Experiential avoidance in participants with borderline personality disorder and other personality disorders

BACKGROUND

The present study has descriptive and predictive aims. The descriptive aims were to determine if participants with borderline personality disorder (BPD) reported higher levels of experiential avoidance (EA) than participants with other personality disorders (OPD) as well as determine if non-recovered participants with BPD reported higher levels of EA than participants with BPD who have recovered symptomatically and psychosocially. The predictive aim was to determine if the level of EA reported by participants with BPD was predicted by the severity of aspects of childhood or adult adversity and/or aspects of temperament.

METHODS

The Overall Anxiety Severity and Impairment Scale (OASIS) was administered to 248 participants at 24-year follow-up in the McLean Study of Adult Development (MSAD). Adversity and temperament were assessed during index admission using interviews (Revised Childhood Experience Questionnaire [CEQ-R], Adult History Interview [AHI], and the NEO-FFI self-report measure).

RESULTS

Participants with BPD reported significantly higher levels of EA than those with OPD. Within the BPD group, non-recovered participants reported significantly higher levels of EA than recovered participants. Severity of childhood sexual abuse and lower levels of extraversion were found to be significant multivariate predictors of levels of EA in those with BPD.

CONCLUSIONS

Taken together, these results suggest that EA is a serious problem for participants with BPD, particularly those who have not recovered. They also suggest that both the severity of childhood adversity and a temperament marked by lower levels of extroversion are significantly related to levels of EA reported by participants with BPD.

Longitudinal Description and Prediction of Smoking Among Borderline Patients: An 18-Year Follow-Up Study

Objective: The objectives of this study were (1) to compare smoking between recovered and non-recovered patients with borderline personality disorder (BPD) over the course of 18 years and (2) to assess baseline predictors of tobacco use in patients with BPD.

Methods: A total of 264 borderline patients were interviewed concerning their smoking history beginning at the 6-year follow-up wave in a longitudinal study of the course of BPD (McLean Study of Adult Development) and re-interviewed at 2-year intervals over the next 18 years. Initial data collection of the larger study happened between June 1992 and December 1995, and the DSM-III-R and the Revised Diagnostic Interview for Borderlines (DIB-R) were used as the diagnostic instruments for BPD.

Results: Recovered patients had a 48% lower prevalence of smoking than non-recovered patients at 6-year follow-up (a significant difference; P = .01). Also, the rate of decline in smoking for the recovered group was 68% and was significantly faster (P = .008) than for the non-recovered group over the subsequent 18 years. Alcohol abuse or dependence (relative risk [RR] = 1.22; 95% CI, 1.06-1.40; P = .005), lower levels of education (RR = 1.28; 95% CI, 1.15-1.42; P < .001), and higher levels of the defense mechanism of denial (RR = 1.08; 95% CI, 1.03-1.13; P = .002) were significant predictors of smoking in borderline patients in multivariate analyses.

Conclusions: Taken together, the results of this study suggest that recovery status was an important element in the prevalence of smoking among borderline patients over time. They also suggest that smoking was predicted by 3 factors: prior psychopathology, demographics, and psychological maturity.

The 8-Year Course of Acute Physical Pain Reported by Patients With Borderline Personality Disorder and Comparison Subjects With Other Personality Disorders

The present study examines the 8-year course of physical pain and its interference with functioning in patients with borderline personality disorder (BPD) and a comparison group of patients with other personality disorders (other-PD). Participants completed the Brief Pain Inventory (BPI) at five assessments, each separated by 2 years. Results showed that across all 13 domains assessed, participants with BPD reported significantly higher levels of acute physical pain and its functional interference than other-PD comparison subjects. The severity of physical pain and its interference with multiple domains of functioning were relatively stable over 8 years of assessment for both study groups. Within the BPD group, pain was significantly associated with older age, comorbid major depressive disorder (MDD), and history of a physically violent partner. Taken together, these results suggest that physical pain is a serious health issue for individuals with BPD that interferes with functioning across a wide spectrum of areas.

Course and predictors of social security disability insurance in patients with borderline personality disorder over 24 years of prospective follow-up

BACKGROUND

The utilization of Social Security Disability Insurance (SSDI) is frequent in patients with borderline personality disorder (BPD) and may represent a meaningful marker of a patient's symptom severity, poor psychosocial functioning, and/or inner suffering. Over 24 years of prospective follow-up, the present study aims to describe the course of SSDI and assess the role of clinically relevant predictors.

METHODS

A total of 290 inpatients with BPD were interviewed at baseline and 12 consecutive follow-up waves, each separated by two years, after index hospitalization. Included were also 72 inpatients with other personality disorders. Surviving patients were reinterviewed. A series of interviews and self-report measures were used to assess psychosocial functioning and treatment history, axis I and II disorders, and childhood/adult adversity.

RESULTS

Results show that rates of SSDI utilization were relatively stable over 24 years of follow-up (on average, 47.2% of the patients with BPD were on SSDI). Patients with BPD were three times more likely to be on SSDI than patients with other PDs. Patients with BPD displayed flexibility in their usage of SSDI. By 24 years, 46% of patients remitted, out of which 85% experienced recurrence and 50% of the patients had a new onset over time. In multivariate analyses, four variables were found to predict SSDI status in patients with BPD over time. These variables were: age 26 or older, lower IQ, severity of non-sexual childhood abuse, and presence of PTSD.

CONCLUSIONS

The results of this study suggest that a combination of a demographic factors, childhood adversity, natural endowment, and comorbidity are significant predictors of receiving SSDI over time. On a group level, there is a relative stability of SSDI usage over time, but on the individual level, the present study found a high fluctuation in receiving SSDI over 24 months of prospective follow-up.

Pathways to Health Reported by Patients With Borderline Personality Disorder With a Good Overall Outcome Versus a Fair-Poor Outcome Over 24 Years of Prospective Follow-Up

Our objective was to determine pathways to health reported by patients with borderline personality disorder (BPD) who had and had not attained a good overall outcome over 24 years of prospective follow-up. Overall outcome symptomatically and psychosocially and 11 pathways to health related to vocation, relationships, activities, and psychiatric treatment that patients reported were helpful to their functioning or feeling better about themselves were assessed at 12 contiguous 2-year follow-up periods using a semistructured interview. Good outcome patients reported significantly higher rates of pathways related to work performance, relationships with friends, relationship with a partner/spouse, and athletic activities. In contrast, patients with a fair-poor outcome reported significantly higher rates of psychotherapy and psychotropic medication as pathways. Taken together, the results of this study suggest that a good overall outcome is significantly associated with reported vocational, interpersonal, and activity pathways, while a fair-poor outcome is significantly associated with reported treatment-related pathways.

Perceived Caretaker Malevolence During Childhood Reported by Borderline Patients and Personality-Disordered Comparison Subjects: Description and Prediction

This study has two purposes. The first is to assess the rates of childhood malevolence by caretakers reported by a well-defined sample of inpatients with borderline personality disorder (BPD) and comparison subjects with other personality disorders. The second purpose is to determine the relationship between reported malevolence of caretakers and possible risk factors for this experience. Two reliable interviews were administered to 290 borderline inpatients and 72 personality-disordered comparison subjects to address these aims. Malevolence was reported by a significantly higher percentage of borderline patients than comparison subjects (58% vs. 33%). In multivariate analyses, severity of other forms of abuse, severity of neglect, and a family history of a dramatic cluster personality disorder were found to significantly predict perceived malevolence. Taken together, the results of this study suggest that experiencing malevolence is common and distinguishing for BPD, and that the risk factors for reported childhood malevolence are multifactorial in nature.

