: views of experienced clinicians

People with personality disorders are frequent users of both inpatient and outpatient psychiatric services, representing a significantly large proportion of all mental health clients. Despite this, most services find it a challenge to offer the most appropriate and effective treatment models for people with personality disorders. This paper is a report of a study of clinician opinions about how organizations can improve the delivery of services to people with personality disorders. Data was collected from experienced clinicians attending a personality disorders clinical and scientific meeting who were asked to work together in groups and present solutions for how organizations can improve the services provided to people with personality disorders. Qualitative data was collected and thematically and semantically analyzed using Nvivo and Leximancer. The Nvivo analysis revealed five main areas in which clinicians believe organizations can improve services for people with personality disorders. These focused on: (i) more training and education for health professionals and carers; (ii) better support through supervision and leadership; (iii) adoption of a more consistent evidence-based approach to client management and treatment; (iv) clearer guidelines and protocols; and (v) changed attitudes about personality disorder to decrease stigma. The Leximancer analysis of responses indicated the identified themes were not distinct; rather they were interconnected and related to one another, semantically. In summary, clinicians across a large and diverse geographical area developed a consensus that mainstream management of personality disorder is largely poor and inadequate. The findings lend support to an integrative and collaborative whole-service approach that enhances evidence-based practice in the community.

Genetic modulation of borderline personality disorder: systematic review and meta-analysis

Borderline personality disorder (BPD) is a highly prevalent psychiatric disorder with high morbidity and mortality. Early theories ascribed an environmental etiology of BPD, but growing evidence supports a genetic vulnerability as well. The primary aim of this study was to systematically review genetic association studies focused on BPD. PubMed, ISI Web of Knowledge and PsycINFO databases were searched for studies published until December 2012. Meta-analyses were also performed when three or more studies reported genetic data on the same polymorphism. Data were analyzed with Cochrane Collaboration Review Manager Software (RevMan, version 5.0). Quality and publication bias were assessed. The systematic review of association studies examining genetic polymorphisms and BPD produced conflicting results. Meta-analyses were performed for three serotonergic polymorphisms: two common polymorphisms of the serotonin transporter gene (SLC6A4), the promoter insertion/deletion (5-HTTLPR) and the intron 2 VNTR (STin2 VNTR), and the rs1800532 (A218C) polymorphism of the tryptophan hydroxylase 1 gene (TPH1), all showing no association. No direct role of genetic polymorphisms was found in BPD. However, a few studies only are present in literature to draw definite conclusions. Further studies focusing on gene × gene and gene × environment interactions are needed to more deeply dissect the genetic role in the modulation of BPD.

Burden and support needs of carers of persons with borderline personality disorder: a systematic review

BACKGROUND

A major feature of personality disorders is significant impairment in interpersonal functioning, which may create challenges in close relationships. This article aims to systematically review the experience of carers of persons with personality disorders.

METHOD

The PRISMA systematic review method was followed, and empirical studies written in English, published between 1996 and 2011, and cited in major electronic databases were searched. Studies meeting the following selection criteria were included: (1) carers or families of persons with personality disorders; (2) intervention involving the carers or families; (3) burden or related construct used. Studies were required to meet either criteria 1 and 3 or criteria 2 and 3. Reference lists were scanned, and experts were consulted for further studies.

RESULTS

Six studies met inclusion criteria, representing data on 465 carers. Five of the six studies focused on carers of persons with borderline personality disorder. The findings indicated that carers experience elevated objective and subjective burden, grief, impaired empowerment, and mental health problems, including depression and anxiety. Scores on objective and subjective burden were half a standard deviation above the mean compared to carers of inpatients with other serious mental illnesses.

CONCLUSIONS

This study is the first to report data on a large, aggregated sample of carers of persons with personality disorders. Significant gaps in the literature remain, and it is recommended that future research focus on the burden and support needs of carers of persons across different personality disorders, that attention be paid to the gender balance of patients, and that data be reported in a way to allow meta-analysis.

What Can Psychiatric Disorders Tell Us about Neural Processing of the Self?

Many psychiatric disorders are associated with abnormal self-processing. While these disorders also have a wide-range of complex, and often heterogeneous sets of symptoms involving different cognitive, emotional, and motor domains, an impaired sense of self can contribute to many of these. Research investigating self-processing in healthy subjects has facilitated identification of changes in specific neural circuits which may cause altered self-processing in psychiatric disorders. While there is evidence for altered self-processing in many psychiatric disorders, here we will focus on four of the most studied ones, schizophrenia, autism spectrum disorder (ASD), major depression, and borderline personality disorder (BPD). We review evidence for dysfunction in two different neural systems implicated in self-processing, namely the cortical midline system (CMS) and the mirror neuron system (MNS), as well as contributions from altered inter-hemispheric connectivity (IHC). We conclude that while abnormalities in frontal-parietal activity and/or connectivity in the CMS are common to all four disorders there is more disruption of integration between frontal and parietal regions resulting in a shift toward parietal control in schizophrenia and ASD which may contribute to the greater severity and delusional aspects of their symptoms. Abnormalities in the MNS and in IHC are also particularly evident in schizophrenia and ASD and may lead to disturbances in sense of agency and the physical self in these two disorders. A better future understanding of how changes in the neural systems sub-serving self-processing contribute to different aspects of symptom abnormality in psychiatric disorders will require that more studies carry out detailed individual assessments of altered self-processing in conjunction with measurements of neural functioning.

Developmental differences in diffusion tensor imaging parameters in borderline personality disorder

BACKGROUND

Borderline personality disorder (BPD) often presents during adolescence. Early detection and intervention decreases its subsequent severity. However, little is known about early predictors and biological underpinnings of BPD. The observed abnormal functional connectivity among brain regions in BPD led to studies of white matter, as the neural substrate of connectivity. However, diffusion tensor imaging (DTI) studies in adult BPD have been inconclusive, and, as yet, there are no published DTI studies in borderline adolescents.

METHODS

We conducted DTI tractography in 38 BPD patients (14-adolescents, 24-adults) and 32 healthy controls (13-adolescents, 19-adults).

RESULTS

We found bilateral tract-specific decreased fractional anisotropy (FA) in inferior longitudinal fasciculus (ILF) in BPD adolescents compared to adolescent controls. ILF FA was significantly higher in adolescent controls compared to BPD adolescents, BPD adults and adult controls (Wilks F(3,57) = 3.55, p < 0.02). Follow-up voxelwise TBSS analysis demonstrated lower FA in BPD adolescents compared to adolescent controls also in uncinate and occipitofrontal fasciculi.

