Prediction of time-to-attainment of recovery for borderline patients followed prospectively for 16 years

OBJECTIVE

The purpose of this study was to determine the most clinically relevant baseline predictors of time-to-recovery from borderline personality disorder.

METHOD

Two hundred and ninety in-patients meeting rigorous criteria for borderline personality disorder were assessed during their index admission using a series of semistructured interviews and self-report measures. Recovery status, which was defined as concurrent symptomatic remission and good social and full-time vocational functioning, was reassessed at eight contiguous 2-year time periods. Survival analytic methods (Cox regression), which controlled for overall baseline severity, were used to estimate hazard ratios and their confidence intervals.

RESULTS

All told, 60% of the borderline patients studied achieved a 2-year recovery. In bivariate analyses, seventeen variables were found to be significant predictors of earlier time-to-recovery. Six of these predictors remained significant in multivariate analyses: no prior psychiatric hospitalizations, higher IQ, good full-time vocational record in 2 years prior to index admission, absence of an anxious cluster personality disorder, high extraversion, and high agreeableness.

CONCLUSION

Taken together, the results of this study suggest that prediction of time-to-recovery for borderline patients is multifactorial in nature, involving factors related to lack of chronicity, competence, and more adaptive aspects of temperament.

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.

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.

The 10-year course of physically self-destructive acts reported by borderline patients and axis II comparison subjects

OBJECTIVE

The purpose of this paper was to determine the frequency and methods of two forms of physically self-destructive acts (i.e. self-mutilation and suicide attempts) reported by borderline patients and axis II comparison subjects over 10 years of prospective follow-up.

METHOD

Two hundred and ninety borderline patients and 72 axis II comparison subjects were interviewed about their physically self-destructive acts during their index admission and at five contiguous 2-year follow-up periods.

RESULTS

It was found that a high percentage of borderline patients reported multiple acts and methods of each of these two forms of physically self-destructive behavior prior to their index admission. It was also found that the percentage of borderline patients reporting multiple acts and methods declined significantly over time. However, these acts remained significantly more common among borderline patients than axis II comparison subjects.

CONCLUSION

The course of self-mutilation and suicide attempts among borderline patients is initially more serious and ultimately more benign than previously recognized.

Axis II comorbidity of borderline personality disorder: description of 6-year course and prediction to time-to-remission

OBJECTIVE

The purpose of this study was to compare the axis II comorbidity of 202 patients whose borderline personality disorder (BPD) remitted over 6 years of prospective follow-up to that of 88 whose BPD never remitted.

METHOD

The axis II comorbidity of 290 patients meeting both DIB-R and DSM-III-R criteria for BPD was assessed at baseline using a semistructured interview of demonstrated reliability. Over 96% of surviving patients were reinterviewed about their co-occurring axis II disorders blind to all previously collected information at three distinct follow-up waves: 2-, 4-, and 6-year follow-up.

RESULTS

Both remitted and non-remitted borderline patients experienced declining rates of most types of axis II disorders over time. However, the rates of avoidant, dependent, and self-defeating personality disorders remained high among non-remitted borderline patients. Additionally, the absence of these three disorders was found to be significantly correlated with a borderline patient's likelihood-of-remission and time-to-remission; self-defeating personality disorder by a factor of 4, dependent personality disorder by a factor of 3 1/2, and avoidant personality disorder by a factor of almost 2.

CONCLUSION

The results of this study suggest that axis II disorders co-occur less commonly with BPD over time, particularly for remitted borderline patients. They also suggest that anxious cluster disorders are the axis II disorders which most impede symptomatic remission from BPD.

Olanzapine treatment of female borderline personality disorder patients: a double-blind, placebo-controlled pilot study

BACKGROUND

The intent of this study was to compare the efficacy and safety of olanzapine versus placebo in the treatment of women meeting criteria for borderline personality disorder (BPD).

METHOD

We conducted a double-blind, placebo-controlled study of olanzapine in 28 female subjects meeting Revised Diagnostic Interview for Borderlines and DSM-IV criteria for BPD. The subjects were randomly assigned to olanzapine or placebo in a 2:1 manner. Treatment duration was 6 months. Primary outcome measures were self-reported changes on anxiety, depression, paranoia, anger/hostility, and interpersonal sensitivity scales of the Symptom Checklist-90.

RESULTS

Nineteen subjects were randomly assigned to olanzapine; 9. to placebo. When random effects regression modeling of panel data was used, controlling for baseline level of severity, olanzapine was associated with a significantly (p < .05) greater rate of improvement over time than placebo in all of the symptom areas studied except depression. Weight gain was modest in the olanzapine-treated group but was significantly higher than in those treated with placebo (p < .02). In addition, no serious movement disorders were noted.