Levels of Depersonalization and Derealization Reported by Recovered and Non-recovered Borderline Patients Over 20 Years of Prospective Follow-up

Borderline personality disorder (BPD) is a serious psychiatric illness, and it is often associated with dissociative symptoms. The purpose of this study was to assess the course of depersonalization and derealization symptoms in recovered and non-recovered borderline patients over 20 years of prospective follow-up. The Dysphoric Affect Scale (DAS) - a 50-item self-report measure was administered to 290 borderline inpatients at baseline, and the remaining participants (85%) at 10 follow-up interviews conducted over 20 years. The level of depersonalization and derealization experienced by borderline patients was assessed using three items (feeling unreal, feeling completely numb, and feeling like people and things aren't real) from the DAS. The patients who recovered from BPD reported significantly lower scores in all three inner states (62 - 63%) at baseline compared to those patients who did not recover. Furthermore, scores of recovered and non-recovered groups decreased significantly in all three inner states studied over 20 years of prospective follow-up. Overall, these results suggest that the severity of depersonalization and derealization symptoms decreased significantly over 20 years of prospective follow-up and had a strong association with BPD recovery status.

Levels of Acceptance and Forgiveness Reported by Patients With BPD and Personality-Disordered Comparison Subjects Over 20 Years of Prospective Follow-Up

This study had two objectives: to determine the levels of acceptance and forgiveness reported by patients with borderline personality disorder (BPD) and personality-disordered comparison subjects and by recovered versus non-recovered patients with BPD over 20 years of prospective follow-up. Levels of acceptance and forgiveness were reassessed every 2 years. Patients with BPD reported levels of these states that were approximately 70% lower than comparison subjects at baseline. These states increased significantly over time for patients with BPD but not for comparison subjects. Recovered patients with BPD reported approximately three times the levels of these states than non-recovered patients with BPD. These levels increased for both groups over time; one state (accepting of myself) increased at a significantly steeper rate for recovered patients with BPD. These results suggest that patients with BPD report becoming more accepting and forgiving over time. Additionally, recovery status is significantly associated with increasing time in these states.

The 24-year course of major depression in patients with borderline personality disorder and personality-disordered comparison subjects

BACKGROUND

This study had two main objectives. The first was to detail the prevalence of major depressive disorder over 24 years of follow-up for both patients with borderline personality disorder (BPD) and comparison subjects with other personality disorders (OPD). The second was to determine time-to-remission, recurrence, and new onset of major depression among these two groups of patients.

METHODS

The SCID-I was administered to 290 borderline inpatients and 72 personality-disordered comparison subjects during their index admission. It was also re-administered at 12 contiguous two-year follow-up periods.

RESULTS

The prevalence of major depression was significantly higher for borderline patients over time but declined significantly over time for those in both study groups. In terms of time to events, 93% of borderline patients meeting criteria for major depression at baseline experienced a two-year remission by the time of the 24-year follow-up. Recurrences were about as common (90% for those with remitted major depression). New onsets of major depression were also very common (86% for those without major depression during their index admission).

LIMITATIONS

Results may not pertain to less severely ill patients with BPD and those in less treatment.

CONCLUSIONS

Taken together, the results of this study suggest that the remitting-recurring course of major depression in borderline patients is very similar to the course of major depression in those with other types of personality disorder and those for whom major depression is their primary disorder.

Predictors of Slower Time-to-Cessation of Individual Therapy for Borderline Patients Over 16 Years of Prospective Follow-Up

The current study assesses time-to-cessation of individual therapy for patients with borderline personality disorder (BPD) and comparison subjects with other personality disorders (OPD) after 16 years of prospective follow-up. It also details the multivariate factors that predict this outcome for those with BPD. At baseline, 290 patients met criteria for BPD and 72 met criteria for OPD. Individuals with BPD had a significantly slower time-to-cessation of individual therapy than OPD comparison subjects. Seven baseline variables were found to be significant multivariate predictors of a slower time-to-cessation of individual therapy: older age, being white, severity of childhood neglect, history of a mood disorder, an IQ less than 90, poor vocational record prior to index admission, and higher level of trait neuroticism. The results of this study suggest that prediction of slower time-to-cessation of individual therapy is multifactorial in nature, involving factors related to demographics, childhood adversity, comorbidity, individual competence, and temperament.

Deaths by Suicide and Other Causes Among Patients With Borderline Personality Disorder and Personality-Disordered Comparison Subjects Over 24 Years of Prospective Follow-Up

OBJECTIVE

This study has 4 aims. The first is to determine rates of mortality due to suicide and other causes for patients with borderline personality disorder (BPD) and personality-disordered comparison subjects over 24 years of prospective follow-up. The second and third aims are to determine the best predictors of time-to-suicide and time-to-premature death (not due to suicide) in patients with BPD. A final aim is to determine whether mortality rates are impacted by recovery status.

METHODS

A total of 290 adult inpatients meeting rigorous Revised Diagnostic Interview for Borderlines and DSM-III-R criteria for BPD and 72 personality-disordered comparison subjects were recruited during inpatient admission at McLean Hospital between June 1992 and December 1995. Participants were followed and reassessed every 2 years, with data collection now entering its 26th year. Participant deaths were tracked over time.

RESULTS

A total of 5.9% of borderline patients and 1.4% of comparison subjects died by suicide. Additionally, 14.0% of borderline patients and 5.5% of comparison subjects died by non-suicide causes. Among borderline patients, number of prior hospitalizations significantly predicted completed suicide (HR = 1.62, P = .037). Sociodemographic factors, physical health indicators, and psychiatric history significantly predicted premature death (not due to suicide) in bivariate analyses (all P values < .05). In multivariate analyses, male sex (HR = 3.56, P = .003) and more prior psychiatric hospitalizations (HR = 2.93, P < .001) significantly predicted premature death. Most borderline patients who died either by suicide (87.5%) or non-suicide-related causes (88%) were not recovered before death.

CONCLUSIONS

Taken together, these findings suggest that individuals with BPD are at elevated risk of premature death. Patients who did not achieve recovery were at a disproportionately higher risk of early death than recovered patients.

Facets of identity disturbance reported by patients with borderline personality disorder and personality-disordered comparison subjects over 20 years of prospective follow-up

This study had two objectives. The first was to determine the levels of identity disturbance reported by 290 patients with borderline personality disorder (BPD) and 72 personality-disordered comparison subjects over 20 years of prospective follow-up. The second aim was to describe the levels of identity disturbance reported by 152 ever recovered vs. 138 never recovered borderline patients over 20 years of prospective follow-up. Participants were followed and re-assessed every two years for a total of 20 years of follow-up. Borderline patients reported levels of these states that were more than three times higher than personality-disordered comparison subjects, with both groups demonstrating significant declines in these states over time. For three of these inner states ("I feel like I am worthless," "I feel like a complete failure," and "I feel like I am evil"), recovered borderline patients had lower baseline scores and significantly different patterns of decline than non-recovered patients. For the fourth state, "I feel like I am a bad person," recovered patients had lower scores over time, but the groups declined at the same rate. These results suggest that borderline patients report experiencing inner states related to having a negative identity less often over time. Additionally, recovery status is significantly associated with decreased time experiencing these states.

