Mental health service utilization by borderline personality disorder patients and Axis II comparison subjects followed prospectively for 6 years

OBJECTIVE: The purpose of this study was to describe the psychiatric treatment received by a well-defined sample of patients with borderline personality disorder and Axis II comparison subjects over 6 years of prospective follow-up. METHOD: 362 inpatients were interviewed about their treatment histories during their index admission (1992-1995). 290 patients met both Revised Diagnostic Interview for Borderlines and DSM-III-R criteria for borderline personality disorder and 72 met DSM-III-R criteria for at least 1 nonborderline Axis II disorder (and neither criteria set for borderline personality disorder). Over 94% of surviving patients were re-interviewed about their psychiatric treatment histories 2, 4, and 6 years later. RESULTS: Only 33% of borderline patients were hospitalized during the final 2 years of the 6-year follow-up, a substantial decline from the 79% who had prior hospitalizations at baseline. Much the same pattern emerged for day and/or residential treatment (from 55% to 22%). In contrast, about three quarters of borderline patients were still in psychotherapy and taking psychotropic medications after 6 years of follow-up. Additionally, over 70% of borderline patients participating in these outpatient modalities did so for at least 75% of each follow-up period. While rates of intensive psychotherapy declined significantly over time (from 36% to 16%), rates of intensive polypharmacy remained relatively stable over time, with about 40% of borderline patients taking 3 or more concurrent standing medications during each follow-up period, about 20% taking 4 or more, and about 10% taking 5 or more. CONCLUSIONS: The results of this study suggest that the majority of borderline patients continue to use outpatient treatment in a sustained manner through 6 years of follow-up, but only a declining minority use more restrictive and costly forms of treatment.     

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.     

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

Zanarini MC, Hörz S, Frankenburg FR, Weingeroff J, Reich DB, Fitzmaurice G. 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.     

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.     

Severity of reported childhood sexual abuse and its relationship to severity of borderline psychopathology and psychosocial impairment among borderline inpatients

This study has two purposes. The first purpose is to describe the severity of sexual abuse reported by a well-defined sample of borderline inpatients. The second purpose is to determine the relationship between the severity of reported childhood sexual abuse, other forms of childhood abuse, and childhood neglect and the severity of borderline symptoms and psychosocial impairment. Two semistructured interviews of demonstrated reliability were used to assess the severity of adverse childhood experiences reported by 290 borderline inpatients. It was found that more than 50% of sexually abused borderline patients reported being abused both in childhood and in adolescence, on at least a weekly basis, for a minimum of 1 year, by a parent or other person well known to the patient, and by two or more perpetrators. More than 50% also reported that their abuse involved at least one form of penetration and the use of force or violence. Using multiple regression modeling and controlling for age, gender, and race, it was found that the severity of reported childhood sexual abuse was significantly related to the severity of symptoms in all four core sectors of borderline psychopathology (affect, cognition, impulsivity, and disturbed interpersonal relationships), the overall severity of borderline personality disorder, and the overall severity of psychosocial impairment. It was also found that the severity of childhood neglect was significantly related to five of the 10 factors studied, including the overall severity of borderline personality disorder, and that the severity of other forms of childhood abuse was significantly related to two of these factors, including the severity of psychosocial impairment. Taken together, the results of this study suggest that the majority of sexually abused borderline inpatients may have been severely abused. They also suggest that the severity of childhood sexual abuse, other forms of childhood abuse, and childhood neglect may all play a role in the symptomatic severity and psychosocial impairment characteristic of borderline personality disorder.     

Head-injured subjects aged over 50 years: correlations between variables of trauma and neuropsychologial follow-up

Summary Neuropsychological follow-up was studied in 70 consecutive head-injured subjects aged over 50 years. Diffuse deterioration (28%), moderate deterioration (25%) and dementia (21%) were the most frequent sequelae. Analysis of correlations between neuropsychological sequelae and trauma variables showed that: (1) mild trauma did not necessarily imply good prognosis and could be followed by very severe consequences; (2) duration of post-traumatic amnesia was correlated with coma duration but not with neuropsychological out come; (3) on the whole, no prognostic predictor of the outcome was found.     

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

Zanarini MC, Frankenburg FR, Bradford Reich D, Fitzmaurice G. 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.     