CONCLUSION

Olanzapine appears to be a safe and effective agent in the treatment of women with criteria-defined BPD, significantly affecting all 4 core areas of borderline psychopathology (i.e., affect, cognition, impulsivity, and interpersonal relationships).

Attainment and maintenance of reliability of axis I and II disorders over the course of a longitudinal study

The baseline interrater reliability, test-retest reliability, follow-up interrater reliability, and follow-up longitudinal reliability of axis I and axis II diagnoses were assessed using the Structured Clinical Interview for DSM-III-R Axis I Disorders (SCID-I) and the Diagnostic Interview for DSM-III-R Personality Disorders (DIPD-R). Excellent kappas (>.75) were found in each of these reliability substudies for the majority of axis II disorders diagnosed five times or more. Dimensional reliability figures for axis II diagnoses were generally somewhat higher than those for their categorical counterparts; most intraclass correlation coefficients (ICCs) were in the excellent range. Excellent kappas were also found in each of these four reliability substudies for over half of the axis I disorders diagnosed five times or more. Taken together, the results of this study suggest that the reliability of axis II disorders is both good to excellent and practically equivalent to that found for most axis I disorders. The results of this study also suggest that high levels of reliability, once achieved, can be maintained over time for both axis I and II disorders.

Treatment histories of borderline inpatients

In this study, we describe the types and amounts of psychiatric treatment received by a well-defined sample of borderline personality disorder (BPD) inpatients, and compare these parameters with those of a group of carefully diagnosed personality-disordered controls. Finally, we assess the risk factors associated with a history of intensive, high-cost treatment, which we defined as having had two or more prior psychiatric hospitalizations. The treatment histories of 290 borderline inpatients and 72 axis II controls were assessed using a reliable semistructured interview. All nine forms of treatment studied except electroconvulsive therapy (ECT) were common among borderline patients (36% to 96%). In addition, a significantly higher percentage of borderline patients than axis II controls reported a history of individual and group therapy, day and residential treatment, psychiatric hospitalization, participating in self-help groups, and taking standing medications. They were also significantly younger when they first entered individual therapy and began to take standing medications. In addition, borderline patients spent more time than axis II controls in individual therapy and psychiatric hospitals, and were on standing medications for a significantly longer period of time. They also reported a significantly higher number of psychiatric hospitalizations, lifetime number of standing medications, and number of psychotropic medications taken at the same time. In addition, we found a highly significant multivariate predictive model for multiple prior hospitalizations. The six significant predictors were age 26 or older, a history of quasi psychotic thought, lifetime number of self-mutilative efforts and suicide attempts, a childhood history of reported sexual abuse, and an adult history of being physically and/or sexually assaulted. Taken together, these results confirm clinical impressions concerning the high rates of mental health services used by borderline patients. They also suggest that particularly high rates of costly inpatient treatment are associated with a complex admixture of older age, BPD symptoms in the cognitive and impulse realms, and traumatic life experiences occurring in both childhood and adulthood.

Biparental failure in the childhood experiences of borderline patients

The purpose of this study was to assess the role of biparental abuse and neglect in the development of borderline personality disorder (BPD). A semistructured research interview was used to blindly assess the childhood experiences of biparental abuse and neglect reported by 358 borderline inpatients and 109 axis II controls. Eighty-four percent of borderline patients reported having experienced some type of biparental abuse or neglect before the age of 18; 55% reported a childhood history of biparental abuse; 77% reported a childhood history of biparental neglect. These experiences were also reported by a substantial percentage of Axis II controls (biparental abuse or neglect [61%], biparental abuse [31%], and biparental neglect [55%]). However, borderline patients were significantly more likely than axis II controls to report having been verbally, emotionally, and physically but not sexually abused by caretakers of both sexes. They were also significantly more likely than controls to report having caretakers of both sexes deny the validity of their thoughts and feelings, fail to provide them with needed protection, neglect their physical care, withdraw from them emotionally, and treat them inconsistently. It was also found that female borderlines who reported a previous history of neglect by a female caretaker and abuse by a male caretaker were at significantly higher risk for having been sexually abused by a noncaretaker. Taken together, the results of this study suggest that biparental failure may be a significant factor in the etiology of BPD. They also suggest that biparental failure may significantly increase a preborderline girl's risk of being sexually abused by someone other than her parents.