DISCUSSION

FA generally develops along an inverted U-shape curve, increasing through adolescence, and slowly decreasing in adulthood. Our findings suggest that, in adolescent BPD, this normal developmental "peak" in FA, which is seen in healthy controls, is not achieved. This suggests a possible neural substrate for the previously reported OFC-amygdala disconnect in adults with BPD. It raises the possibility that a white matter tract abnormality in BPD present in adolescence may not be appreciable in adulthood, but a functional abnormality in the coordination among brain regions persists. Our finding represents a possible biological marker to identify those at risk for developing BPD.

Omega-3 fatty acid supplementation in adolescents with borderline personality disorder and ultra-high risk criteria for psychosis: a post hoc subgroup analysis of a double-blind, randomized controlled trial

OBJECTIVE

To investigate whether long-chain omega-3 (n-3) polyunsaturated fatty acids (PUFAs) improve functioning and psychiatric symptoms in young people with borderline personality disorder (BPD) who also meet ultra-high risk criteria for psychosis.

METHODS

We conducted a post hoc subgroup analysis of a double-blind, randomized controlled trial. Fifteen adolescents with BPD (mean age 16.2 years, [SD 2.1]) were randomized to either 1.2 g/day n-3 PUFAs or placebo. The intervention period was 12 weeks. Study measures included the Positive and Negative Syndrome Scale, the Montgomery-Åsberg Depression Rating Scale, and the Global Assessment of Functioning. Side effects were documented with the Udvalg for Kliniske Undersøgelser. Fatty acids in erythrocytes were analyzed using capillary gas chromatography.

RESULTS

At baseline, erythrocyte n-3 PUFA levels correlated positively with psychosocial functioning and negatively with psychopathology. By the end of the intervention, n-3 PUFAs significantly improved functioning and reduced psychiatric symptoms, compared with placebo. Side effects did not differ between the treatment groups.

CONCLUSIONS

Long-chain n-3 PUFAs should be further explored as a viable treatment strategy with minimal associated risk in young people with BPD. (

CLINICAL TRIAL REGISTRATION NUMBER

NCT00396643).

Treatment preference among suicidal and self-injuring women with borderline personality disorder and PTSD

OBJECTIVES

This study examined treatment preferences among suicidal and self-injuring women with borderline personality disorder (BPD) and PTSD.

METHOD

Women (N = 42, M(age) = 34) with BPD, PTSD and recent intentional self-injury were evaluated upon entry into a psychotherapy outcome study.

RESULTS

The majority preferred a combined dialectical behavior therapy (DBT) and prolonged exposure (PE) treatment (73.8%), followed by DBT alone (26.2%), and PE alone (0%). Women who preferred the combined treatment were more likely to report a desire to obtain relief from PTSD and to receive specific DBT and PE treatment components as reasons underlying this preference. Few women (21.4%) reported concerns about PE, but those who did were more likely to prefer DBT alone. More severe PTSD re-experiencing symptoms, a childhood index trauma, and less reduction in positive affect after a trauma interview predicted a preference for the combined treatment.

CONCLUSIONS

These results may help to inform treatment for these complex patients.

Predictors and moderators in the randomized trial of multifamily psychoeducational psychotherapy for childhood mood disorders

This study investigated predictors and moderators of mood symptoms in the randomized controlled trial (RCT) of Multi-Family Psychoeducational Psychotherapy (MF-PEP) for childhood mood disorders. Based on predictors and moderators in RCTs of psychosocial interventions for adolescent mood disorders, we hypothesized that children's greater functional impairment would predict worse outcome, whereas children's stress/trauma history and parental expressed emotion and psychopathology would moderate outcome. Exploratory analyses examined other demographic, functioning, and diagnostic variables. Logistic regression and linear mixed effects modeling were used in this secondary analysis of the MF-PEP RCT of 165 children, ages 8 to 12, with mood disorders, a majority of whom were male (73%) and White, non-Hispanic (90%). Treatment nonresponse was significantly associated with higher baseline levels of global functioning (i.e., less impairment; Cohen's d = 0.51) and lower levels of stress/trauma history (d = 0.56) in children and Cluster B personality disorder symptoms in parents (d = 0.49). Regarding moderators, children with moderately impaired functioning who received MF-PEP had significantly decreased mood symptoms (t = 2.10, d = 0.33) compared with waitlist control. MF-PEP had the strongest effect on severely impaired children (t = 3.03, d = 0.47). Comprehensive assessment of demographic, youth, parent, and familial variables should precede intervention. Treatment of mood disorders in high-functioning youth without stress/trauma histories and with parents with elevated Cluster B symptoms may require extra therapeutic effort, whereas severely impaired children may benefit most from MF-PEP.

Prevention and early intervention for borderline personality disorder: current status and recent evidence

Borderline personality disorder (BPD) is a leading candidate for developing empirically based prevention and early intervention programmes because it is common in clinical practice, it is among the most functionally disabling of all mental disorders, it is often associated with help-seeking, and it has been shown to respond to intervention, even in those with established disorder. Moreover, it can be reliably diagnosed in its early stages and it demarcates a group with high levels of current and future morbidity and mortality. Data also suggest considerable flexibility and malleability of BPD traits in youth, making this a key developmental period during which to intervene. Novel indicated prevention and early intervention programmes have shown that BPD in young people responds to intervention. Further work is required to develop appropriate universal and selective preventive interventions.

Prenatal adversity: a risk factor in borderline personality disorder?

BACKGROUND

Patients with borderline personality disorder (BPD) show a high prevalence of early adversity, such as childhood trauma. It has also been reported that prenatal adverse conditions, such as prenatal maternal stress, drug taking, tobacco smoking or medical complications, may be associated with an increased risk of mental disorders in the offspring. Prenatal adversity is investigated here for the first time as a potential risk factor in the diagnosis of BPD. Method A total of 100 patients with a DSM-IV diagnosis of BPD and 100 matched healthy controls underwent semi-structured interviews about the course of pregnancy, maternal stressors, birth complications and childhood trauma. Further information was obtained from the participants' mothers and from prenatal medical records.