Description and prediction of time-to-attainment of excellent recovery for borderline patients followed prospectively for 20 years

One purpose of this study was to determine the cumulative rates of excellent recovery for borderline patients and axis II comparison subjects followed prospectively for 20 years. Another purpose was to find the best set of baseline predictors of excellent recovery for borderline patients. A total of 290 inpatients meeting rigorous criteria for borderline personality disorder and 72 axis II comparison subjects completed semistructured interviews and self-report measures during their index admission. Subjects were reassessed prospectively over 10 contiguous two-year waves of follow-up. Thirty-nine percent of borderline patients and 73% of personality-disordered comparison subjects met our operationalized definition of excellent recovery (concurrent remission of borderline or another primary personality disorder, good social and full-time vocational functioning, and absence of an axis I disorder associated decreased social and/or vocational functioning). Five variables formed our multivariate predictive model of excellent recovery for borderline patients: higher IQ, good childhood work history, good adult vocational record, lower trait neuroticism, and higher trait agreeableness. The results of this study suggest that complete recovery is difficult for borderline patients to achieve even over long periods of time. They also suggest that competence displayed in both childhood and adulthood is the best predictor of this important outcome.

The 10-year course of adult aggression toward others in patients with borderline personality disorder and axis II comparison subjects

This study had two aims. The first was to assess and compare various types of aggressive behavior toward others reported by borderline patients and axis II comparison subjects over time. The second was to determine the best baseline and time-varying predictors of aggressive behavior in these borderline patients. At baseline, a series of interviews and self-report measures were administered to 290 borderline patients and 72 axis II comparison subjects. Measures assessing aggression toward others, axis I and II disorders as well as adult adversity were re-administered every two years over the course of ten years. It was found that borderline patients reported significantly higher rates of verbal, emotional, and physical aggression toward others than comparison subjects but the rates of these forms of aggression toward others declined significantly for those in both study groups. Multivariate analyses indicated that the strongest predictors of adult aggression towards others were severity of adult adversity and a substance use disorder. Taken together, these results suggest that borderline patients commonly report aggression toward others but that this aggression declines significantly over time. These results also suggest that this aggression toward others is most strongly associated with adult experiences of adversity and concurrent substance abuse.

Description and prediction of the income status of borderline patients over 10 years of prospective follow-up

BACKGROUND

Research shows that individuals suffering from borderline personality disorder are economically disadvantaged, but longitudinal data is lacking.

AIM

This study examined the income of borderline personality disorder (BPD) patients and axis II comparison subjects over 10 years of follow-up and assessed predictors of income among BPD patients.

METHOD

Data on income was obtained for 264 BPD patients and 63 axis II comparison subjects at 6-year follow-up and for surviving patients at five follow-up waves. Baseline and time-varying predictors of income were assessed using information from interviews and self-report measures.

RESULTS

Regardless of diagnosis, a greater proportion of people shifted into the higher income groups over time. Being in a higher income group was more likely to happen and happened more rapidly for axis II comparison subjects than for BPD patients. Results regarding the BPD patients indicated that childhood emotional, verbal and/or physical abuse were associated with a greater likelihood of being in a lower income group, whereas years of education and a higher IQ were associated with a greater likelihood of being in a higher income group.

CONCLUSION

Borderline personality disorder (BPD) patients show enduring lowered economic functioning. Their economic functioning seems to be negatively affected by childhood emotional, verbal and/or physical abuse but positively affected by years of education and IQ. Copyright © 2016 John Wiley & Sons, Ltd.

Prevalence and course of sexual relationship difficulties in recovered and non-recovered patients with borderline personality disorder over 16 years of prospective follow-up

Although borderline patients experience a wide range of sexual problems, including promiscuity, there is less evidence documenting their sexual relationship difficulties. This study had two aims. The first was to examine the prevalence of these difficulties (i.e. avoidance of sex and being symptomatic after sex) over 16 years of prospective follow-up among recovered and non-recovered patients with borderline personality disorder (BPD). The second was to determine time-to-remission, recurrence and new onset of these sexual relationship difficulties. The sexual relationship difficulties of 290 patients meeting both DIB-R and DSM-III-R criteria for BPD were assessed at baseline using the Abuse History Interview and reassessed every two years over eight waves of prospective follow-up. The prevalence of sexual relationship difficulties declined significantly over time for both groups of patients, while remaining significantly more common among non-recovered patients. By 16-year follow-up, over 95% of each group achieved remission for both types of difficulties. Recurrences of avoidance of sex were significantly more common in non-recovered patients. Non-recovered patients had higher rates of new onsets compared to recovered patients for each type of sexual relationship difficulty. Taken together, the results suggest that sexual relationship difficulties are not chronic for those with BPD regardless of recovery status. Copyright © 2016 John Wiley & Sons, Ltd.

Fluidity of the Subsyndromal Phenomenology of Borderline Personality Disorder Over 16 Years of Prospective Follow-Up

OBJECTIVE

The purpose of this study was to determine the cumulative rates of 2- and 4-year remission, and the recurrences that follow them, of 24 symptoms of borderline personality disorder over 16 years of prospective follow-up.

METHOD

A total of 290 inpatients meeting rigorous criteria for borderline personality disorder and 72 axis II comparison subjects were assessed during their index admission using a series of semistructured diagnostic interviews. The same instruments were readministered at eight contiguous 2-year time periods.

RESULTS

The 12 acute symptoms (e.g., self-mutilation, help-seeking suicide attempts) of borderline personality disorder were more likely to remit for a period of 2 years and for a period of 4 years than the 12 temperamental symptoms (e.g., chronic anger/frequent angry acts, intolerance of aloneness) of this disorder. They were also less likely to recur after a remission lasting 2 years or a remission lasting 4 years.

CONCLUSIONS

Taken together, the symptoms of borderline personality disorder are quite fluid, with remissions and recurrences being common. However, the more clinically urgent acute symptoms of borderline personality disorder seem to have a better prognosis than the less turbulent temperamental symptoms of the disorder.

Development of the self-report version of the Zanarini Rating Scale for Borderline Personality Disorder

The purpose of this study was to assess the psychometric properties of the self-report version of the Zanarini Rating Scale for Borderline Personality Disorder (ZAN-BPD). The measure covers a 1-week time frame, and each of the nine criteria for BPD is rated on a five-point anchored rating scale of 0-4. Seventy-five subjects meeting DSM-IV criteria for BPD were recruited from the community. The convergent validity of the interview and self-report versions of the ZAN-BPD was found to be high (with a median value of 0.70). In terms of reliability, the internal consistency of the nine criteria scores of the ZAN-BPD was found to be good (Cronbach's alpha = 0.84). In addition, 13 of 14 intraclass correlations for same-day test-retest reliability were in the excellent range (> 0.75). Finally, the sensitivity of both versions of the ZAN-BPD to change was assessed 7-10 days after they were first administered and found to be adequate (e.g. r = 0.66 for total score of ZAN-BPD). Taken together, the results of this study suggest that the self-report ZAN-BPD is a promising self-report scale for the assessment of change in the severity of borderline psychopathology over time.

The course of marriage/sustained cohabitation and parenthood among borderline patients followed prospectively for 16 years

The purpose of this study was to determine the rate of marriage/sustained cohabitation and parenthood reported by recovered and nonrecovered borderline patients, the age first undertaken, and the stability of these relationships. Borderline patients were interviewed about these topics during their index admission and eight times over 16 years of prospective follow-up. Recovered borderline patients were significantly more likely than nonrecovered borderline patients to have married/lived with an intimate partner and to have become a parent. In addition, they first married/cohabited and became a parent at a significantly older age. They were also significantly less likely to have been divorced or ended a cohabiting relationship. In addition, they were significantly less likely to have given up or lost custody of a child. Taken together, the results of this study suggest that stable functioning as a spouse/partner and as a parent are strongly associated with recovery status for borderline patients.