The dissociative experiences of borderline patients

The study objective was to assess the severity and quality of dissociative experiences reported by borderline patients. Two hundred ninety criteria-defined borderline patients and 72 axis II controls completed the Dissociative Experiences Scale (DES), a 28-item self-report measure with demonstrated reliability and validity. Thirty-two percent of borderline patients had a low level of dissociation, 42% a moderate level, and 26% a high level similar to that reported by patients meeting criteria for posttraumatic stress disorder (PTSD) or dissociative disorders. The controls had a significantly different distribution of overall DES scores: 71% reported a low level of dissociation, 26% reported a moderate level, and only 3% reported a high level. In addition, borderline patients had a significantly higher score than the controls on 21 of 28 DES items and a significantly higher overall DES score, as well as the score on the 3 factors that have been found to underlie the DES, absorption, amnesia, and depersonalization. The results of this study suggest that the severity of dissociation experienced by borderline patients is more heterogeneous than previously reported. They also suggest that borderline patients have a wider range of dissociative experiences than are commonly recognized, including experiences of absorption and amnesia, as well as experiences of depersonalization.

Risk factors associated with the dissociative experiences of borderline patients

The objective of this study was to identify the risk factors associated with the dissociative symptomatology of borderline patients. The Dissociative Experiences Scale--a 28-item self-report measure that has well documented reliability and validity--was administered to 290 criteria-defined borderline patients and 72 axis II comparison subjects. Semistructured interviews pertaining to difficult childhood experiences and adult experiences of being a victim of violence were administered to these patients blind to diagnostic status. In the sample of borderline patients alone, multiple regression analyses revealed that four risk factors were found to be significantly associated with the level of dissociation reported by these 290 patients: inconsistent treatment by a caretaker, sexual abuse by a caretaker, witnessing sexual violence as a child, and adult rape history. In the combined sample of axis II patients, the borderline diagnosis joined these four "traumatic" factors as a significant predictor of the overall level of dissociation reported by these 362 personality-disordered inpatients. The results of this study suggest that both sexual trauma and something intrinsic to the borderline diagnosis itself are risk factors for dissociative phenomena among borderline patients.

Violence in the lives of adult borderline patients

The purpose of this study was to assess the experiences of adult violence reported by a sample of criteria-defined borderline patients and axis II controls. The experiences of having had a physically abusive partner and/or having been raped reported by 362 personality-disordered inpatients were assessed blind to diagnostic status using a semistructured research interview. Forty-six percent of borderline patients reported having been a victim of violence since the age of 18. Borderline patients (N = 290) were significantly more likely than axis II controls (N = 72) to report having had a physically abusive partner, having been raped, having been raped multiple times, having been raped by a known perpetrator, and having been both physically assaulted by a partner and raped. Female borderline patients were significantly more likely than male borderline patients to have been physically and/or sexually assaulted as adults (50% vs. 26%). However, a significantly higher percentage of borderline patients of both genders reported experiences of adult violence than controls of the same gender. Four risk factors were found to significantly predict whether borderline patients had an adult history of being a victim of violence: female gender, a substance use disorder that began before the age of 18, childhood sexual abuse, and emotional withdrawal by a caretaker. The results of this study suggest that both male and female borderline patients are at substantial risk for being physically and/or sexually victimized as adults.

Choices in antipsychotic therapy in schizophrenia

Pharmacotherapy for the treatment of schizophrenia now consists, for the most part, of two groups of agents. The conventional antipsychotic agents are exemplified by chlorpromazine and haloperidol, and the atypical agents by clozapine, risperidone, olanzapine, and quetiapine. In this article, the history of the development of these two groups, and their advantages and disadvantages, are reviewed. Effectiveness, side-effect burden, mode of delivery, and cost are discussed. The new practice of "stalled or reversed taper" is described. The clinician now has a wider range of options from which to choose, but many clinical questions remain unanswered.

Axis I comorbidity of borderline personality disorder

OBJECTIVE

The purpose of this study was to assess the lifetime rates of occurrence of a full range of DSM-III-R axis I disorders in a group of patients with criteria-defined borderline personality disorder and comparison subjects with other personality disorders.

METHOD

The axis I comorbidity of 504 inpatients with personality disorders was assessed by interviewers who were blind to clinical diagnosis and who used a semistructured research interview of demonstrated reliability.

RESULTS

Four new findings emerged from this study. First, anxiety disorders were found to be almost as common among borderline patients (N=379) as mood disorders but far more discriminating from axis II comparison subjects (N=125). Second, posttraumatic stress disorder (PTSD) was found to be a common but not universal comorbid disorder among borderline patients, a finding inconsistent with the view that borderline personality disorder is actually a form of chronic PTSD. Third, male and female borderline patients were found to differ in the type of disorder of impulse in which they "specialized." More specifically, substance use disorders were significantly more common among male borderline patients, while eating disorders were significantly more common among female borderline patients. Fourth, a lifetime pattern of complex comorbidity (i.e., met DSM-III-R criteria for both a disorder of affect and a disorder of impulse at some point before the patients' index admission) was found to have strong positive predictive power for the borderline diagnosis as well as a high degree of sensitivity and specificity.