RESULTS

Borderline patients were significantly more often exposed to adverse intrauterine conditions, such as prenatal tobacco exposure (p=0.004), medical complications (p=0.008), prenatal maternal traumatic stress (p=0.015), familial conflicts (p=0.004), low social support (p=0.004) and partnership problems during pregnancy (p=0.014). Logistic regression analyses revealed that the reported prenatal risk factors accounted for 25.7% of the variance in BPD. Prenatal tobacco exposure [odds ratio (OR) 3.37, 95% confidence interval (CI) 1.49-7.65, p=0.004] and medical complications (OR 2.87, 95% CI 1.29-6.38, p=0.010) emerged as important predictors. After controlling for childhood adversity and parental socio-economic status (SES), prenatal risk factors predicted relevant borderline subdomains, such as impulsivity, affective instability, identity disturbance, dissociation and severity of borderline symptoms.

CONCLUSIONS

This study provides evidence of an association between prenatal adversity and the diagnosis of BPD. Our findings suggest that prenatal adversity may constitute a potential risk factor in the pathogenesis of BPD.

Validation of the Spanish version of the Borderline Symptom List, short form (BSL-23)

BACKGROUND

The Borderline Symptom List-23 (BSL-23) is a reliable and valid self-report instrument for assessing Borderline Personality Disorder (BPD) severity. The psychometric properties of the original version have proven to be adequate. The aim of the present study was to validate the Spanish language version of the BSL-23.

METHODS

The BSL-23 was administered to 240 subjects with BPD diagnosis. Factor structure, reliability, test-retest stability, convergent validity, and sensitivity to change were analyzed.

RESULTS

The Spanish version of the BSL-23 replicates the one-factor structure of the original version. The scale has high reliability (Cronbach's alpha=.949), as well as good test-retest stability, which was checked in a subsample (n=74; r=.734; p<.01). The Spanish BSL-23 shows moderate to high correlations with depressive symptomatology, state and trait anxiety, hostility and impulsivity scores and BPD measures. The Spanish BSL-23 is able to discriminate among different levels of BPD severity and shows satisfactory sensitivity to change after treatment, which was verified by assessing change before and after 12 group sessions of Dialectical Behavioral Therapy in a subgroup of 31 subjects.

CONCLUSIONS

Similar to the original BSL-23, the Spanish BSL-23 is a reliable and valid instrument for assessing BPD severity and sensitivity to change.

Two to tango: a dyadic analysis of links between borderline personality traits and intimate partner violence

Although research has shown links between borderline personality and intimate partner violence (IPV), few studies have examined how each partner's personality traits may influence the other's behavior (Hines, 2008). This study incorporated dimensional assessments of borderline personality organization (BPO) in both partners into a dyadic model that examined associations with IPV. In a community sample of 109 couples, an Actor-Partner Interdependence Model was used to examine links between BPO traits in each partner and victimization and perpetration of IPV. Men's level of BPO traits was associated with more IPV toward and more victimization by their partners. Women's level of BPO traits was associated with their victimization only. This study is unique in examining links between BPO and IPV in couples using analyses that account for the interdependence of these variables in dyads.

Characteristics of patients with borderline personality disorder in a state psychiatric hospital

Borderline personality disorder is common across mental health settings and associated with substantial suffering, disability, and mortality risk. However, it is often underdiagnosed and no prevalence data are available for state hospital settings. This study aims to provide a preliminary assessment of the prevalence and characteristics of borderline personality disorder (BPD) within an inpatient unit of a state psychiatric hospital. In order to improve the quality of care at a state psychiatric hospital, all patients admitted to a 40-bed unit from April 2008 to June 2009 were routinely administered a structured diagnostic interview for BPD. A total of 65 patients were screened and their charts were reviewed. Twenty patients (31%) met criteria for BPD, but only eight of them (40%) had a chart diagnosis of BPD. Compared to patients without BPD, patients with BPD were significantly more likely to be female (75%), to carry a diagnosis of major depressive disorder, and to have been admitted within the past year. Twenty-four percent of patients with a primary psychotic disorder also met criteria for BPD. BPD patients tended to have shorter lengths of stay, but they had significantly more management problems, including incidents of self-harm, episodes of restraint, and stat administrations of medications. The authors conclude that BPD can be a common but underappreciated co-occurring condition in a state psychiatric hospital. In this setting, BPD is associated with more frequent admissions and numerous management challenges, suggesting the need for comprehensive screening, coordination of care, and specialized treatment programming.

Examining the association of NRXN3 SNPs with borderline personality disorder phenotypes in heroin dependent cases and socio-economically disadvantaged controls

BACKGROUND

Borderline personality disorder (BPD) and substance use disorders frequently co-occur; their dual presence predicts poor prognosis. The genetic underpinnings of BPD have not been well-characterized and could offer insight into comorbidity. The current report focuses on the association of neurexin 3 (NRXN3) single nucleotide polymorphisms (SNPs) with BPD symptoms in heroin dependent cases and controls.

METHODS

The sample of the Comorbidity and Trauma Study, a genetic association study of heroin dependence, consists of Australian heroin dependent cases ascertained from opioid replacement therapy clinics and controls ascertained in nearby economically disadvantaged neighborhoods. The assessment included a screening instrument for BPD, used previously in Australian population surveys. Genotypic and BPD phenotypic data were available for 1439 cases and 507 controls. We examined the association of 1430 candidate gene SNPs with BPD phenotypes.

RESULTS

One or more NRXN3 SNPs were nominally associated with all BPD phenotypes; however, none met the conservative significance threshold we employed to correct for multiple testing. The most strongly associated SNPs included rs10144398 with identity disturbance (p=4.9×10(-5)) and rs10151731 with affective instability (p=8.8×10(-5)). The strongest association with screening positive for BPD was found for the NRXN3 SNP, rs10083466 (p=.0013). Neither the correlation of BPD phenotypes nor the linkage disequilibrium relationships of the SNPs account for the number of observed associations involving NRXN3 SNPs.

CONCLUSIONS

Our findings provide intriguing preliminary evidence for the association of NRXN3 with BPD phenotypes. The strongest associations were found for traits (i.e., affective instability; identity disturbance) also observed with other disorders.

Impulsivity in relation to stress in patients with borderline personality disorder with and without co-occurring attention-deficit/hyperactivity disorder: an exploratory study

Impulsivity is regarded as a key feature in borderline personality disorder (BPD). However, discrepancies in previous research indicate that the role of impulsivity in BPD is not yet fully understood. For example, state-dependent impulsivity in individuals with BPD may be related to co-occurring psychiatric conditions such as attention-deficit/hyperactivity disorder (ADHD) and to emotional states. We assessed self-reports of trait and state impulsivity and response inhibition before and after an experimental stress induction in 15 patients with BPD without ADHD, 15 patients with BPD and ADHD, 15 patients with ADHD, and 15 healthy participants. The patients in both BPD subgroups reported a stress-dependent increase of state impulsivity, which was not observed in the other groups. Response inhibition was impaired in the patients with BPD and ADHD but not in those without ADHD compared with the healthy participants. We suggest that stress levels and co-occurring ADHD should receive attention in future studies on impulsivity in BPD.