Treatment rates for patients with borderline personality disorder and other personality disorders: a 16-year study

OBJECTIVE

The goal of this study was to document the use of 16 treatment modalities reported by 290 patients with borderline personality disorder and 72 patients with other axis II disorders over 16 years of prospective follow-up.

METHODS

This study built upon previous findings of the McLean Study of Adult Development. Treatment use was assessed at baseline and at eight two-year follow-up periods with a semistructured interview of proven reliability and validity.

RESULTS

Patients with borderline personality disorder reported significantly higher rates of use of 12 of the 16 treatment modalities studied. Only four of the 16 treatment modalities were used by roughly the same percentage of patients with borderline personality disorder and those with other axis II disorders: individual therapy, intensive individual therapy, couples or family therapy, and electroconvulsive therapy. In addition, rates of participation in 13 treatment modalities declined significantly over the first eight years of follow-up for those in both study groups. However, the rates of participation in 15 of 16 treatment modalities did not decline significantly over the second eight years of follow-up for those in either study group.

CONCLUSIONS

The results of this study suggest that rates of treatment use by patients with borderline personality disorder decline significantly over the short and medium term. They also suggest that these rates remain stable or fail to decline further over the longer term.

Severity of anxiety symptoms reported by borderline patients and Axis II comparison subjects: description and prediction over 16 years of prospective follow-up

The first purpose of this study was to determine the severity of anxiety symptoms reported by borderline patients and Axis II comparison subjects over 16 years of follow-up. The second purpose was to determine the most salient predictors of the severity of anxiety symptoms of borderline patients. Initially, 290 borderline inpatients and 72 comparison subjects were assessed using measures of anxiety, childhood adversity, and normal personality. The severity of anxiety symptoms was reassessed every 2 years. Borderline patients reported approximately twice as severe symptoms of anxiety as comparison subjects. However, these symptoms decreased significantly over time for those in both groups. Among borderline patients, two variables were found to be significant multivariate predictors of severity of overall anxiety: nonsexual childhood abuse and trait neuroticism. The results of this study suggest that anxiety symptoms form a distinct profile for borderline patients-a profile related to both childhood adversity and a vulnerable temperament.

Pain in patients with borderline personality disorder

OBJECTIVE

Patients with borderline personality disorder (BPD) frequently present to primary care physicians and specialists with pain problems. The aims of the current study are to (1) examine the prevalence of pain symptoms in patients with a diagnosis of BPD compared with a diagnosis of another personality disorder and (2) identify the factors that predict pain experienced in patients with BPD.

METHODS

Two hundred and ninety inpatients meeting Revised Diagnostic Interview for Borderlines and DSM-III-R criteria for BPD and 72 patients who met DSM-III-R criteria for another personality disorder were assessed at baseline using semistructured interviews and self-report measures. Ratings of pain were assessed 16 years after baseline diagnosis and compared between diagnostic groups using t-tests. Regression analyses were used to identify predictors of pain among patients with BPD.

RESULTS

Patients with BPD are more likely to experience pain and rate their pain as more severe than patients with other personality disorders. In multivariable regression models, there were three significant predictors of severity of pain among patients with BPD: older age, the presence of major depressive disorder, and the severity of childhood abuse other than sexual abuse.

CONCLUSION

Patients with BPD report significant pain, which interferes with their lives. A focus on the management of medical and psychiatric comorbidities may improve their long-term functioning.

The 16-year course of shame and its risk factors in patients with borderline personality disorder

The current study had two aims. The first was to examine the course of shame over 16 years of prospective follow-up among borderline patients and axis II comparison subjects. The second was to determine risk factors associated with feelings of shame among borderline patients. A total of 290 borderline inpatients and 72 axis II comparison subjects were assessed using a series of semi-structured interviews and self-report measures at baseline, and 87% of surviving patients were reassessed at eight waves of follow-up. Borderline patients reported significantly higher levels (2.6 times) of shame (assessed with one item) across 16 years of follow-up than axis II comparison subjects. However, the severity of shame decreased (78% relative decline) significantly over time for both groups. Regarding risk factors, four lifetime adversity risk factors were found to be significantly associated with feelings of shame. Two of these factors (severity of childhood sexual abuse and severity of childhood neglect) remained significant in multivariate analyses. Taken together, the results of this study suggest that borderline patients struggle with intense but decreasing feelings of shame. They also suggest that childhood adversities are significant risk factors for this dysphoric affective state.

The use of prescription opioid medication by patients with borderline personality disorder and axis II comparison subjects: a 10-year follow-up study

OBJECTIVE

The first purpose was to determine the rate of use of prescription opioid medication reported by patients with borderline personality disorder and to compare that to the rate reported by Axis II comparison subjects during a 10-year period of prospective follow-up. The second purpose was to determine the most clinically relevant predictors of prescription opioid use among borderline patients.

METHOD

The medical conditions and Axis I disorders of 264 borderline patients and 63 Axis II comparison subjects were assessed at 6-year follow-up and 5 contiguous follow-up waves that were 2 years apart. These assessments were conducted between July 1998 and December 2010. Family history of psychiatric disorder was assessed at baseline by interviewers blind to the diagnostic status of the subjects. All 3 areas were assessed using semistructured interviews with proven psychometric properties: the Medical History and Services Utilization Interview (MHSUI), the Structured Clinical Interview for DSM-III-R Axis I Disorders (SCID-I), and the Revised Family History Questionnaire.

RESULTS

Borderline patients were significantly more likely to report the use of prescription opioid medication over time than Axis II comparison subjects (OR = 1.79; 95% CI, 1.01-3.17). The best predictors of opioid use among borderline patients were the time-varying presence of back pain (OR = 1.95; 95% CI, 1.41-2.70), fibromyalgia (OR = 3.29; 95% CI, 1.70-6.36), and osteoarthritis (OR =3.32; 95% CI, 2.08-5.29) as well as a baseline history of drug abuse (OR= 1.89; 95% CI, 1.27-2.81).

CONCLUSIONS

The sustained use of prescription opioids is common among and discriminating for patients with borderline personality disorder. The results also suggest that these borderline patients may be particularly sensitive to physical pain-mirroring their well-known heightened sensitivity to emotional pain.

Prevalence and risk factors for irritable bowel syndrome in recovered and non-recovered borderline patients over 10 years of prospective follow-up

This study examined rates of irritable bowel syndrome (IBS) over 10 years of prospective follow-up among recovered and non-recovered patients with borderline personality disorder (BPD). Subsequently, risk factors for IBS were examined in female BPD patients. As part of the McLean Study of Adult Development, 264 BPD patients were assessed at baseline, and their medical conditions and time-varying predictors of IBS were assessed over five waves of follow-up (from 6-year follow-up to 16-year follow-up). Semi-structured interviews were used to assess both our IBS outcome variable and our baseline and time-varying predictor variables. Rates of IBS were not significantly different between recovered and non-recovered borderline patients when men and women were considered together and when men were considered alone. However, a significant difference in IBS rates was found between recovered and non-recovered female BPD patients, with the latter reporting significantly higher rates. The rates of IBS in women with BPD were found to be significantly predicted by a family history of IBS and a childhood history of verbal, emotional and/or physical abuse. Taken together, the results of this study suggest that both biological/social learning factors and childhood adversity may be risk factors for IBS in women with BPD.