CONCLUSIONS

These results suggest that the lifetime pattern of axis I comorbidity characteristic of borderline patients and distinguishing for the disorder is a particularly good marker for borderline personality disorder.

The pain of being borderline: dysphoric states specific to borderline personality disorder

The objective of this study was to identify the dysphoric states that best characterize patients meeting criteria for borderline personality disorder and distinguish them from those in patients with other forms of personality disorder. One hundred forty-six patients with criteria-defined borderline personality disorder and 34 Axis II controls filled out the Dysphoric Affect Scale, a 50-item self-report measure that was designed for this purpose and has good internal consistency and test-retest reliability. Twenty-five dysphoric states (mostly affects) were found to be significantly more common among borderline patients than controls but nonspecific to borderline personality disorder. Twenty-five other dysphoric states (mostly cognitions) were found to be both significantly more common among borderline patients than controls and highly specific to borderline personality disorder. These states tended to fall into one of four clusters: (1) extreme feelings, (2) destructiveness or self-destructiveness, (3) fragmentation or "identitylessness," and (4) victimization. In addition, three of the 25 more-specific states (feeling betrayed, like hurting myself, and completely out of control), when occurring together, were particularly strongly associated with the borderline diagnosis. Equally important, overall mean Dysphoric Affect Scale scores correctly distinguished borderline personality disorder from other personality disorders in 84% of the subjects. Taken together, the results of this study suggest that the subjective pain of borderline patients may be both more pervasive and more multifaceted than previously recognized, and that the overall "amplitude" of this pain may be a particularly good marker for the borderline diagnosis.

Axis II comorbidity of borderline personality disorder

The purpose of this study was to assess the prevalence of a full range of DSM-III-R axis II disorders in a sample of criteria-defined borderline patients and axis II controls. The axis II comorbidity of 504 personality-disordered inpatients was assessed blind to clinical diagnosis using a semistructured research interview. Odd, anxious, and dramatic cluster disorders were each common among borderline patients. However, only odd and anxious cluster disorders were significantly more common among borderline patients (N = 379) than axis II controls (N = 125). Paranoid, avoidant, and dependent personality disorders were the most highly discriminating disorders between borderline patients and controls. In addition, male and female borderline patients exhibited somewhat different patterns of comorbidity. Although the rates of avoidant and dependent personality disorders were similar, male borderlines were significantly more likely than female borderlines to meet DSM-III-R criteria for paranoid, passive-aggressive, narcissistic, sadistic, and antisocial personality disorders. These results suggest that there is a particularly strong relationship between anxious cluster disorders and borderline personality disorder (BPD). They also suggest that gender plays an important role in the expression of axis II comorbidity, particularly with respect to dramatic cluster disorders.

Clozapine and body mass change

BACKGROUND

Patients treated with clozapine have been reported to gain weight. We hypothesized that patients would also experience an increase in body mass, which can be more directly related to cardiovascular morbidity.

METHODS

Forty-two patients who had been treated with clozapine for at least 1 year were weighed and measured, and waist-hip ratios (WHR) and body mass index (BMI), measured as kg/m2, were calculated. Patients were also asked about a series of factors potentially related to change in body mass.

RESULTS

Female patients gained both weight and body mass. Their WHR after 37 months of clozapine therapy was .83, with a significant increase in BMI from 23.2 to 29.1 kg/m2 (p = .001). Male subjects also gained weight and body mass. Their WHR after 39 months of clozapine therapy was .93, with a significant increase in BMI from 26.4 to 29.7 kg/m2 (p < .001). Stepwise multiple-regression analysis showed that factors related to final body mass were initial body mass, dose of clozapine, and decrease in smoking. Baseline BMI contributed most to the final BMI, but the addition of dose and decrease in smoking made significant contributions to the model.

CONCLUSIONS

Both female and male patients treated with clozapine gain body mass. This may place them at greater risk for cardiovascular morbidity.

Reported pathological childhood experiences associated with the development of borderline personality disorder

OBJECTIVE

The purpose of this study was to assess a full range of pathological childhood experiences reported by patients with criteria-defined borderline personality disorder and comparison patients with other personality disorders.

