Discriminant efficiency of antisocial and borderline personality disorder criteria in Hispanic men with substance use disorders

The hidden borderline patient: patients with borderline personality disorder who do not engage in recurrent suicidal or self-injurious behavior

BACKGROUND

Despite the significant psychosocial morbidity associated with borderline personality disorder (BPD), its underrecognition is a significant clinical problem. BPD is likely underdiagnosed, in part, because patients with BPD usually present with chief complaints associated with mood, anxiety, and substance use disorders. When patients with BPD do not exhibit self-harm behavior, we suspect that BPD is less likely to recognized. An important question is whether the absence of this criterion, which might attenuate the likelihood of recognizing and diagnosing the disorder, identifies a subgroup of patients with BPD who are 'less borderline' than patients with BPD who do not manifest this criterion.

METHODS

Psychiatric outpatients were evaluated with a semi-structured diagnostic interview for DSM-IV BPD, 390 of whom were diagnosed with BPD. We compared the demographic and clinical characteristics of patients with BPD who do and do not engage in repeated suicidal and self-harm behavior.

RESULTS

Approximately half of the patients with BPD did not meet the suicidality/self-injury diagnostic criterion for the disorder. There were no differences between the patients who did and did not meet this criterion in occupational impairment, likelihood of receiving disability payments, impairment in social functioning, level of educational achievement, comorbid psychiatric disorders, history of childhood trauma, or severity of depression, anxiety, or anger upon presentation for treatment.

CONCLUSIONS

Repeated self-injurious and suicidal behavior is not synonymous with BPD. It is critical for clinicians to be aware that the absence of repeated self-injury and suicide threats/gestures or attempts does not rule out the diagnosis of BPD.

Borderline personality disorder in men: A literature review and illustrative case vignettes

The aim is to review the salient literature on borderline personality disorder (BPD) in men and link those findings with case vignettes. We provide a literature review and then report case examples of those who met DSM and clinical BPD criteria, and consider the extent to which the small male sub-set corresponded developmentally and phenomenologically with prototypic BPD in women. The review considered phenomenological, epidemiological, biological and developmental BPD factors, finding BPD men evidence elevated substance abuse, and 'externalising' patterns of behavior, antisocial personality traits, violent self-harm and interpersonal aggression, whereas women display more 'internalising' strategies. The five male vignettes enriched the literature review providing support for gender differences reported in our review. The literature and case vignette findings should assist clinicians in recognising that BPD in men may not be as rare as generally viewed, and which may reflect BPD being commonly viewed as weighted to women and being misdiagnosed as an antisocial personality disorder (ASPD) in men.

Phenomenology of borderline personality disorder: the role of race and socioeconomic status

Little is known about racial differences in borderline personality disorder (BPD) that may influence etiology, phenomenology, and treatment of women with BPD. A total of 83 women with BPD participated in this cross-sectional study: n = 41 white and n = 42 African-American women. Structured interviews were used to assess Axis I and II disorders, and a series of interviews and questionnaires captured internalizing and externalizing symptoms. The white women with BPD reported more severe internalizing symptoms, whereas the African-American women reported more severe externalizing symptoms. Except for the association between race and number of suicide attempts, the relationship between race and internalizing/externalizing symptoms was mediated by socioeconomic status. In conclusion, African-American women with BPD may present with more severe symptoms of lack of anger control and fewer suicidal behaviors than those of white women with BPD, raising the possibility that they are misdiagnosed and receive treatments that are not optimal for BPD.

Ethnic variations in the structure of borderline personality disorder symptomatology

The goal of this study was to examine differences in the factor structure of borderline personality disorder symptoms among different ethnic groups. The authors obtained information regarding ethnic identity and endorsement of borderline personality disorder criteria for an ethnically diverse community sample of 1140 young adult subjects from south Florida. Using this information the authors conducted an exploratory factor analysis examining differences between Caucasian, Hispanic and African American groups. A principal-components factor analysis (PCA) with Varimax rotation for each ethnic group revealed a reasonably generalizable four-factor structure: affective dysregulation, cognitive disturbance, disturbed relatedness and behavioral dysregulation. The emergence of a four-factor structure across three separate, relatively large samples suggests that the factors obtained have merit. However, the loadings of some BPD symptoms, such as impulsivity, varied for each ethnic group. The results of this study indicate that ethnic variations in borderline personality disorder should be considered during assessment and treatment of this disorder. Also, future research should examine if this same factor structure holds for ethnic minorities with BPD diagnoses, examine ethnic differences in the etiology and maintenance of BPD symptomatology, and explore the effects that these differences might have in treatment settings.