Relationship between maladaptive cognitions about sleep and recovery in patients with borderline personality disorder

Borderline personality disorder (BPD) has been associated with maladaptive cognitive processes including dysfunctional attitudes and a negative attribution style. Comorbid insomnia affects the course of multiple psychiatric disorders, and has been associated with the absence of recovery from BPD. Because dysfunctional beliefs and attitudes are common among patients with insomnia, the purpose of this study was to evaluate the association between maladaptive sleep-related cognitions and recovery status (symptomatic remission plus good concurrent psychosocial functioning) in patients with BPD. Two hundred and twenty three BPD patients participating in the McLean Study of Adult Development (MSAD) were administered the Dysfunctional Beliefs and Attitudes about Sleep questionnaire (DBAS-16) as part of the 16-year follow-up wave. Maladaptive sleep cognitions were compared between recovered (n=105) and non-recovered (n=118) BPD participants, in analyses that adjusted for age, sex, depression, anxiety, and primary sleep disorders. Results demonstrated that non-recovered BPD patients had significantly more severe maladaptive sleep-related cognitions as measured by the overall DBAS-16 score. These results demonstrate an association between dysfunctional beliefs and attitudes about sleep and recovery status among BPD patients. Further research is warranted to evaluate treatments targeted towards maladaptive sleep-related cognitions, and their subsequent effects on the course of BPD.

Reasons for self-mutilation reported by borderline patients over 16 years of prospective follow-up

The main objective of this study was to assess the reasons for episodes of self-mutilation engaged in by patients with borderline personality disorder (BPD) over 16 years of prospective follow-up. Two hundred and ninety patients meeting both DIB-R and DSM-III-R criteria for BPD were interviewed every 2 years. The authors divided the borderline patients into two groups: those with a more extensive and those with a less extensive lifetime history of self-mutilation at study entry. These groups were not significantly different than one another on either of the interpersonally directed reasons for self-mutilation studied. However, those in the more extensive group were significantly more likely to report each of the five internally directed reasons studied. The results of this study suggest that borderline patients with a more extensive history of self-mutilation are best distinguished from those with a less extensive history by episodes of self-harm that are motivated, at least in part, by dysphoric inner states.

The relationship of chronic medical illnesses, poor health-related lifestyle choices, and health care utilization to recovery status in borderline patients over a decade of prospective follow-up

BACKGROUND

The interaction of borderline personality disorder (BPD) with physical health has not been well characterized. In this longitudinal study, we investigated the long-term relationship of chronic medical illnesses, health-related lifestyle choices, and health services utilization to recovery status in borderline patients over a decade of prospective follow-up.

METHOD

264 borderline patients were interviewed concerning their physical health at 6-year follow-up in a longitudinal study of the course of BPD. This sample was then reinterviewed five times at two-year intervals over the next ten years. We defined recovery from BPD based on a Global Assessment of Functioning score of 61 or higher, which required BPD remission, one close relationship, and full-time competent and consistent work or school attendance. We controlled for potentially confounding effects of time-varying major depressive disorder.

RESULTS

Never-recovered borderline patients were significantly more likely than ever-recovered borderline patients to have a medical syndrome, obesity, osteoarthritis, diabetes, urinary incontinence, or multiple medical conditions (p<0.0063). They were also significantly more likely to report pack-per-day smoking, weekly alcohol use, no regular exercise, daily sleep medication use, or pain medication overuse (p<0.0083). In addition, never-recovered borderline patients were significantly more likely than ever-recovered borderline patients to undergo a medical emergency room visit, medical hospitalization, X-ray, CT scan, or MRI scan (p<0.0063).

CONCLUSIONS

Over a decade of prospective follow-up, failure to recover from BPD seems to be associated with a heightened risk of chronic medical illnesses, poor health-related lifestyle choices, and costly health services utilization.

Cognitive experiences reported by patients with borderline personality disorder and axis II comparison subjects: a 16-year prospective follow-up study

OBJECTIVE

The authors assessed three main types of disturbed cognition: nonpsychotic thought (odd thinking, unusual perceptual experiences, and nondelusional paranoia), quasi-psychotic thought, and true psychotic thought in patients with borderline personality disorder followed prospectively for 16 years. They also compared the rates of these disturbed cognitions with those reported by axis II comparison subjects.

METHOD

The cognitive experiences of 362 inpatients (290 borderline patients and 72 axis II comparison subjects) were assessed at study entry using the cognitive section of the Revised Diagnostic Interview for Borderlines. Participants' cognitive experiences were reassessed every 2 years using the same interview.

RESULTS

Each of the five main types of thought studied was reported by a significantly higher percentage of patients in the borderline group than in the axis II comparison group over time. Each of these types of thought, except true psychotic thought, declined significantly over time for participants in both groups. Eleven of the 17 more specific forms of thought studied were also reported by a significantly higher percentage of patients in the borderline group over the follow-up period: magical thinking, overvalued ideas, recurrent illusions, depersonalization, derealization, undue suspiciousness, ideas of reference, other paranoid ideation, quasi-psychotic delusions, quasi-psychotic hallucinations, and true psychotic hallucinations. Fourteen specific forms of thought were found to decline significantly over time for participants in both groups: all forms of thought mentioned above except true psychotic hallucinations plus marked superstitiousness, sixth sense, telepathy, and clairvoyance.

CONCLUSIONS

Disturbed cognitions are common in patients with borderline personality disorder and are distinguishing for the disorder. They also decline substantially over time but remain a problem, particularly those of a nonpsychotic nature.

Relationship between sleep disturbance and recovery in patients with borderline personality disorder

OBJECTIVE

Patients with borderline personality disorder (BPD) frequently experience sleep disturbance, however, the role of sleep quality in the course of BPD is unknown. The purpose of this study was to evaluate the cross-sectional association between sleep quality and recovery status (symptomatic remission plus good concurrent psychosocial functioning) in a well-characterized cohort of patients with BPD to examine the role of sleep disturbance in the course of the disorder.

METHODS

223 patients with BPD participating in the McLean Study of Adult Development (MSAD) were administered the Pittsburgh Sleep Quality Index (PSQI) as part of the 16-year follow-up wave. Sleep quality was compared between recovered (n=105) and non-recovered (n=118) BPD participants, including adjustment for age, sex, depression, anxiety, and primary sleep disorders.

RESULTS

Non-recovered BPD patients had significantly worse sleep quality than recovered BPD participants as measured by the global PSQI score (adjusted means 12.01 vs. 10.73, p=0.03). In addition, non-recovered BPD participants had longer sleep onset latency (adjusted means 39.20 vs. 28.11minutes, p=0.04), as well as increased odds of using sleeping medication (adjusted OR 1.49, p=0.009) and experiencing daytime dysfunction as a result of their sleep disturbance (adjusted OR 1.48, p=0.008).

CONCLUSION

These results demonstrate an association between subjective sleep disturbance and recovery status among BPD patients. Further research is indicated to evaluate the mechanisms underlying sleep disturbance in BPD, and whether treatment of sleep complaints improves the symptomatic and psychosocial course of the disorder.

Defense mechanisms reported by patients with borderline personality disorder and axis II comparison subjects over 16 years of prospective follow-up: description and prediction of recovery

OBJECTIVE

The authors assessed the defensive functioning of 290 patients with borderline personality disorder and compared it with that of 72 patients with other forms of axis II psychopathology over 16 years of prospective follow-up. They also assessed the relationship between time-varying defenses and recovery from borderline personality disorder.

METHOD

The Defense Style Questionnaire, a self-report measure with demonstrated criterion validity and internal consistency, was initially administered at study entry. It was readministered at eight contiguous 2-year follow-up periods.