Patterns of interpersonal problems in borderline personality disorder

Borderline personality disorder (BPD) is characterized by a wide variety of interpersonal problems. We examined whether there are different characteristic interpersonal patterns in BPD and how these patterns are related to symptom distress and therapeutic alliance. In 228 inpatients with diagnoses of BPD, interpersonal subtypes based on the Inventory of Interpersonal Problems (Horowitz et al., Inventar zur Erfassung Interpersonaler Probleme, 2000) were examined through cluster analyses. The global symptom severity and therapeutic alliance were also assessed. We identified five characteristic interpersonal patterns, which we labeled as follows: Cluster 1, "Vindictive"; Cluster 2, "Moderate Submissive"; Cluster 3, "Nonassertive"; Cluster 4, "Exploitable"; and Cluster 5, "Socially Avoidant." The clusters differed significantly in terms of interpersonal distress, interpersonal differentiation, and severity of global symptoms. The ratings of the therapeutic alliance by therapists during treatment significantly differed between the interpersonal subtypes, and the lowest ratings for patients were in the "Socially Avoidant" cluster. Our results stress the impact of interpersonal style on the appearance and treatment of BPD.

Neural correlates of negative emotionality in borderline personality disorder: an activation-likelihood-estimation meta-analysis

BACKGROUND

Emotional vulnerabilities at the core of borderline personality disorder (BPD) involve a dysfunction of frontolimbic systems subserving negative emotionality. The specific regions identified in individual studies, however, vary widely and provide an incomplete understanding of the functional brain abnormalities that characterize this illness. A quantitative synthesis of functional neuroimaging studies might clarify the neural systems dysfunctions that underlie negative emotionality in BPD.

METHODS

An electronic search of Medline and PsycInfo databases from 2000 to 2012 identified 18 potential studies, of which 11 met inclusion criteria for the meta-analysis and comprised a pooled sample of 154 BPD patients and 150 healthy control subjects. Contrasts of negative versus neutral emotion conditions were analyzed with an activation-likelihood-estimation meta-analytic approach. Group comparisons were performed on study-reported between-subjects contrasts and independent subtraction analyses based on within-subjects contrasts.

RESULTS

Healthy control subjects activated a well-characterized network of brain regions associated with processing negative emotions that included the anterior cingulate cortex and amygdala. Compared with healthy control subjects, BPD patients demonstrated greater activation within the insula and posterior cingulate cortex. Conversely, they showed less activation than control subjects in a network of regions that extended from the amygdala to the subgenual anterior cingulate and dorsolateral prefrontal cortex.

CONCLUSIONS

Processing of negative emotions in BPD might be subserved by an abnormal reciprocal relationship between limbic structures representing the degree of subjectively experienced negative emotion and anterior brain regions that support the regulation of emotion. Contrary to early studies, BPD patients showed less activation than control subjects in the amygdala under conditions of negative emotionality.

Response to psychotherapy in borderline personality disorder and methylation status of the BDNF gene

Downregulation of brain-derived neurotrophic factor (BDNF) gene expression with corresponding increased methylation at specific promoters has been associated with stressful experiences in early life and may explain later adulthood psychopathology. We measured the percentage of methylation at BDNF CpG exons I and IV as well as plasma BDNF protein levels in 115 subjects with borderline personality disorder (BPD) and 52 controls. BPD subjects then underwent a 4-week course of intensive dialectical behavior therapy (I-DBT). BDNF methylation status and protein levels were re-assessed at the end of treatment. BPD subjects had significantly higher methylation status in both CpG regions than controls. In addition, the higher the number of childhood trauma, the higher was the methylation status. In BPD subjects, BDNF methylation significantly increased after I-DBT. Nonresponders accounted for the majority of this increase, whereas responders showed a decrease in methylation status over time. Accordingly, the changes in methylation status over time were significantly associated with changes in depression scores, hopelessness scores and impulsivity. No association was found between protein levels and BDNF methylation status. We here found a relationship between child maltreatment and higher DNA methylation of BDNF. These results moreover support the idea that these epigenetic marks may be changed through psychotherapeutic approaches and that these changes underline changes in cognitive functions.

The emerging evidence for long-term psychodynamic therapy

There is growing evidence from RCTs supporting the efficacy of both short-term (STPP) and long-term psychodynamic psychotherapy (LTPP) for specific mental disorders. In a first series of meta-analyses, LTPP was shown to be superior to shorter forms of psychotherapy, especially in complex mental disorders. However, the evidence for LTPP has not gone unchallenged. After several responses have addressed the raised concerns, a recent meta-analysis by Smit and colleagues (2012) again challenges the efficacy of LTPP.

METHOD

From a methodological perspective, a critical analysis of the Smit et al. meta-analysis was performed. Furthermore, we conducted two new metaanalyses adding studies not included in previous meta-analyses. The purpose was to examine whether the results of the previous meta-analyses are stable.

RESULTS

Due to differing inclusion criteria, the meta-analysis by Smit et al. actually compared LTPP to other forms of long-term psychotherapy. Thus, they essentially showed that LTPP was as efficacious as other forms of long-term therapy. For this reason the meta-analysis by Smit et al. does not question the results of previous meta-analyses showing that LTPP is superior to shorter forms of psychotherapy. In addition, the Smit et al. meta-analysis was shown to suffer from several methodological shortcomings. The new meta-analyses we performed did not find significant deviations from previous results. In complex mental disorders LTPP proved to be significantly superior to shorter forms of therapy corroborating results of previous meta-analyses.

CONCLUSIONS

Data on dose-effect relations suggest that for many patients with complex mental disorders, including chronic mental disorders and personality disorders, short-term psychotherapy is not sufficient. For these patients, long-term treatments may be indicated. The meta-analyses presented here provide further support for LTPP in these populations. Nevertheless, there is a need for more research in LTPP and other long-term psychotherapies.

Neurocognitive profiles of people with borderline personality disorder

PURPOSE OF REVIEW

This review summarizes recent neurocognitive research to better delineate the nosology, prognostication and cause underlying borderline personality disorder (BPD).