METHOD

The pathological childhood experiences reported by 467 inpatients with personality disorders were assessed by interviewers who used a semistructured research interview and were blind to clinical diagnosis.

RESULTS

Of the 358 patients with borderline personality disorder, 91% reported having been abused, and 92% reported having been neglected, before the age of 18. The borderline patients were significantly more likely than the 109 patients with other personality disorders to report having been emotionally and physically abused by a caretaker and sexually abused by a noncaretaker. They were also significantly more likely to report having a caretaker withdraw from them emotionally, treat them inconsistently, deny their thoughts and feelings, place them in the role of a parent, and fail to provide them with needed protection. The borderline patients with a childhood history of sexual abuse were significantly more likely than those without such a history to report having experienced all but one of the types of abuse and neglect studied. When all significant risk factors were considered together, four were found to be significant predictors of a borderline diagnosis: female gender, sexual abuse by a male noncaretaker, emotional denial by a male caretaker, and inconsistent treatment by a female caretaker.

CONCLUSIONS

The results suggest that sexual abuse is neither necessary nor sufficient for the development of borderline personality disorder and that other childhood experiences, particularly neglect by caretakers of both genders, represent significant risk factors.

Pathways to the development of borderline personality disorder

The available empirical evidence concerning the etiology of borderline personality disorder is reviewed. A tripartite model of the development of BPD is then presented. This model has three elements: a traumatic childhood (broadly defined), a vulnerable (hyperbolic) temperament, and a triggering event or series of events. The authors conclude that each borderline patient has a unique pathway to the development of BPD that is a painful variation on an unfortunate but familiar theme.

The effect of clozapine on saliva flow rate: a pilot study

This study examined the effect of clozapine on saliva flow rate. Unstimulated whole saliva was collected from 9 patients taking clozapine (dose range = 50-400 mg/day) and from 8 controls who had never used clozapine. There was no significant difference between the average saliva flow rates in the two groups (p > .10), nor was there significant correlation between saliva flow rate and daily clozapine dose (p > .10). Alternative explanations for observations or complaints of excessive salivation, drooling, or a choking feeling while taking clozapine are proposed.

Serum levels of clozapine and norclozapine in patients treated with selective serotonin reuptake inhibitors

OBJECTIVE

The selective serotonin reuptake inhibitor (SSRI) fluoxetine can increase serum levels of clozapine and norclozapine, but effects of other SSRIs are unknown. Thus, the authors evaluated interactions of clozapine with fluoxetine, paroxetine, and sertraline.

METHOD

Serum clozapine and norclozapine concentrations were assayed in 80 psychiatric patients, matched for age and clozapine dose, given clozapine (mean dose = 279 mg/day) alone or with fluoxetine (mean dose = 39.3 mg/day), paroxetine (mean = 31.2 mg/day), or sertraline (mean = 92.5 mg/ day). Each patient's dose of clozapine was stable for at least a month before serum sampling.

RESULTS

Concentrations of clozapine plus norclozapine averaged 43% higher, and the risk of levels higher than 1000 ng/ml was 10-fold greater (25%), in the patients taking SSRIs, with minor differences between patients taking the individual SSRIs.

CONCLUSIONS

SSRIs can increase circulating concentrations of clozapine and norclozapine, sometimes to potentially toxic levels.

Clozapine-caused eosinophilic colitis

Four patients with diarrhea and eosinophilia associated with clozapine therapy are presented. In two cases clozapine therapy was interrupted but then restarted; all patients eventually tolerated clozapine well. A syndrome of clozapine-induced eosinophilic colitis is suggested.

Relation of leukocyte counts during clozapine treatment to serum concentrations of clozapine and metabolites

OBJECTIVE

This study was done to test the hypothesis that serum concentration of norclozapine is a risk factor for leukopenia during treatment with clozapine.

METHOD

Maximum decreases in leukocyte counts in 44 unselected patients treated with clozapine were determined and then correlated with drug doses and serum concentrations of clozapine, norclozapine, and clozapine-N-oxide.

RESULTS

White cell and granulocyte counts decreased by up to 60%-73%, but there were no positive correlations between these decrements and drug dose, drug level, ratio of drug level to drug dose, or ratio of norclozapine level to clozapine level, nor were the decreases related to age or gender.

CONCLUSIONS

While these results do not suggest in vivo hemotoxicity of norclozapine, further study of patients with clinically significant leukopenia is required.