RESULTS

Borderline patients had significantly lower scores than axis II comparison subjects on one mature defense mechanism (suppression) and significantly higher scores on seven of the other 18 defenses studied: one neurotic-level defense (undoing), four immature defenses (acting out, emotional hypochondriasis, passive aggression, and projection), and two image-distorting/borderline defenses (projective identification and splitting). Over the follow-up period, borderline patients showed significant improvement on 13 of the 19 defenses studied, with significantly higher scores over time on one mature defense (anticipation) and significantly lower scores on two neurotic defenses (isolation and undoing), all immature defenses, and all image-distorting/borderline defenses except primitive idealization. In addition, four time-varying defense mechanisms were found to predict time to recovery: humor, acting out, emotional hypochondriasis, and projection.

CONCLUSIONS

Taken together, these results suggest that the longitudinal defensive functioning of borderline patients is distinct and improves substantially over time. They also suggest that immature defenses are the best predictor of time to recovery.

Predictors of suicide attempts in patients with borderline personality disorder over 16 years of prospective follow-up

BACKGROUND

It is clinically important to understand the factors that increase the likelihood of the frequent and recurrent suicide attempts seen in those with borderline personality disorder (BPD). Although several studies have examined this subject in a cross-sectional manner, the aim of this study was to determine the most clinically relevant baseline and time-varying predictors of suicide attempts over 16 years of prospective follow-up among patients with BPD.

METHOD

Two-hundred and ninety in-patients meeting Revised Diagnostic Interview for Borderlines (DIB-R) and DSM-III-R criteria for BPD were assessed during their index admission using a series of semistructured interviews and self-report measures. These subjects were then reassessed using the same instruments every 2 years. The generalized estimating equations (GEE) approach was used to model the odds of suicide attempts in longitudinal analyses, controlling for assessment period, yielding an odds ratio (OR) and 95% confidence interval (CI) for each predictor.

RESULTS

Nineteen variables were found to be significant bivariate predictors of suicide attempts. Eight of these, seven of which were time-varying, remained significant in multivariate analyses: diagnosis of major depressive disorder (MDD), substance use disorder (SUD), post-traumatic stress disorder (PTSD), presence of self-harm, adult sexual assault, having a caretaker who has completed suicide, affective instability, and more severe dissociation.

CONCLUSIONS

The results of this study suggest that prediction of suicide attempts among borderline patients is complex, involving co-occurring disorders, co-occurring symptoms of BPD (self-harm, affective reactivity and dissociation), adult adversity, and a family history of completed suicide.

The course of anxiety disorders other than PTSD in patients with borderline personality disorder and Axis II comparison subjects: a 10-year follow-up study

The objectives of this study were to assess the rates of comorbid anxiety disorders other than PTSD in patients with borderline personality disorder (BPD) and Axis II comparison subjects over ten years of prospective follow-up and to determine time-to-remission, recurrence, and new onset of these disorders. The SCID I was administered to 290 borderline patients and 72 Axis II comparison subjects at baseline and at five contiguous 2-year follow-up waves. The rates of anxiety disorders for those in both groups declined significantly over time, although they remained significantly higher among borderline patients. By 10-year follow-up, the rates of remission for borderline patients who met criteria for these disorders at baseline were high, while the rates of recurrences and new onsets were moderate. These results suggest that anxiety disorders are very common over time among borderline patients. They also suggest that these disorders have an intermittent course among those with BPD.

Attainment and stability of sustained symptomatic remission and recovery among patients with borderline personality disorder and axis II comparison subjects: a 16-year prospective follow-up study

OBJECTIVE

The purposes of this study were to determine time to attainment of symptom remission and to recovery lasting 2, 4, 6, or 8 years among patients with borderline personality disorder and comparison subjects with other personality disorders and to determine the stability of these outcomes.

METHOD

A total of 290 inpatients with borderline personality disorder and 72 comparison subjects with other axis II disorders were assessed during their index admission using a series of semistructured interviews, which were administered again at eight successive 2-year follow-up sessions. For inclusion in the study, patients with borderline personality disorder had to meet criteria for both the Revised Diagnostic Interview for Borderlines and DSM-III-R.

RESULTS

Borderline patients were significantly slower to achieve remission or recovery (which involved good social and vocational functioning as well as symptomatic remission) than axis II comparison subjects. However, by the time of the 16-year follow-up assessment, both groups had achieved similarly high rates of remission (range for borderline patients: 78%-99%; range for axis II comparison subjects: 97%-99%) but not recovery (40%-60% compared with 75%-85%). In contrast, symptomatic recurrence and loss of recovery occurred more rapidly and at substantially higher rates among borderline patients than axis II comparison subjects (recurrence: 10%-36% compared with 4%-7%; loss of recovery: 20%-44% compared with 9%-28%).

CONCLUSIONS

Our results suggest that sustained symptomatic remission is substantially more common than sustained recovery from borderline personality disorder and that sustained remissions and recoveries are substantially more difficult for individuals with borderline personality disorder to attain and maintain than for individuals with other forms of personality disorder.

The 10-year course of PTSD in borderline patients and axis II comparison subjects

OBJECTIVE

The first objective is to detail the prevalence of post-traumatic stress disorder (PTSD) over a decade of follow-up for those in both study groups. The second is to determine time-to-remission, recurrence, and new onset of PTSD, and the third is to assess the relationship between sexual adversity and the likelihood of remission and recurrence of PTSD.

METHOD

The SCID I was administered to 290 borderline in-patients and 72 axis II comparison subjects during their index admission and re-administered at five contiguous 2-year follow-up periods.

RESULTS

The prevalence of PTSD declined significantly over time for patients with borderline personality (BPD) (61%). Over 85% of borderline patients meeting criteria for PTSD at baseline experienced a remission by the time of the 10-year follow-up. Recurrences (40%) and new onsets (27%) were less common. A childhood history of sexual abuse significantly decreased the likelihood of remission from PTSD, and an adult history of sexual assault significantly increased the likelihood of a recurrence of PTSD.

CONCLUSION

Taken together, the results of this study suggest that PTSD is not a chronic disorder for the majority of borderline patients. They also suggest a strong relationship between sexual adversity and the course of PTSD among patients with BPD.

Relationship between cumulative BMI and symptomatic, psychosocial, and medical outcomes in patients with borderline personality disorder

We examined the relationship between cumulative body mass index (BMI) and symptomatic, psychosocial, and medical outcomes in patients with borderline personality disorder (BPD). Two hundred female borderline patients were weighed and measured during their index admission. They were subsequently interviewed at six-, eight-, and 10-year intervals. Over 10 years of prospective follow-up, increases in cumulative BMI were significantly associated with self-mutilation and dissociation (but not suicide attempts). Increases in cumulative BMI were also significantly associated with having no life partner, a poor work or school history, being on disability, being rated with a GAF score in the fair or poor range, and having a low income. In addition, increases in BMI were related to having two or more other medical conditions and using costly forms of health care. Increases in cumulative BMI may be a marker for adverse symptomatic, functional, and medical outcomes in patients with BPD.

Predictors of self-mutilation in patients with borderline personality disorder: A 10-year follow-up study

BACKGROUND

Self-mutilation is a common and serious problem in patients with borderline personality disorder (BPD). The purpose of this study was to determine the most clinically relevant baseline and time-varying predictors of self-mutilation over 10 years of prospective follow-up among patients with BPD.

METHOD

Four semistructured interviews assessing axis I disorders, childhood adversity, adult experiences of abuse, and experiences of self-mutilation were administered at baseline to 290 patients meeting DIB-R and DSM-III-R criteria for BPD. Three of these interviews (all except for the childhood adversity interview) and two self-report measures pertaining to dysphoric affects and cognitions were administered at each of five contiguous two-year follow-up periods.