RECENT FINDINGS

BPD had marked clinical heterogeneity with high comorbidity. Executive dysfunction in this disorder was linked to suicidality and treatment adherence, and may serve as an endophenotype. BPD was also characterized by cognitive distortions such as risky decision-making, deficient feedback processing, dichotomous thinking, jumping to conclusion, monocausal attribution and paranoid cognitive style. Social cognition deficits recently described in BPD include altered social inference and emotional empathy, hypermentalization, poorer facial emotional recognition and facial expressions. In electrophysiological studies, BPD was found to have predominantly right hemispheric deficit in high-order cortical inhibition. Reduced left orbitofrontal activity by visual evoked potential and magnetoencephalography correlated with depressive symptoms and functional deterioration. Brain structures implicated in BPD include the hippocampus, dorsolateral prefrontal cortex and anterior cingulate cortex. Abnormal anatomy and functioning of frontolimbic circuitry appear to correlate with cognitive deficits.

SUMMARY

Frontolimbic structural and functional abnormalities underlie the broad array of cognitive abnormalities in BPD. Further research should espouse broader considerations of effects of comorbidity and clinical heterogeneity, and include community samples and, possibly, longitudinal designs.

Getting the word out about treating borderline personality disorder: an online information resource

This column reviews the need for greater awareness among mental health clinicians regarding evidence-based treatments for borderline personality disorder (BPD) and describes an online resource that has been developed to partially address this need. This resource is the Borderline Personality Disorder Clinician Resource Centre, which can be accessed at http://www.treatingBPD.ca.

Long-term and bizarre self-injurious behavior: an approach to underlying psychological mechanisms and management

Repeated self-harm usually presents with associated psychopathology, mostly in the form of obsessive-compulsive disorder, malingering, or personality disorders, and may persist for many years. This case presentation focuses on self-harm involving the deliberate ingestion of foreign bodies. This behavior remains poorly understood, and the relevant literature focuses almost entirely on gastroenterological and surgical management, with little or no discussion of underlying psychological mechanisms, psychopathology, or psychotherapeutic intervention. The goal of this article is to begin to fill that gap by presenting the case of a young woman who was diagnosed with borderline personality disorder and followed for 20 years, who repeatedly swallowed objects as a form of self-harming behavior. The nosological status and possible functions of this behavior are discussed, as are the difficulties of caring for patients with such long-standing, repeated selfinjury. This case illustrates how the boundaries between different self-injurious behaviors are blurred and also how different self-injurious behaviors are likely to share common patterns, functional integrity, and meanings. It should also serve to remind us how far we have to go in terms of understanding, classifying, and successfully treating certain patients who present with longterm and bizarre self-injurious behavior.

[The efficacy of psychodynamic therapy: a controversy]

There is growing evidence from randomized controlled trials supporting the efficacy of psychodynamic psychotherapy (PDT) in specific mental disorders. Yet the evidence for the efficacy of psychodynamic psychotherapy has not gone unchallenged. Several responses have addressed these concerns, showing that most of the criticism was not justified. Nevertheless, the evidence for psychodynamic psychotherapy continues to be frequently ignored, criticized or presented in a distorted way. A recent controversy published in the Nervenarzt may serve as an illustrative example, which is discussed here more in detail. This example shows that some authors are not interested in a truly scientific discussion, but rather try to discredit a rival method of psychotherapy and its scientific representatives for political reasons.

Axis I and II comorbidity and psychosocial functioning in female adolescents with borderline personality disorder

BACKGROUND

Borderline personality disorder (BPD) is known to be associated with high rates of comorbidity and severe impairment of psychosocial functioning in adults. The aim of this study was to investigate Axis I and Axis II disorders, as well as psychosocial functioning, in a clinical sample of adolescents with BPD and to compare these with participants with mixed psychiatric diagnoses.

METHODS

Female adolescent patients were consecutively recruited from the child and adolescent psychiatry department of a university hospital. Axis I and Axis II diagnoses were assessed by experienced clinicians using well-established semistructured interviews, along with psychosocial functioning.

RESULTS

The final sample (87 participants) comprised 31 participants with a diagnosis of BPD and 56 participants with mixed psychiatric diagnoses. The most common comorbid disorders in the adolescent BPD sample were mood, eating, dissociative, and substance use disorders in Axis I, and cluster C personality disorders in Axis II. The BPD group showed a significantly higher average number of comorbid Axis I and Axis II diagnoses and significantly lower psychosocial functioning compared with the clinical control group. Regression analyses revealed that psychosocial functioning was predicted by socioeconomic status and comorbid disorders, as well as the unique influence of BPD itself.

CONCLUSION

Adolescent BPD in females is accompanied by high rates of psychiatric comorbidity and poor psychosocial functioning. This underscores the need for diagnosis of BPD at its early stages, in order to facilitate appropriate interventions.

Physiological and self-assessed emotional responses to emotion-eliciting films in borderline personality disorder

According to Linehan's biosocial model, the core characteristic of borderline personality disorder (BPD) is emotional dysregulation. In the present study, we investigated two components of this model: baseline emotional intensity and emotional reactivity. A total of 60 women, 30 with BPD diagnosis and 30 age and sex-matched healthy subjects (HCs), participated in two experiments. In the first experiment, we evaluated emotional responses to six films designed to elicit discrete emotions (anger, fear, sadness, disgust, amusement and neutral). The second experiment evaluated emotional reactions to three emotion-eliciting films containing BPD-specific content (sexual abuse, emotional dependence and abandonment/separation). Skin conductance level, heart rate, and subjective emotional response were recorded for each film. Although self-reported data indicated that negative emotions at baseline were stronger in the BPD group, physiological measures showed no differences between the groups. Physiological results should be interpreted with caution since most BPD participants were under pharmacological treatment. BPD subjects presented no subjective heightened reactivity to most of the discrete emotion-eliciting films. Subjective responses to amusement and "BPD-specific content" films revealed significant between-group differences. These findings suggest that the main characteristic of BPD might be negative emotional intensity rather than heightened emotional reactivity.

The 5-HT deficiency theory of depression: perspectives from a naturalistic 5-HT deficiency model, the tryptophan hydroxylase 2Arg439His knockin mouse

A decreased level of brain 5-hydroxytryptamine (5-HT) has been theorized to be a core pathogenic factor in depression for half a century. The theory arose from clinical observations that drugs enhancing extracellular levels of 5-HT (5-HT(Ext)) have antidepressant effects in many patients. However, whether such drugs indeed correct a primary deficit remains unresolved. Still, a number of anomalies in putative biomarkers of central 5-HT function have been repeatedly reported in depression patients over the past 40 years, collectively indicating that 5-HT deficiency could be present in depression, particularly in severely ill and/or suicidal patients. This body of literature on putative 5-HT biomarker anomalies and depression has recently been corroborated by data demonstrating that such anomalies indeed occur consequent to severely reduced 5-HT(Ext) levels in a mouse model of naturalistic 5-HT deficiency, the tryptophan hydroxylase 2 His(439) knockin (Tph2KI) mouse. In this review, we will critically assess the evidence for 5-HT deficiency in depression and the possible role of polymorphisms in the Tph2 gene as a causal factor in 5-HT deficiency, the latter investigated from a clinical as well as preclinical angle.