Uses of clozapine in nonschizophrenic patients

Clozapine is a novel antipsychotic agent used in the treatment of schizophrenic patients who have not responded to or have been unable to tolerate conventional neuroleptic therapy. In this paper, the literature surveying the uses of clozapine in the treatment of patients with nonschizophrenic illnesses, in particular psychotic affective disorders (bipolar disorder and schizoaffective disorder), will be reviewed. (A Medline search was done for all papers concerning clozapine; those that represented major contributions to the literature were used.) Results from a prospective study at McLean Hospital assessing the effects of diagnosis on response will be presented. Several other uses in nonschizophrenic patients will also be discussed. Because of its relative freedom from extrapyramidal side effects, it is an important agent in the treatment of patients with Parkinson's disease who also have psychotic symptoms. It may be effective in the treatment of tardive dyskinesia in nearly 50% of patients with that symptom. In addition, the drug may be useful in treating violent patients and those with certain movement disorders, atypical borderline personality disorder, or chronic psychotic symptoms. Due to the risk of agranulocytosis, clozapine cannot yet be considered a first-choice treatment for psychotic symptoms, but many studies indicate it to be helpful with a wide variety of treatment-resistant ones.

History of the development of antipsychotic medication

The story of the development of effective antipsychotic medications involves the collaboration of many people and organizations, ranging from Ayurvedic physicians to pharmaceutical companies, and the confluence of many quests, from that for improved synthetic dyes to that for an improved antimalarial agent. The disturbed behavior of patients and their evident anguish fueled the development of these drugs, which in turn has led to more research into the biochemistry of psychotic illnesses. Double-blind, placebo-controlled trials have established the true although partial utility of these new treatments. Most patients with schizophrenia--even those who have good responses to antipsychotic agents--continue to have some psychotic symptoms and to require a great deal of rehabilitation. It is hoped that physicians in the future will not find today's therapies as harmful as we find those of the past.

Clozapine and seizures: a review

Clozapine, a novel antipsychotic agent, is an alternative to standard neuroleptic therapy for psychotic disorders. Some advantages of clozapine over neuroleptics are that it may be a more effective antipsychotic in treatment resistant patients and has a lower incidence of extrapyramidal side effects. However, seizures associated with clozapine treatment occur at a rate of about three percent. Factors which seem to increase the likelihood of seizures include high doses of clozapine, rapid dose titration, the concurrent use of other epileptogenic agents and a previous history of neurological abnormalities. A strategy that has been proposed to reduce the occurrence of seizures is the addition of an anticonvulsant agent. At present, little rigorous scientific evidence exists to establish the effectiveness of this strategy or the choice of an anticonvulsant. However, based on what evidence there is and the side effect profiles of the various anticonvulsants, the authors propose the use of valproic acid for the prophylaxis and management of clozapine related seizures.

Clozapine and metabolites: concentrations in serum and clinical findings during treatment of chronically psychotic patients

Clozapine (CLZ) and metabolites norclozapine and clozapine-N-oxide were assayed with a new, sensitive (2 pmol), and selective method in 68 serum samples from 44 psychotic subjects, 20 to 54 years old, ill 16 years, and treated with CLZ for 2.2 years (currently at 294 mg, 3.4 mg/kg daily). CLZ levels averaged 239 ng/ml (0.73 microM; 92 ng/ml per mg/kg dose) or 48% of total analytes (norclozapine = 41% [91% of CLZ] and clozapine-N-oxide = 11%); metabolite and CLZ levels were highly correlated (rs = 0.9), and CLZ levels varied with daily dose (rs = 0.7). Sampling twice yielded similar within-subject analyte levels (r = 0.8 to 0.9; difference = 24% to 33%). Range and variance narrowed when levels were expressed per weight-corrected dose (ng/ml per mg/kg). Levels per dose were 40% higher in nonsmoking women than men, despite a 60% lower milligram per kilogram dose in women, and did not vary by diagnosis or age in this limited sample. Fluoxetine increased serum CLZ analytes by 60%; valproate had less effect. Patients rated treatment very positively; observer-assessed benefits typically were more moderate. Common late side effects were sialorrhea (80%), excess sedation (58%), obesity (55% > 200 lb), mild tachycardia (51%), constipation (32%), and enuresis (27%); there were no seizures or leukopenia. There was little evident relationship of drug dose or serum level to current clinical measures or side effect risks.

Clozapine in the elderly

The authors reviewed the use of clozapine in eight patients over age 65 years with treatment-resistant psychoses. Six patients improved. Two patients became more confused. The authors suggest that clozapine be considered in treating elderly psychotic patients, and that its use need not be restricted to schizophrenic patients.