RESULTS

Eleven variables were found to be significant bivariate predictors of self-mutilation over the five follow-up periods. Six of these predictors remained significant in multivariate analyses: female gender, severity of dysphoric cognitions (mostly overvalued ideas), severity of dissociative symptoms, major depression, history of childhood sexual abuse, and sexual assaults as an adult.

CONCLUSIONS

Taken together, the results of this study suggest that factors pertaining to traumatic experiences throughout the lifespan are significant risk factors for self-mutilation over time. These results also suggest that major depressive episodes and cognitive symptoms, particularly overvalued ideas and dissociation, significantly heighten the risk of self-injurious behaviors tracked for a decade.

The course of substance use disorders in patients with borderline personality disorder and Axis II comparison subjects: a 10-year follow-up study

AIM

The purpose of this study is to detail the course of substance use disorders (SUDs) over 10 years of prospective follow-up among patients with borderline personality disorder (BPD) and Axis II comparison subjects.

DESIGN

This study uses data from the McLean Study of Adult Development (MSAD), a multi-faceted study of the longitudinal course of BPD using reliable repeated measures administered every 2 years over a decade of prospective follow-up.

SETTING

All subjects were initially in-patients at McLean Hospital in Belmont Massachusetts. PARTICIPANTS; A total of 290 patients with BPD and 72 Axis II comparison subjects were assessed at baseline and five waves of follow-up.

MEASUREMENTS

The Structured Clinical Interview for DSM-III-R Axis I Disorders (SCID-I), the Revised Diagnostic Interview for Borderlines (DIB-R) and the Diagnostic Interview for DSM-III-R Personality Disorders (DIPD-R) were administered six times. Generalized estimating equations were used to assess longitudinal prevalence of SUDs. Kaplan-Meier analyses were used to assess time-to-remission, recurrence and new onsets of SUDs.

RESULTS

The prevalence of SUDs among borderline patients and Axis II comparison subjects declined significantly over time, while remaining significantly more common among those with BPD. More than 90% of borderline patients meeting criteria for a SUD at baseline experienced a remission by 10-year follow-up. Recurrences and new onsets of SUDs were less common (35-40% and 21-23%).

CONCLUSIONS

Remissions of alcohol and drug abuse/dependence among borderline patients are both common and relatively stable. Results also suggest that new onsets of these disorders are less common than might be expected.

The 10-year course of psychosocial functioning among patients with borderline personality disorder and axis II comparison subjects

OBJECTIVE

The purpose of this study was to determine the 10-year course of the psychosocial functioning of patients with borderline personality disorder (BPD).

METHOD

The social and vocational functioning of 290 inpatients meeting both the Revised Diagnostic Interview for Borderlines (DIB-R) and DSM-III-R criteria for BPD and 72 axis II comparison subjects were carefully assessed during their index admission. Psychosocial functioning was reassessed using similar methods at five contiguous 2-year time periods.

RESULTS

Borderline patients without good psychosocial functioning at baseline reported difficulty attaining it for the first time. Those who had such functioning at baseline reported difficulty retaining and then regaining it. In addition, over 90% of their poor psychosocial functioning was due to poor vocational but not social performance.

CONCLUSION

Good psychosocial functioning that involves both social and vocational competence is difficult for borderline patients to achieve and maintain over time. In addition, their vocational functioning is substantially more compromised than their social functioning.

A longitudinal study of the 10-year course of interpersonal features in borderline personality disorder

The literature on borderline personality disorder (BPD) describes interpersonal disturbances as a core sector of psychopathology. The longitudinal course of these features remains poorly understood. Our aim is to describe the course of interpersonal features of BPD in a more detailed way than has been done previously. Twenty interpersonal aspects of borderline psychopathology were assessed using two reliable semi-structured diagnostic interviews at baseline and at five successive two-year follow-up waves in the ongoing McLean Study for Adult Development. Behaviorally-oriented features, such as recurrent breakups, sadism, demandingness, entitlement, regression in treatment, and boundary violations, remitted quickly and were rare at the end of follow-up. The interpersonal features slowest to remit were affective responses to being alone, active caretaking, discomfort with care, and dependency. The behavioral interpersonal features of BPD remit rapidly, while core affectively-oriented features related to intolerance of aloneness and conflicts over dependency are more persistent.

Time to attainment of recovery from borderline personality disorder and stability of recovery: A 10-year prospective follow-up study

OBJECTIVE

The purposes of this study were to determine time to attainment of recovery from borderline personality disorder and to assess the stability of recovery.

METHOD

A total of 290 inpatients who met both DSM-III-R and Revised Diagnostic Interview for Borderlines criteria for borderline personality disorder were assessed during their index admission using a series of semistructured interviews and self-report measures. The same instruments were readministered every 2 years for 10 years.

RESULTS

Over the study period, 50% of participants achieved recovery from borderline personality disorder, which was defined as remission of symptoms and having good social and vocational functioning during the previous 2 years. Overall, 93% of participants attained a remission of symptoms lasting at least 2 years, and 86% attained a sustained remission lasting at least 4 years. Of those who achieved recovery, 34% lost their recovery. Of those who achieved a 2-year remission of symptoms, 30% had a symptomatic recurrence, and of those who achieved a sustained remission, only 15% experienced a recurrence.

CONCLUSIONS

Taken together, the results of this study suggest that recovery from borderline personality disorder, with both symptomatic remission and good psychosocial functioning, seems difficult for many patients to attain. The results also suggest that once attained, such a recovery is relatively stable over time.

Ten-year use of mental health services by patients with borderline personality disorder and with other axis II disorders

OBJECTIVE

The study determined the prevalence of use of three treatment modalities (individual therapy, medication, and hospitalization) reported over a ten-year period by patients with borderline personality disorder and by those in a comparison group with other axis II disorders. Time to cessation and time to resumption for each modality among patients with borderline personality disorder were also determined.

METHODS

Treatment history of inpatients with a reliable diagnosis of borderline personality disorder (N=290) and of other axis II disorders (N=72) was assessed with an interview of proven reliability during the index admission. Treatment history was reassessed at two-year intervals for ten years.

RESULTS

For all three treatment modalities, prevalence of use declined significantly among patients with borderline personality disorder and among those in the comparison group. Among patients with borderline personality disorder, 52% reported having stopped individual therapy and 44% reported having stopped medication at one or more of the follow-up interviews over ten years. However, 85% of those who had stopped psychotherapy and 67% of those who stopped taking medication resumed these treatments during a subsequent two-year period. In contrast, 88% had experienced at least one two-year period without a psychiatric hospitalization by the time of the ten-year follow-up; however, almost half of these patients were subsequently rehospitalized.

CONCLUSIONS

The results suggest that patients with borderline personality disorder tend to use outpatient treatments without interruption over prolonged periods. They also suggest that inpatient treatment is used far more intermittently by patients with borderline personality disorder.

The course of eating disorders in patients with borderline personality disorder: a 10-year follow-up study

OBJECTIVE

The purpose of this study was to describe the longitudinal course of eating disorders in patients with borderline personality disorder.

METHOD

The SCID I was administered to 290 borderline inpatients and 72 participants with other axis II disorders during their index admission and at five contiguous 2-year follow-up periods.

RESULTS

The prevalence of anorexia, bulimia, and eating disorder not otherwise specified (EDNOS) declined significantly over time for those in both study groups but the prevalence of EDNOS remained significantly higher among borderline patients. While over 90% of borderline patients meeting criteria for anorexia, bulimia, or EDNOS at baseline experienced a stable remission by the time of the 10-year follow-up, diagnostic migration was common, particularly for those with anorexia or bulimia. In addition, both recurrences (52%) and new onsets (43%) of EDNOS were more common among borderline patients than recurrences and new onsets of anorexia (28% and 4%) and bulimia (29% and 11%).