Validation of the Long-term Difficulties Inventory (LDI) and the List of Threatening Experiences (LTE) as measures of stress in epidemiological population-based cohort studies

BACKGROUND

Stress questionnaires are included in many epidemiological cohort studies but the psychometric characteristics of these questionnaires are largely unknown. The aim of this study was to describe these characteristics for two short questionnaires measuring the lifetime and past year occurrence of stress: the List of Threatening Events (LTE) as a measure of acute stress and the Long-term Difficulties Inventory (LDI) as a measure of chronic stress.

METHOD

This study was performed in a general population cohort consisting of 588 females (53.7%) and 506 males (46.3%), with a mean age of 53.5 years (s.d.=11.3 years). Respondents completed the LTE and the LDI for the past year, and for the age categories of 0-12, 13-18, 19-39, 40-60, and >60 years. They also completed questionnaires on perceived stress, psychological distress (the General Health Questionnaire, GHQ-12), anxiety and depression (the Symptom Checklist, SCL-8) and neuroticism (the Eysenck Personality Questionnaire - Revised Short Scale, EPQ-RSS-N). Approximately 2 years later, 976 respondents (89%) completed these questionnaires for a second time.

RESULTS

The stability of the retrospective reporting of long-term difficulties and life events was satisfactory: 0.7 for the lifetime LDI and 0.6 for the lifetime LTE scores. The construct validity of these lists is indicated by their positive associations with psychological distress, mental health problems and neuroticism.

CONCLUSIONS

This study in a large population-based sample shows that the LDI and LTE have sufficient validity and stability to include them in major epidemiological cohort studies.

Psychiatry should not become hostage to placebo: an alternative interpretation of antidepressant-placebo differences in the treatment response in depression

BACKGROUND

It is widely believed that in randomized controlled trials of antidepressants the difference between drug and placebo response rates is rather small (around 20%), leading to a common perception that antidepressants have limited efficacy.

AIM

The aim of the present paper was to present an alternative calculation and interpretation of antidepressant-placebo difference in the treatment response to antidepressant in drug trials which may shed a new light on the efficacy of antidepressants.

ISSUES

We have previously highlighted several controversial points concerning the calculation of antidepressant and placebo response rates in randomised controlled trials, which may influence views concerning the efficacy of drugs, and demonstrated several factors which may lead to overestimation of the placebo effect and underestimation of antidepressant efficacy. The traditional interpretation of antidepressant-placebo difference in randomized controlled trials on major depression has been also challenged previously from at least five points of view but all leading to a conclusion that currently prevailing opinions concerning relative placebo and antidepressant response rates overestimate placebo response, and thereby underestimate efficacy of antidepressant drugs. In our present paper we propose another method for calculating placebo and antidepressant response rates which may shed new light on an overlooked aspect of the efficacy of these drugs.

CONCLUSIONS

We contend that opinions on the effectiveness of antidepressants should be reconsidered, and comparisons with placebo should be more carefully applied. Interpretation of the placebo response is of crucial importance for establishing the efficacy of antidepressive medications, and psychiatry should not become the hostage of placebo.

Cluster B maladaptive personality traits in Spanish adolescents

INTRODUCCTION

The prevalence and expression of Cluster B personality disorders during adolescence have been poorly analyzed. The main aim of this research was to analyze the rate of Cluster B maladaptive personality traits in Spanish adolescents. We also examined dimensional structure underlying the influence of sex and age in its phenotypic expression, was also examined.

METHOD

The sample consisted of a total of 1440 participants (Mean=15.9 years, SD=1.2). The self-reporting questionnaire used was the Personality Diagnostic Questionnaire-4 + (PDQ-4 +).

RESULTS

Maladaptative «dramatic» or «erratic» personality traits are common among adolescents, particularly antisocial and borderline facets. Using the PDQ-4+ cut-off points, 20.3% of the sample submitted had a Cluster B personality disorder. The analysis of the internal structure of the Cluster B items of the PDQ-4 + yielded a factorial solution centred on three interrelated factors, including: Antisocial, Borderline and Histrionic/Narcissistic. There were differences by gender in the subscales of Cluster B, but not in function of age.

CONCLUSIONS

These data yield new insights that improve the understanding of the Cluster B personality disorders and traits in this sector of the population. Future studies should use measurement tools that take into account the concern, conviction and distress associated with such experiences.

Can neuroimaging be used as a support to diagnosis of borderline personality disorder? An approach based on computational neuroanatomy and machine learning

Several recent studies in literature have identified brain morphological alterations associated to Borderline Personality Disorder (BPD) patients. These findings are reported by studies based on voxel-based-morphometry analysis of structural MRI data, comparing mean gray-matter concentration between groups of BPD patients and healthy controls. On the other hand, mean differences between groups are not informative about the discriminative value of neuroimaging data to predict the group of individual subjects. In this paper, we go beyond mean differences analyses, and explore to what extent individual BPD patients can be differentiated from controls (25 subjects in each group), using a combination of automated-morphometric tools for regional cortical thickness/volumetric estimation and Support Vector Machine classifier. The approach included a feature selection step in order to identify the regions containing most discriminative information. The accuracy of this classifier was evaluated using the leave-one-subject-out procedure. The brain regions indicated as containing relevant information to discriminate groups were the orbitofrontal, rostral anterior cingulate, posterior cingulate, middle temporal cortices, among others. These areas, which are distinctively involved in emotional and affect regulation of BPD patients, were the most informative regions to achieve both sensitivity and specificity values of 80% in SVM classification. The findings suggest that this new methodology can add clinical and potential diagnostic value to neuroimaging of psychiatric disorders.

Borderline personality disorder and depression: an update

To review the literature related to recent temperamental and biological findings on borderline personality disorder (BPD) and major depression, the close link between the two disorders, and the latest therapeutical findings on BPD, focusing on the conditions of co-morbidity between depression and BPD. The National Institutes of Health's PubMed database was used to identify indexed studies on BPD, depression and the co-morbidity between the two. Only studies published between 2000 and 2011 were assessed. Similar temperamental features have been demonstrated in BPD and depression. The strong link between the two disorders seems to be widely recognized by scientific community. Psychotherapy and new antipsychotics are the topics of current major interest of research. The therapeutic targets in the case of co-morbidity are BPD features associated with depressive symptoms, thus influencing prognosis. A global assessment is, in fact, fundamental for a successful therapy for the treatment of the several aspects of a complex psychopathological phenomenon.