Serum concentrations of clozapine and its major metabolites: effects of cotreatment with fluoxetine or valproate

Serum concentrations of clozapine, norclozapine, and clozapine-N-oxide were assayed in psychotic patients treated with clozapine alone (N = 17), clozapine with fluoxetine added (N = 6), or clozapine with valproic acid added (N = 11). Subjects were matched for age and other treatments, and concentrations were corrected for daily dose of clozapine (milligrams per kilogram of body weight). With valproic acid, there was a minor increase in total clozapine metabolites, which was even less with dose correction. Fluoxetine increased all clozapine analytes, in some cases to twice the levels in the subjects given only clozapine.

Emotional hypochondriasis, hyperbole, and the borderline patient

The authors define a new defense mechanism, emotional hypochondriasis, that is hypothesized to be central to borderline psychopathology. The behavioral manifestation of this defense-the hyperbolic stance of the borderline patient-is also defined and related to the complex phenomenology of borderline personality disorder. Borderline patients are seen as making an active attempt to maintain a tolerable, if tenuous, adaptation in the face of tremendous subjective emotional pain that has been shaped in large measure by traumatic childhood events that have never been validated. Twelve treatment implications and three expectable, if overlapping, stages of treatment stemming from the use of this defense and its behavioral sequelae are detailed.

Clozapine treatment of borderline patients: a preliminary study

Clinicians frequently encounter patients who present with borderline personality disorder (BPD) and prolonged and/or pronounced psychotic symptoms of an atypical nature. Fifteen such patients were treated with clozapine and rerated blind to baseline symptomatology and functional level from 2 to 9 months after beginning treatment (mean = 4.2 +/- 2.1). The overall symptomatology of these patients as rated on the Brief Psychiatric Rating Scale (BPRS) decreased significantly from a mean of 57.0 +/- 10.4 to a mean of 37.8 +/- 7.7 (t = 7.03, df = 14, P = .001). Their positive, negative, and general symptoms as rated by the BPRS also decreased significantly. Additionally, their Global Assessment Scale (GAS) score increased significantly from a mean of 30.8 +/- 4.7 to a mean of 43.1 +/- 8.6 (t = 5.19, df = 14, P = .001). These results suggest that clozapine may be an effective antipsychotic agent for this subset of BPD patients. However, double-blind, placebo-controlled studies are necessary to confirm these preliminary results.

Determination of clozapine, norclozapine, and clozapine-N-oxide in serum by liquid chromatography

We report a new assay to measure the serum concentrations of the atypical antipsychotic drug clozapine and two major metabolites, norclozapine and clozapine-N-oxide. The analytes and an internal standard (triprolidine) were extracted from alkalinized samples into ethyl acetate and back-extracted into 0.1 mol/L HCl. The acid extracts were chromatographed on a reversed-phase liquid chromatographic column with photodiode array detection (210-340 nm). With the 254-nm signal, between-run imprecision (CV) was &lt; 2% for clozapine and norclozapine at 400 micrograms/L, and 4.1% for clozapine-N-oxide at 100 micrograms/L. Absolute recovery exceeded 65%, and the detection limit was approximately 3-4 micrograms/L. In 25 patients at steady state at a mean daily clozapine dosage of 269 mg (3.09 mg/kg), clozapine averaged 231 +/- 144 micrograms/L (mean +/- SD); norclozapine and clozapine-N-oxide concentrations averaged 84% and 23% that of clozapine. Analyte concentrations were significantly correlated with daily dose. The method's ability to quantify clozapine and two major metabolites simultaneously with precision and sensitivity makes it useful in pharmacokinetic studies and therapeutic monitoring.

Determination of clozapine, norclozapine, and clozapine-N-oxide in serum by liquid chromatography

We report a new assay to measure the serum concentrations of the atypical antipsychotic drug clozapine and two major metabolites, norclozapine and clozapine-N-oxide. The analytes and an internal standard (triprolidine) were extracted from alkalinized samples into ethyl acetate and back-extracted into 0.1 mol/L HCl. The acid extracts were chromatographed on a reversed-phase liquid chromatographic column with photodiode array detection (210-340 nm). With the 254-nm signal, between-run imprecision (CV) was < 2% for clozapine and norclozapine at 400 micrograms/L, and 4.1% for clozapine-N-oxide at 100 micrograms/L. Absolute recovery exceeded 65%, and the detection limit was approximately 3-4 micrograms/L. In 25 patients at steady state at a mean daily clozapine dosage of 269 mg (3.09 mg/kg), clozapine averaged 231 +/- 144 micrograms/L (mean +/- SD); norclozapine and clozapine-N-oxide concentrations averaged 84% and 23% that of clozapine. Analyte concentrations were significantly correlated with daily dose. The method's ability to quantify clozapine and two major metabolites simultaneously with precision and sensitivity makes it useful in pharmacokinetic studies and therapeutic monitoring.