Axis I comorbidity in patients with borderline personality disorder: 6-year follow-up and prediction of time to remission

OBJECTIVE: The purpose of this study was to assess the prevalence of axis I disorders among patients with borderline personality disorder over 6 years of prospective follow-up. METHOD: A semistructured interview of demonstrated reliability was used to assess presence or absence of comorbid axis I disorders in 290 patients who met Revised Diagnostic Interview for Borderlines criteria and DSM-III-R criteria for borderline personality disorder and 72 patients who did not meet these criteria but did meet DSM-III-R criteria for another axis II disorder. Over 94% of surviving patients were reinterviewed about their axis I disorders at 2-year, 4-year, and 6-year follow-up periods. RESULTS: Although the patients with borderline personality disorder experienced declining rates of many axis I disorders over time, the rates of these disorders remained high, particularly the rates of mood and anxiety disorders. Patients whose borderline personality disorder remitted over time experienced substantial decline in all comorbid disorders assessed, but those whose borderline personality disorder did not remit over time reported stable rates of comorbid disorders. When the absence of comorbid axis I disorders was used to predict time to remission, the absence of substance use disorders was a far stronger predictor of remission from borderline personality disorder than was the absence of posttraumatic stress disorder, mood disorders, other anxiety disorders, or eating disorders, respectively. CONCLUSIONS: The results of this study suggest that axis I disorders are less common over time in patients with initially severe borderline personality disorder, particularly for patients whose borderline personality disorder remits over time. The findings also suggest that substance use disorders are most closely associated with the failure to achieve remission from borderline personality disorder.     

Axis II comorbidity in borderline personality disorder is influenced by sex, age, and clinical severity

Borderline personality disorder (BPD) is a severe psychiatric disorder that has a high clinical heterogeneity and frequent co-occurrence with other personality disorders (PDs). Although several studies have been performed to assess axis II comorbidity in BPD, more research is needed to clarify associated factors. The aim of this study was to determine the prevalence of co-occurrent axis II disorders in a large sample of patients with BPD and to investigate the influence of sex, age, and severity on this comorbidity.Data were collected from 484 patients with BPD through 2 semistructured interviews. We analyzed the frequency of axis II comorbidity and assessed differences regarding sex, age, and severity of BPD. About 74% of patients with BPD had at least 1 co-occurrent axis II disorder. The most common were paranoid, passive-aggressive, avoidant, and dependent PDs. Significant sex differences were found. Women presented more comorbidity with dependent PD, whereas men showed higher rates of comorbidity with antisocial PD. We also observed a significant positive correlation between age and the number of co-occurrent axis II disorders in women with BPD. Another finding was the positive correlation between BPD severity and the number of co-occurrent axis II disorders. These findings suggest that comorbidity with other axis II disorders and sex, age, and severity should be taken into account when developing treatment strategies and determining the prognosis of BPD.     

The role of childhood abuse in Axis I and Axis II psychiatric disorders and medical disorders of unknown origin among irritable bowel syndrome patients

OBJECTIVE: High rates of early abuse and psychopathology are commonly reported among treatment-seeking patients with irritable bowel syndrome (IBS). The purpose of this study is to further explore the relations among IBS, early abuse, Axes I and II psychopathology, and other medically unexplained disorders. METHODS: One hundred and ninety-six IBS patients seeking nondrug treatment for their symptoms were characterized in terms of their gastrointestinal (GI) status, psychiatric status (Axis I and Axis II), early abuse status, and the presence of other functional disorders. Patients were divided into two groups based on early abuse status. RESULTS AND CONCLUSION: No significant differences emerged between abused and nonabused groups on either the presence of Axis II disorders or other functional health conditions, although there were high levels of both in the IBS population. Patients with a history of abuse were significantly more likely to meet criteria for an Axis I disorder, especially substance abuse disorders, dysthymia, and generalized anxiety disorder.     

Concurrence of Axis I and Axis II illness in treatment-resistant hospitalized patients

Initial results of a retrospective chart study of treatment-resistant hospitalized patients is described, showing an association between Axis I and Axis II prevalence in this group. Implications for hospital treatment are listed.     

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.     

Treatment of aggression with topiramate in male borderline patients, part II: 18-month follow-up.

OBJECTIVE: We previously tested topiramate, an anticonvulsant, in the treatment of aggression in men with borderline personality disorder (BPD) (Nickel M, Nickel C, Kaplan P, Lahmann C, Mühlbacher M, Tritt K, et al. Treatment of aggression with topiramate in male borderline patients: a double-blind, placebo-controlled study. Biol Psychiatry 2005;57:495-9), and found significant changes on most scales of the state-trait anger expression inventory (STAXI) and significant weight loss eight weeks later. The aim of this trial was to assess topiramate's efficacy in the long-term therapy for aggression in men with BPD. METHODS: This 18-month follow-up observation, in which the previous patients (topiramate group: n=22; former placebo group: n=22) were examined bianually, was carried out. RESULTS: According to the intent-to-treat principle, significant changes on all scales of the STAXI were observed in the subjects treated with topiramate. Additional significant weight loss was observed. All subjects tolerated topiramate relatively well. CONCLUSIONS: Topiramate appears to be an effective, relatively safe agent in the long-term treatment of patients with BPD. Mild, non-transient weight loss can be expected.     

