Calling for a Unified Redefinition of "Borderlineness": Commentary on Gunderson et al

Nature and Assessment of Personality Pathology and Diagnosis

This article demonstrates the contribution of Otto Kernberg's object relations theory of personality pathology to the current understanding of the nature and assessment of personality pathology and diagnosis. The article introduces recent advances in psychiatric nosology and presents differing views on the meaning of the general severity criterion common to all personality pathology (i.e., level of personality functioning as described in criterion A of the Alternative DSM-5 Model for Personality Disorders). Next, the significance of Kernberg's theory to recent nosological advances is discussed, with a focus on two important features: first, a definition of personality that goes beyond signs and symptoms to include structural motivational components, in the domains of self- and interpersonal functioning, that are common to all personality manifestations and that fulfill an intrapsychic, organizing function; second, identity formation and consolidation as the ultimate end point of healthy personality functioning. That these cornerstone features of Kernberg's theory, articulated more than 50 years ago, align with the most up-to-date conceptualization of personality pathology confirms that Kernberg's theory represents an idea whose time has finally come.

Prevalence and comorbidity of borderline personality traits in the Quebec general population aged 12-14 years

PURPOSE

The early identification of borderline personality traits (BPT) in adolescents helps to prevent their progression. Data are available for the clinical population, but little has been published on the general population, especially regarding age and sex distribution in adolescence. Even less is known about the comorbidity of BPT with other mental disorders.

METHODS

We estimated the prevalence of BPT, by sex, age, and comorbidity, in a sample of adolescents aged 12-14 years (n = 799) from the Quebec Mental Health Survey. A complex sampling design was used to ensure representativeness. BPT was assessed with the abbreviated-diagnostic interview for borderlines-revised, with the adolescent as an informant. Reliability coefficients were above 0.80. Several levels of severity were explored using an independent criterion, defined by impairment according to the Columbia impairment scale.

RESULTS

The overall prevalence of BPT was 6.3%. Prevalence estimates for the most impaired were 3.2% for the entire sample and 1.3% for 12-year-olds. Prevalence increased significantly with age for most impairment levels but did not differ significantly between the sexes. In adolescents, BPT displayed moderate-to-strong comorbidity with anxiety (AD) and insomnia disorders, and very strong comorbidity with depressive (DD), attention deficit hyperactivity (ADHD), and oppositional defiant/conduct disorders (ODD/CD).

CONCLUSION

We, therefore, make two clinical recommendations for child psychiatry practice: (1) with respect to the lower rate of male adolescents attending BPT Health Programs, increase BPT screening in male adolescents; (2) evaluate BPT when children with ADHD or ODD/CD develop AD or DD during adolescence.

Expectation of Selfishness From Others in Borderline Personality Disorder

Social difficulties are apparent in borderline personality disorder (BPD). Behavior in BPD is characterized by mistrust and expectations of malevolence from others. We examined whether there is an asymmetry between their social behavior and their belief about other people’s social motivations. Subjects completed a task where they had to allocate money between themselves and an imagined other they will not meet and interact with. In addition they also had to report their expectations about how the imagined other would solve the task. We hypothesized that even though BPD patients will act in a prosocial way, they will expect selfish behavior from the other. We used the Slider Measure of social value orientation (SVO) and also created a modified version of the measure to examine the discrepancy between the subjects’ own SVO and their expectations from other people. We compared the results of thirty clinically diagnosed BPD patients to a matched sample of healthy participants. Our results show that the BPD group’s selfishness expectations significantly outweigh the expectations of selfishness in the HC group (U = 269, p = 0.007). This result further supports the mistrust and negativity bias observed in various aspects of social interactions in BPD.

Latent profiles of patients with borderline pathology based on the alternative DSM-5 model for personality disorders

BACKGROUND

There have been multiple attempts to try to parse out heterogeneity within borderline pathology by identifying patient subtypes; thus far, these works have yielded few consistent results. Recent developments in the operationalization of borderline pathology may provide new opportunities to identify clinically and conceptually meaningful subgroups of patients. The Alternative DSM-5 Model for Personality Disorders (AMPD) offers a categorical-dimensional operationalization of Borderline personality disorder (BPD) that has yet to be tested for identification of patient subgroups. The purpose of the present study is to test whether the combination of the Criterion A elements (pertaining to level of severity) and the seven pathological facets from Criterion B that define BPD in the AMPD can yield meaningful patient profiles.

METHODS

A total of 211 outpatients from a specialized PD treatment program (133 women, Mage = 33.66, SD = 10.97) were selected based on the presence of at least moderate borderline pathology according to cutoffs recently proposed for the Borderline Symptom List-23. Valid Criterion A (Self and Interpersonal Functioning Scale) and B (Personality Inventory for DSM-5 Faceted Brief Form) self-reports were administered to measure elements and facets that define BPD in the AMPD model; these variables were used as indicators in a latent profile analysis (LPA).

RESULTS

The optimal solution generated by LPA yielded four distinct profiles: (a) Borderline traits; (b) Moderate pathology with Impulsivity; (c) Moderate pathology with Identity problems and Depressivity; and (d) Severe pathology. Clinically meaningful distinctions emerged among profiles on AMPD indicators and external variables relevant to PD, especially aggression and impulsivity.

CONCLUSIONS

Profiles reflected both the "severity" and "style" components imbedded within Criterion A and B of the AMPD, as they were mainly distinguished by a continuum of severity but also by some meaningful qualitative differences that may have important clinical implications for treatment planning and contracting. Results also suggest that the four Criterion A elements have independent value to identify important differences in patients with borderline pathology. They also highlight that some Criterion B facets that define BPD in the AMPD may be especially important to identify subgroups of patients, mainly Impulsivity and Depressivity.