The face validity of the DSM-III and DSM-III-R criteria sets for borderline personality disorder

OBJECTIVE

The main objective of this study was to determine the congruence between DSM-III and DSM-III-R diagnoses of borderline personality disorder derived through the use of semistructured research interviews or given by experienced clinicians after lengthy consultations with an interdisciplinary team.

METHOD

The presence of the DSM-III and DSM-III-R criteria sets for borderline personality disorder was assessed in a study group of 253 patients with personality disorders (148 inpatients and 105 outpatients) by raters who were blind to clinical diagnoses and who used information from two semistructured interviews of proven reliability. These diagnoses were then compared with "longitudinal expert all data" (LEAD) standard clinical diagnoses provided by therapists specifically asked to base their diagnoses on DSM criteria.

RESULTS

Both criteria sets were found to be overinclusive when compared with the LEAD standard. Most criteria were also found to lack specificity. However, the three DSM-III-R criteria that are new or revisions of DSM-III criteria were found to be more specific, and raising the cutoff on the DSM-III-R criteria from five to six improved specificity.

CONCLUSIONS

Both the DSM-III and DSM-III-R criteria sets for borderline personality disorder as assessed by semistructured interview lack face validity because they are nonspecific when compared with a rigorous but representative clinical standard, and the results of studies using these criteria sets may prove misleading to researchers and clinicians because they seem to define a nonspecific type of serious character pathology.

Four cases of obstructive sleep apnea associated with treatment-resistant mania

The authors describe four cases in which obstructive sleep apnea complicated the course and treatment of mania. An association between weight gain, obstructive sleep apnea, and lithium treatment is also illustrated.

Discriminating borderline personality disorder from other axis II disorders

The authors used the Revised Diagnostic Interview for Borderline Patients to assess 22 clinical features of 120 patients with borderline personality disorder and 103 control subjects with other axis II disorders. Four of the 22 features were common in but nondiscriminating for borderline disorder, 11 were discriminating for but nonspecific to borderline disorder, and seven were more specific to borderline disorder. The authors conclude that many clinical features thought to be indicative of borderline disorder are better viewed as personality disorder traits and that the seven more specific features, alone or in conjunction with one another, may be particularly useful markers for borderline personality disorder.

Progressive ventricular enlargement in schizophrenia: comparison to bipolar affective disorder and correlation with clinical course

Previous studies of long-term serial changes in ventricular size in schizophrenia (SCZ) have yielded mixed, albeit predominantly negative results. The current study examined ventricular changes in CT scans over intervals of 1-to 4 1/2 years in chronic schizophrenic and bipolar patients. The results indicated significant progression of ventricular size from initial to final scan in the schizophrenia group but not in the bipolar or control groups; the percent increase in VBR over baseline was 25% (p less than 0.01) in the schizophrenia group as compared with 11% (n.s.) in the bipolar group. The increases in ventricular enlargement in the schizophrenic group did not correlate with duration of illness but did appear to show an irregular stepwise pattern in several patients. It is concluded that progressive ventricular enlargement after onset of illness does occur in a subgroup of schizophrenic patients characterized by a chronic or deteriorating clinical course. The etiological implications of this finding are discussed.

Axis II comorbidity of normal-weight bulimia

The axis II comorbidity of 34 women with active bulimia, 18 women with remitted bulimia, and 20 women with a history of major depression was assessed blind to axis I diagnosis using the Diagnostic Interview for Personality Disorders (DIPD), a semistructured interview of demonstrated reliability. Fifty percent of the active bulimic subjects, 44% of the remitted bulimic subjects, and 35% of the depressed controls met DSM-III criteria for at least one axis II disorder. Despite the generally higher prevalence of axis II pathology in both bulimic groups than depressed controls, these between-group differences did not reach significance. The clinical implications of these findings are discussed.

Cognitive features of borderline personality disorder

Of 50 patients with borderline personality disorder, 100% reported disturbed but nonpsychotic thought, 40% (N = 20) reported quasi-psychotic thought, and none reported true psychotic thought during the past 2 years; only 14% (N = 7) reported ever experiencing true psychotic thought. Disturbed and quasi-psychotic thought was significantly more common among these patients than among patients with other axis II disorders or schizophrenia and normal control subjects; however, true psychotic thought was significantly more common among schizophrenic patients. While disturbed thought was also common among axis II disorder and schizophrenic patients, quasi-psychotic thought was reported by only one of these subjects, suggesting that quasi-psychotic thought may be a marker for borderline personality disorder.