Attentional processes and responding to affective faces in youth with borderline personality features

This study examined attentional biases for emotional faces in borderline personality disorder (BPD). Twenty-one outpatient youth (aged 15-24 years) meeting three or more DSM-IV BPD criteria and 20 community-derived participants (aged 15-24 years) with no history of psychiatric problems and not meeting any BPD criteria completed a modified dot-probe task that tested automatic (30 ms) and controlled (500 ms) stages of information processing. The findings indicate that, compared with healthy controls, youth with borderline features were faster to respond to congruent rather than incongruent fear stimuli. This effect was independent of state anxiety and was observed during the 30 ms presentation of fearful faces. There was no significant effect for happy or angry faces. Youth with borderline features were also slower to respond to incongruent rather than paired neutral trials, indicating difficulties in disengaging attention from the perceived threat. Such differences were not found for the healthy controls. Thus, youth with borderline features had an attentional bias for fearful faces that reflected difficulty in disengaging attention from threatening information during pre-conscious stages of attention. This finding extends previous research highlighting the diminished capacity for affect regulation and subsequent engagement in behavioural strategies to avoid distress in BPD. Future research should explore the relationship between information processing, emotion regulation in adult BPD samples.

Endoscopy for repeatedly ingested sharp foreign bodies in patients with borderline personality disorder: an international survey

BACKGROUND

The general guidelines on the management of ingested foreign bodies (FBs) do not address specific aspects raised by psychiatric patients, particularly in patients with borderline personality disorders (BPD) who repeatedly ingest FBs. The aim of this survey was to collect data on experience and opinions on the management of FBs in psychiatric patients with BPD and to review the relevant literature.

METHODS

A survey focusing on the indication and the timing of endoscopy for sharp FB removal in patients with BPD was e-mailed to 215 gastroenterologists, psychiatrists, and surgeons in Switzerland, Germany and Austria, discussing this clinical problem using a specific case vignette.

RESULTS

Responses were received from 63 of 215 (29%) contacted physicians. Two-thirds of the respondents knew patients with BPD who had swallowed FBs repeatedly; 86% recommended removing sharp FBs endoscopically even in the case of repeated FB ingestion and 14% of respondents argued against emergent endoscopic FB removal in the case of repeated ingestions. Different specialities expressed partially divergent opinions regarding the management of these patients.

CONCLUSION

Repeated FB ingestions can be a problem in patients with BPD. Although published data show that the perforation risk of unremoved FBs is low, most clinicians support repeated endoscopies also in the case of repeated FB ingestions. Nevertheless, in selected cases, repeated endoscopies need to be discussed and an interdisciplinary consensus and/or the involvement of an ethical committee is advised.

Borderline personality disorder features and history of childhood maltreatment in mothers involved with child protective services

This study examines the history of childhood maltreatment and Borderline Personality Disorder (BPD) symptoms in mothers whose children were removed from the home by Child Protective Services (CPS) to identify potential targets for future intervention efforts. Forty-one mothers of children removed from the home due to abuse and/or neglect and 58 community-control mothers without CPS involvement were assessed for history of childhood maltreatment, alcohol and drug use, and BPD features. CPS-involved mothers scored significantly higher on measures of childhood maltreatment history and BPD features than did control mothers. The highest BPD scores were associated with the most severe histories of mothers' childhood maltreatment. In total, 50% of CPS-involved mothers reported elevated BPD features, compared with 15% of control mothers. Further, 19% of CPS-involved mothers had self-reported scores consistent with a BPD diagnosis, compared with 4% of control mothers. BPD features rather than maltreatment history per se predicted maternal involvement with CPS, controlling for alcohol and drug use predictors. The present data suggest that evidence-based treatments to address BPD symptoms may be indicated for some CPS-involved parents.

'I think we're all guinea pigs really': a qualitative study of medication and borderline personality disorder

National Institute for Clinical Excellence recommended the use of medication only in times of crisis for individuals with borderline personality disorder (BPD). Despite this recommendation most service users referred to a specialist personality disorder service were found to be on numerous medications. Although a number of qualitative studies have explored the experience of individuals with a diagnosis of BPD they have failed to discuss their experience of being treated with medication, despite its high prescription with this group (e.g. Sansone et al.). The aim of this study was to explore the experience of service users being treated with medication for the BPD diagnosis. Semi-structured interviews were carried out with seven service users under a specialist service for personality disorder. Interviews were transcribed and analysed using thematic analysis. The main themes to emerge were: staff knowledge and attitudes, lack of resources for BPD and the recovery pathway for BPD. Overall, service users felt that receiving the BPD diagnosis had had a negative impact on the care they received, with staff either refusing treatment or focusing on medication as a treatment option. The introduction of specialist services for this group appears to improve service user satisfaction with their treatment and adherence to the National Institute for Clinical Excellence guidelines.

Adult attachment in the clinical management of borderline personality disorder

Borderline personality disorder (BPD) is a common psychiatric disorder associated with severe functional impairment, high rates of suicide and comorbid psychiatric illness, intensive use of treatment, and high costs to society. The etiology and pathogenesis of BPD are still uncertain, although an interaction between biological and psychosocial factors has been proposed to explain how the condition develops. Attachment disturbances represent one of the developmental risk factors that have been most consistently found to be associated with BPD, with a number of studies reporting a significant strong association between insecure attachment and BPD, notwithstanding the variety of measures and attachment types employed in these studies. In this article, the author first reviews clinical descriptions and research findings concerning the association between attachment disturbances and BPD and then discusses how attachment theory may help clinicians who work with patients with BPD better understand the psychopathology of the illness and plan treatment.