Personality Functioning and Mentalizing in Patients With Subthreshold or Diagnosed Borderline Personality Disorder: Implications for ICD-11

The 11th revision of the International Classification of Diseases for Mortality and Morbidity Statistics (ICD-11) defines personality disorder according to personality functioning, which relates to self- and interpersonal functioning. The aim of the present study was to assess the relationship between mentalizing and personality functioning in patients with subthreshold or diagnosed borderline personality disorder. A total of 116 eligible participants were included. Mentalizing was assessed using the Mentalization Questionnaire (MZQ), personality functioning (self- and interpersonal functioning) was assessed using the Level of Personality Functioning Scale-Brief Form 2.0 (LPFS-BF), and borderline severity was assessed using the Zanarini Rating Scale (ZAN-BPD). Mediation analysis was employed to test if mentalizing accounted for the relationship between borderline severity and self- and interpersonal functioning. We found a significant relationship between borderline severity and both subscales of the LPFS-BF. Mentalizing fully and significantly mediated the relationship between borderline severity and interpersonal functioning. However, mentalizing only partly mediated the relationship between borderline severity and self-functioning. Controlling for the covariates gender and age did not impact the results. Mentalizing is likely to be involved in the ICD-11 model of personality functioning, especially interpersonal functioning. This could emphasize the relevance of therapy aimed at strengthening mentalizing abilities when treating personality pathology in general and people with borderline personality disorder in particular. However, self-functioning may be more nuanced, as aspects other than mentalizing also influence self-functioning. The study is explorative in nature and has methodological limitations that require caution in the interpretation and generalizability.

DSM-5 Level of Personality Functioning: Refocusing Personality Disorder on What It Means to Be Human

Level of Personality Functioning (LPF) represents the entry criterion (Criterion A) of the Alternative Model for Personality Disorders (AMPD) in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). It is defined as a dimensional general severity criterion common to all personality disorders and conceptually independent of personality types or traits, and it represents maladaptive self (identity and self-direction) and interpersonal (empathy and intimacy) functioning. We review the history, measurement, and significance of LPF. We show that the inclusion of LPF in the AMPD is well justified if it is defined as a general adaptive failure of a subjective intrapsychic system needed to fulfill adult life tasks. If so defined, LPF distinguishes itself from maladaptive traits (Criterion B of the AMPD) and captures the contribution humans make as agentic authors to the interpretation and management of the self. While Criterion B maladaptive traits provide important descriptive nuance to manifestations of personality pathology, maladaptive LPF is conditional to the diagnosis of personality disorder.

Adolescent Personality Pathology and the Alternative Model for Personality Disorders: Self Development as Nexus

This paper reviews maladaptive trait development (DSM-5 Section III Criterion B), the development of DSM-5 Section II borderline personality disorder, and research on the development of identity, self-direction, empathy/mentalizing, and intimacy (DSM-5 Section III Criterion A). Combined, these previously disparate literatures begin to point to an integrated developmental theory of personality pathology, which suggests that Criterion A concepts (identity, self-direction, empathy, and intimacy) coalesce around the development of self, marking a discontinuous (qualitative) developmental shift. This developmental shift is a function of the demands placed on individuals to take on independent adult role function, combined with biologically-based maturational cognitive and emotional advances during adolescence. Section II personality disorder ensues when an integrated and coherent sense of self fails to develop, resulting in nonfulfilment of adult role function. In this sense, Criterion A self function can account for the onset of Section II personality disorder in adolescence, while Criterion B provides a useful descriptive account of continuous aspects of personality function over time.

Borderline personality disorder in adolescents: prevalence, diagnosis, and treatment strategies

Using the same Diagnostic and Statistical Manual of Mental Disorders, fifth version (DSM-V) criteria as in adults, borderline personality disorder (BPD) in adolescents is defined as a 1-year pattern of immature personality development with disturbances in at least five of the following domains: efforts to avoid abandonment, unstable interpersonal relationships, identity disturbance, impulsivity, suicidal and self-mutilating behaviors, affective instability, chronic feelings of emptiness, inappropriate intense anger, and stress-related paranoid ideation. BPD can be reliably diagnosed in adolescents as young as 11 years. The available epidemiological studies suggest that the prevalence of BPD in the general population of adolescents is around 3%. The clinical prevalence of BPD ranges from 11% in adolescents consulting at an outpatient clinic to 78% in suicidal adolescents attending an emergency department. The diagnostic procedure is based on a clinical assessment with respect to developmental milestones and the interpersonal context. The key diagnostic criterion is the 1-year duration of symptoms. Standardized, clinician-rated instruments are available for guiding this assessment (eg, the Diagnostic Interview for Borderlines-Revised and the Childhood Interview for DSM-IV-TR BPD). The assessment should include an evaluation of the suicidal risk. Differential diagnosis is a particular challenge, given the high frequency of mixed presentations and comorbidities. With respect to clinical and epidemiological studies, externalizing disorders in childhood constitute a risk factor for developing BPD in early adolescence, whereas adolescent depressive disorders are predictive of BPD in adulthood. The treatment of adolescents with BPD requires commitment from the parents, a cohesive medical team, and a coherent treatment schedule. With regard to evidence-based medicine, psychopharmacological treatment is not recommended and, if ultimately required, should be limited to second-generation antipsychotics. Supportive psychotherapy is the most commonly available first-line treatment. Randomized controlled trials have provided evidence in favor of the use of specific, manualized psychotherapies (dialectic-behavioral therapy, cognitive analytic therapy, and mentalization-based therapy).