Psychopharmacologic management of patients with borderline personality disorder

The inpatient evaluation and treatment of a self-professed budding serial killer

The authors present the case of a man who was hospitalized after claiming that he was about to become a serial killer. The patient presented with extensive written homicidal fantasies and homicidal intentions without evidence of actual homicidal acts. In addition to routine assessments, hospital staff members used case conferences, psychological testing, outside forensic consultation, and a forensic review process to make decisions regarding diagnosis, treatment planning, and discharge. The patient was discharged after 8 months of inpatient treatment and was apparently free of homicidal impulses or symptoms of severe mental illness. A 2-year court commitment allowed for the enactment and potential enforcement of a discharge plan that was endorsed by the patient, the hospital, and community care providers. The authors review diagnostic and risk management issues. Comparisons with known features of typical serial killers are made.

Developing effective services for patients with personality disorders

OBJECTIVE

This review focused on empirical research that addressed the effectiveness of service models for the care of patients with personality disorders.

METHOD

Services discussed included those delivering acute care, such as crisis and emergency services and acute psychiatric hospitalization; continuing care, such as outpatient services, day hospital treatment, and assertive community treatment programs; and other community programming, such as integrated treatment for comorbid substance abuse and psychoeducational interventions for families of patients with personality disorders. The review focused on studies that included patients with personality disorders, and it measured outcomes relevant to patients with personality disorders. Evidence from randomized controlled trials was highlighted.

RESULTS

Few systematic studies of acute services were available. Community programming can decrease the risk of suicide attempts and reliance on inpatient admissions. Services must develop methods of ensuring compliance with treatment. Assertive community treatment for Axis II patients should be developed, implemented, and tested. Comprehensive programming for patients with personality disorders must include integrated treatment for substance abuse and family psychoeducational programs.

CONCLUSION

Promising new models of care for patients with personality disorders are ready for testing and wider application.

An affective syndrome in psychopaths with borderline personality disorder?

A preliminary study of the repetitive mood swings of 72 female psychopaths with a DSM-III diagnosis of borderline personality disorder demonstrated considerable complexity and specificity in what has been previously considered a criterion of personality disorder. A principal-components analysis of the symptom profile for these affective disturbances revealed four factors (anxiety, anger, depression, and tension) which showed individual patterns of association with additional lifetime diagnoses of major mental illness and other personality disorders. The women also had multiple mood-related behavioural disorders, enacted with a feeling of compulsion, which appeared to relieve the original affective symptoms. It is hypothesised that these women could have a distinct affective syndrome that has not previously been described in the literature.

Biological markers in borderline personality disorders: an overview

The state of knowledge in the area of suggested biological markers that may delineate subpopulations of patients with borderline personality disorders (BPD) is reviewed. There is widespread disagreement as to the specificity of these markers. The clinical implications of Axis I--Axis II, state vs. trait, acute vs. chronic, and definite vs. probable diagnoses, all seem to contribute to the confusion in this area. Some patients with BPD and with schizotypal personality disorders (SPD) share neuroendocrine abnormalities with affective disorders (AD) and schizophrenic (SCH) patients respectively. This interface and/or potential overlap between personality disorders (PD) and the major mental disorders is discussed with special reference to the DST, TRH/TSH test, and REM latency which have already been established as valuable biological markers for certain subtypes of depression. In contrast, biologic abnormalities observed in chronic schizophrenia are also present in some SPD patients. Current data are supportive of the hypothesis that some PD patients are independent whereas others are genetically related to the major mental disorders.