Neuronal correlates of reward and loss in Cluster B personality disorders: a functional magnetic resonance imaging study

Decision making is guided by the likely consequences of behavioural choices. Neuronal correlates of financial reward have been described in a number of functional imaging studies in humans. Areas implicated in reward include ventral striatum, dopaminergic midbrain, amygdala and orbitofrontal cortex. Response to loss has not been as extensively studied but may involve prefrontal and medial temporal cortices. It has been proposed that increased sensitivity to reward and reduced sensitivity to punishment underlie some of the psychopathology in impulsive personality disordered individuals. However, few imaging studies using reinforcement tasks have been conducted in this group. In this fMRI study, we investigate the effects of positive (monetary reward) and negative (monetary loss) outcomes on BOLD responses in two target selection tasks. The experimental group comprised eight people with Cluster B (antisocial and borderline) personality disorder, whilst the control group contained fourteen healthy participants. A key finding was the absence of prefrontal responses and reduced BOLD signal in the subcortical reward system in the PD group during positive reinforcement. Impulsivity scores correlated negatively with prefrontal responses in the PD but not the control group during both, reward and loss. Our results suggest dysfunctional responses to rewarding and aversive stimuli in Cluster B personality disordered individuals but do not support the notion of hypersensitivity to reward and hyposensitivity to loss.

Substance abuse prevalence and treatment among Latinos and Latinas

Substance abuse prevalence rates for Latinos/as generally mirror those of the general U.S. population; however, a number of indicators of assimilation to U.S. culture as well as sociodemographic variables predict substance use and abuse among this group. Latinos/as have poorer outcomes in substance abuse treatment programs. Yet there is little empirical evidence that explains the problems these individuals experience in treatment, and there are few studies on the use and effectiveness of mutual help groups among this population. New developments in the conceptualization and measurement of acculturation will lead to a greater understanding of the role of culture in the prevalence and treatment of substance-related problems.

Inter-rater and test-retest reliability of the Spanish language version of the eating disorder examination interview: clinical and research implications

BACKGROUND

To examine the inter-rater and test-retest reliability of the Spanish Language version of the Eating Disorder Examination (S-EDE) in monolingual Latina women. Established measures are needed to study Latino groups, and short-term test-retest reliability findings are needed to provide context for clinical treatment and outcome studies.

METHODS

Inter-rater reliability (IRR) and short-term (5-14 days) test-retest reliability (TRR) of the S-EDE (using intraclass correlation coefficients [ICCs]) were examined in a non-clinical study group of 60 monolingual Latina women.

RESULTS

IRR was excellent for objective bulimic episodes (ICC = 0.99) but was modest for subjective bulimic episodes (ICC = 0.55). TRR was good for objective bulimic episodes (ICC = 0.79) but was unacceptable for subjective bulimic episodes (ICC = 0.22). IRR and TRR kappa coefficients (0.56 and 0.37, respectively) for identifying the presence or absence of objective bulimic episodes were modest. For the S-EDE subscales, both IRR (ICCs ranged from 0.80 to 0.98) and TRR (ICCs ranged from 0.67 to 0.90) were good to excellent.

CONCLUSIONS

These findings provide preliminary support for the reliability of the S-EDE for use with Latina women. The constructs of eating disorder psychopathology measured by the S-EDE subscales (restraint, eating concern, weight concern, and shape concern) and the core feature of binge eating (objective bulimic episodes) show high short-term consistency. The results for subjective bulimic episodes are consistent with previous studies that have questioned whether these eating behaviors are reliable indicators of eating disorders. Additional evaluation is needed with clinical groups.