Sleep-EEG in borderline patients without concomitant major depression: a comparison with major depressives and normal control subjects.

The link between borderline personality disorder (BPD) and the affective disorders remains controversial. The aim of this study was to examine the relationships between BPD and major depression (MD) from the perspective of sleep parameters and to contribute to the characterisation of the sleep-EEG in BPD. We compared 20 off-medication BPD in-patients without co-existing MD with 20 sex- and age-matched MD patients without BPD and 20 sex- and age-matched control subjects. BPD patients had a greater prevalence of drug or alcohol abuse and suicide attempts than MD patients. MD patients had higher scores on the Hamilton Depression Rating Scale (HDRS). Both BPD and MD patients had less total sleep time, more prolonged sleep onset latency, and a greater percentage of wakefulness than control subjects. BPD patients and control subjects had more stage 2 sleep than MD patients. BPD patients had a longer duration of rapid eye movement (REM) sleep, and less stage 3, stage 4 and slow wave sleep than MD patients and control subjects. REM latency did not differentiate the three groups. BPD and MD patients shared sleep-continuity characteristics, but sleep architecture differentiated the two groups. BPD patients with a past history of MD had more wakefulness and less slow wave sleep than BPD patients without a history of MD; other sleep parameters, age, sex and HDRS scores were not statistically different in the two BPD subgroups. Although BPD and MD may coexist, the present study offers more arguments favouring the concept that they are not biologically linked and that BPD patients with depressive symptoms often experience an affective syndrome different from that in MD patients without BPD, in terms of quality and duration of symptoms and of the biological substrate.     

Mortality in Kraepelinian schizophrenic patients: a prospective study with a median follow-up of 8.4 years

Kraepelinian schizophrenia is a subtype of schizophrenia defined by its very poor outcome.Several studies have demonstrated the validity of this distinction, but the expected excess mortality has not been investigated.The aim of the present study was to test the hypothesis that Kraepelinian schizophrenic subjects have a higher mortality rate, notably due to natural causes, than non-Kraepelinian schizophrenic subjects. The results of a prospective study with a median follow-up of 8.4 years are reported. Three hundred ten schizophrenic subjects meeting the International Classification of Diseases, 10th Revision, criteria for schizophrenia were classified on admission as Kraepelinian schizophrenia (n = 31) and non-Kraepelinian schizophrenia (n = 279); 31 deaths (16 from unnatural causes, 13 from natural causes, and 2 from undetermined causes) were observed during follow-up. Univariate and multivariate Cox regression analyses were performed using schizophrenia subtype (Kraepelinian vs non-Kraepelinian), age, and duration of illness as predictors. Schizophrenia subtype was a significant predictor of mortality in univariate analysis only for death from natural causes, and a trend was observed after adjusting for age and duration of illness. A log-rank test was used to compare mortality rates between Kraepelinian and non-Kraepelinian schizophrenic subjects and showed a significantly higher mortality rate from natural causes in Kraepelinian schizophrenia (16.7%) than in non-Kraepelinian schizophrenia (4.1%).     

Stability and change in reported age of onset of depression,back pain,and smoking over 29 years in a prospective cohort study

Accurate age of onset (AOO) measurement is vital to etiologic and preventive research. While AOO reports are known to be subject to recall error, few population-based studies have been used to investigate agreement in AOO reports over more than a decade. We examined AOO reports for depression, back/neck pain, and daily smoking, in a population-based cohort spanning 29 years. A stratified sample of participants from Zurich, Switzerland (n = 591) completed a psychiatric and physical health interview 7 times between 1979, at ages 20 (males) and 21 (females), and 2008. We used one-way ANOVA to estimate intraclass correlations (ICCs) and weighted mixed models to estimate mean change over time and test for interactions with sex and clinical characteristics. Stratum-specific ICCs among those with 2 + reports were 0.19 and 0.29 for depression, 0.46 and 0.35 for back pain, and 0.66 and 0.75 for smoking. The average yearly increases in AOO report from the wave of first 12-month diagnosis or reported smoking, estimated in mixed models, were 0.57 years (95% confidence interval: 0.35, 0.79) for depression, 0.44 (95%CI: 0.28, 0.59) years for back pain, and 0.08 (95%CI: 0.03, 0.14) years for smoking. Initial impairment and frequency of treatment were associated with differences in average yearly change for depression. There is substantial variability in AOO reports over time and systematic increase with age. The degree of increase may differ by outcome, and for some outcomes, by participant clinical characteristics. Future studies should identify predictors of AOO report stability to ultimately benefit etiologic and preventive research.