Amygdala and hippocampal volume reductions as candidate endophenotypes for borderline personality disorder: a meta-analysis of magnetic resonance imaging studies

Borderline personality disorder (BPD) is a genetically influenced psychiatric illness with disruptions in neural systems supporting cognition and emotion regulation. Volumetric decreases of the hippocampus and amygdala may characterize BPD and serve as putative endophenotypes for the illness. The purpose of the present study was to evaluate whether the magnitude of these volume reductions and their associations with state-of-illness factors and psychiatric disorders which often co-occur with BPD warrant their consideration as potential endophenotypes. Volumetric magnetic resonance imaging results from 11 studies comprising 205 BPD patients and 222 healthy controls were quantitatively synthesized using meta-analytic techniques. Patients showed an average 11% and 13% decrease in the size of the hippocampus and amygdala, respectively. These volumetric differences were not attenuated in patients being treated with psychotropic medications. Comorbid depression, post-traumatic stress disorder, and substance use disorders were unrelated to volumetric decreases in either structure. These findings suggest modest volume reductions of the amygdala and hippocampus bilaterally in BPD which cannot be attributed to illness state or comorbid psychopathology. Decreased volumes of these key limbic structures may hold promise as candidate endophenotypes for BPD.

Registered prevalence of borderline personality disorder in primary care databases

OBJECTIVE

Borderline personality disorder (BPD) is a common personality disorder, with a population prevalence of 1.4-5.9%, although the epidemiology of this disorder in primary care is insufficiently known. Our objective was to determine the registered prevalence of BPD in primary care databases and to study the demographic and clinical characteristics of these patients.

METHODS

We performed a cross-sectional study of the computerized databases of primary care clinical records. The target population consisted of all adults (≥ 16 years old) registered in the Catalan Health Institute (n = 4,764,729).

RESULTS

The prevalence of recorded BPD was 0.017%, and was higher in patients with other mental disorders, particularly substance-abuse disorders (0.161%). These patients had twice as many appointments with the general practitioner as the general population (8.1 vs. 4.4).

CONCLUSION

The number of diagnoses of BPD recorded in primary care is extremely low, which contrasts with the available population-based data.

Psychiatric comorbidity and the persistence of drug use disorders in the United States

AIMS

DSM-IV drug use disorders, a major public health problem, are highly comorbid with other psychiatric disorders, but little is known about the role of this comorbidity when studied prospectively in the general population. Our aims were to determine the role of comorbid psychopathology in the 3-year persistence of drug use disorders.

DESIGN AND SETTING

Secondary data analysis using waves 1 (2001-02) and 2 (2005-05) of the National Epidemiologic Survey on Alcohol and Related Conditions.

PARTICIPANTS

Respondents with current DSM-IV drug use disorder at wave 1 who participated in wave 2 (n = 613).

MEASUREMENTS

Alcohol Use Disorders and Associated Disabilities Interview Schedule IV (AUDADIS-IV) obtained DSM-IV Axis I and II diagnoses. Persistent drug use disorder was defined as meeting full criteria for any drug use disorder between waves 1 and 2.

FINDINGS

Drug use disorders persisted in 30.9% of respondents. No Axis I disorders predicted persistence. Antisocial [odds ratio (OR) = 2.75; 95% confidence interval (CI): 1.27-5.99], borderline (OR = 1.91; 95% CI: 1.06-3.45) and schizotypal (OR = 2.77; 95% CI: 1.42-5.39) personality disorders were significant predictors of persistent drug use disorders, controlling for demographics, psychiatric comorbidity, family history, treatment and number of drug use disorders. Deceitfulness and lack of remorse were the strongest antisocial criteria predictors of drug use disorder persistence, identity disturbance and self-damaging impulsivity were the strongest borderline criteria predictors, and ideas of reference and social anxiety were the strongest schizotypal criteria predictors.

CONCLUSIONS

Antisocial, borderline and schizotypal personality disorders are specific predictors of drug use disorder persistence over a 3-year period.

Developmental pathways to borderline personality disorder

This paper reviews recent studies of biological and environmental risk and protective factors and patterns of continuity leading to borderline personality disorder (BPD). It focuses on prospective studies of children and adolescents and studies of young people with borderline pathology, reporting findings from genetics, neurobiology, experimental psychopathology, environmental risk, and precursor signs and symptoms. Studies of individuals earlier in the course of BPD demonstrate relatively consistent environmental risk factors, but neurobiological and experimental psychopathology findings are still inconsistent. Also, temperamental and mental state abnormalities that resemble aspects of the BPD phenotype emerge in childhood and adolescence and presage the BPD syndrome in adolescence or adulthood. Further work is required to better understand the roles that all these factors play in the developmental pathways to BPD and to increase their specificity for BPD in order to facilitate prevention and early intervention.

Suicidal risk and management in borderline personality disorder

This paper reviews recent advances in our understanding of suicidality in borderline personality disorder (BPD), with a focus on suicide risk assessment, guidelines for treatment, and medicolegal concerns. Relevant material on distinctions between suicide completers and suicide attempters, contributions of published American Psychiatric Association Guidelines, the controversial role of hospitalization, and management strategies regarding litigation is addressed. Despite accumulating data on suicidality in BPD, the current state of knowledge offers only partial clues to help identify the BPD patients most at risk of death by suicide, and offers a limited armamentarium of treatment targeted to suicide prevention, creating discomfort in clinicians and fears regarding litigation in the event of a successful suicide. Promising new interventions include less resource-intensive psychotherapies as well as brief crisis intervention.

Impulsivity, aggression and suicidal behavior in unipolar and bipolar disorders

BACKGROUND

Predictors of suicidal behaviors (SB) in bipolar (BD) and major depressive disorder (MDD) patients are poorly understood. It has been recognized that behavioral dysregulation characterizes SB with traits of impulsivity and aggression being particularly salient. However, little is known about how these traits are segregated among mood disorder patients with and without a history of suicide attempt (SA).

METHODS

This article aims to compare impulsivity and aggression between 143 controls, 138 BD and 186 MDD subjects with or without a history of SA.

RESULTS

BD and MDD patients showed higher impulsivity scores (BIS-10 = 57.9 vs. 44.7, p < 0.0001) and more severe lifetime aggression than controls (Lifetime History of Aggression = 7.3 vs. 3.9, p < 0.0001). Whereas impulsivity helped to distinguish MDD subjects without a history of SA from those with such a history, this was not the case in BD subjects where no difference in impulsive traits was observed between BD without and with history of SA (57.2 vs. 63.2 for BIS-10; p = 0.259). Impulsive and aggressive traits were strongly correlated in suicide attempters (independently of the diagnosis) but not in non-suicide attempters.

LIMITATIONS

Dimensional traits were not characterized at different stages of illness.

CONCLUSIONS

Impulsivity, as a single trait, may be a reliable suicide risk marker in MDD but not in BD patients, and its strong correlation with aggressive traits seems specifically related to SB. Our study therefore suggests that the specific dimension of impulsive aggression should be systematically assessed in mood disorder patients to address properly their suicidal risk.