DISCUSSION

The results of this study suggest that the prognosis for both anorexia and bulimia in borderline patients is complicated, with remissions being stable but migrations to other eating disorders being common. The results also suggest that EDNOS may be the most prevalent and enduring of the eating disorders in these patients.

Sedative-hypnotic use in patients with borderline personality disorder and axis II comparison subjects

Sleep disturbance is a common, yet poorly understood, phenomenon in borderline personality disorder (BPD). We examined the use of sedative-hypnotic medication in BPD, as part of a larger naturalistic study. In comparison to other personality disorder (OPD) comparison subjects, a significantly higher percentage of BPD subjects than OPD subjects used both as needed (prn) and standing medications to help them sleep. Specifically, over the course of the study, BPD subjects were approximately 4 times more likely to have used prn (OR = 4.27, 95% CI: 2.22-8.22) and standing sleeping medications (OR = 3.81, 95% CI: 1.88-7.72). When adjusted for differences in depression, anxiety, and age among BPD and OPD subjects, BPD subjects were approximately 3 times more likely to have used prn (adjusted OR = 3.38, 95% CI: 1.73-6.61) and standing sleeping medications (adjusted OR = 2.81, 95% CI: 1.33-5.95). These results indicate that sedative-hypnotic use is greater among BPD than OPD subjects. They also confirm clinical observations that subjective sleep disturbance is a significant problem in BPD.

Family history study of the familial coaggregation of borderline personality disorder with axis I and nonborderline dramatic cluster axis II disorders

The purpose of this study was to assess the familial coaggregation of borderline personality disorder (BPD) with a full array of axis I disorders and four axis II disorders (antisocial personality disorder, histrionic personality disorder, narcissistic personality disorder, and sadistic personality disorder) in the first-degree relatives of borderline probands and axis II comparison subjects. Four hundred and forty-five inpatients were interviewed about familial psychopathology using the Revised Family History Questionnaire-a semistructured interview of demonstrated reliability. Of these 445 subjects, 341 met both DIB-R and DSM-III-R criteria for BPD and 104 met DSM-III-R criteria for another type of personality disorder (and neither criteria set for BPD). The psychopathology of 1,580 first-degree relatives of borderline probands and 472 relatives of axis II comparison subjects was assessed. Using structural models for familial coaggregation, it was found that BPD coaggregates with major depression, dysthymic disorder, bipolar I disorder, alcohol abuse/dependence, drug abuse/dependence, panic disorder, social phobia, obsessive-compulsive disorder, generalized anxiety disorder, posttraumatic stress disorder, somatoform pain disorder, and all four axis II disorders studied. Taken together, the results of this study suggest that common familial factors, particularly in the areas of affective disturbance and impulsivity, contribute to borderline personality disorder.

The 10-year course of social security disability income reported by patients with borderline personality disorder and axis II comparison subjects

This study had two purposes. The first purpose was to assess the prevalence as well as the stability of reliance on social security disability income (SSDI) among patients with borderline personality disorder (BPD). The second purpose was to detail the prevalence of aspects of adult competence reported by borderline patients who ever received disability payments and those who never received such payments. The disability status and other aspects of psychosocial functioning of 290 borderline inpatients and 72 axis II comparison subjects were assessed using a semi-structured interview at baseline and at each of the five subsequent two-year follow-up periods. Borderline patients were three times more likely to be receiving SSDI benefits than axis II comparison subjects over time, although the prevalence rate for both groups remained relatively stable. Forty percent of borderline patients on such payments at baseline were able to get off disability but 43% of these patients subsequently went back on SSDI. Additionally, 39% of borderline patients who were not on disability at baseline started to receive federal benefits for the first time. However, borderline patients on SSDI were not without psychosocial strengths. By the time of the 10-year follow-up, 55% had worked or gone to school at least 50% of the last two years, about 70% had a supportive relationship with at least one friend, and over 50% a good relationship with a romantic partner. The results of this study suggest that receiving SSDI benefits is both more common and more fluid over time for patients with BPD than previously known.

Defense mechanisms associated with borderline personality disorder

This study assessed the defensive functioning of 290 criteria-defined borderline patients and compared it to that of 72 patients with other forms of axis II psychopathology. The Defense Style Questionnaire (DSQ), a self-report measure with demonstrated criterion validity and internal consistency, was administered to 362 axis II inpatients diagnosed using semistructured interviews of proven reliability. Borderline patients had significantly higher scores than axis II comparison subjects on three of the four defense styles assessed by the DSQ: self-sacrificing, maladaptive action, and image-distorting defenses. They also had significantly higher scores than axis II comparison subjects on eight of the 19 defense mechanisms studied. More specifically, borderline patients had significantly higher scores on one neurotic-level defense (undoing), four immature defenses (acting out, emotional hypochondriasis, passive aggression, and projection), and two image-distorting/borderline defenses (projective identification and splitting). In contrast, axis II comparison subjects had a significantly higher score than borderline patients on one mature defense (suppression). When all significant defenses were considered together, three were found to be significant predictors of a borderline diagnosis: acting out, emotional hypochondriasis, and undoing. This model has both good sensitivity (.95) and positive predictive power (.86). Taken together, the results of this study suggest that the defensive profile of borderline patients is distinct from that of patients with other forms of axis II pathology. They also suggest that the defensive triad of acting out, emotional hypochondriasis, and undoing may serve as a useful clinical marker for the borderline diagnosis, particularly in settings where the base rate of the disorder is high.

Neurosyphilis, malaria, and the discovery of antipsychotic agents

Four of the most disabling human diseases are syphilis, malaria, schizophrenia, and manic-depressive illness. The history of the development of treatments for these seemingly unrelated disorders intersects at several points. Treatment of tertiary cerebral syphilis (general paresis) by inducing fever with malaria led to a Nobel Prize. Although attempts to synthesize quinine, a plant product effective against malaria, failed, these efforts encouraged industrial organic chemists to synthesize many useful substances, including dyes, antibiotics, and antihistamines. The aniline-derived dye methylene blue was a member of a new class of polycyclic chemicals, the phenothiazines. Efforts to modify phenothiazines to find an antimalarial agent also failed but led to novel antiemetic-sedative antihistamines, including promethazine, promazine, and eventually chlorpromazine--the first effective treatment for schizophrenia and mania. Chlorpromazine has antipsychotic and antimanic properties, and it revolutionized the therapeutics of psychotic illnesses.

The course of dissociation for patients with borderline personality disorder and axis II comparison subjects: a 10-year follow-up study

OBJECTIVE

The purpose of this study was to assess the severity of dissociation reported by borderline patients and axis II comparison subjects over 10 years of prospective follow-up.

METHOD

The Dissociative Experiences Scale (DES) - a 28-item self-report measure - was administered to 290 borderline in-patients and 72 axis II comparison subjects during their index admission. It was also re-administered at five contiguous 2-year follow-up periods.

RESULTS

The overall severity of dissociative experiences of those in both study groups decreased significantly over time but was discernibly greater in borderline patients (61% vs. 43%). The same pattern emerged for the subtypes of dissociation that were studied: absorption, depersonalization and amnesia.

CONCLUSION

The severity of dissociation declines significantly over time for even severely ill borderline patients. However, it remains as a recurring problem for over a third of those with DES scores that initially were in the range associated with trauma-spectrum disorders.