The extent of dissociation in borderline personality disorder: A meta-analytic review

Several authors have studied dissociation within the borderline personality disorder (BPD) population and postulated 3 dissociative subgroups. Conversely, other authors suggest that dissociation may play a central role in the development of trauma-related disorders and specifically in BPD. Nevertheless, the role of dissociation in BPD seems to be controversial. Our aim is to perform a meta-analytic review of the literature to evaluate the extent of dissociation in BPD compared to other psychopathological disorders to clarify its role in this specific condition. Ten eligible studies resulted in a total of 2,035 subjects. Results show that levels of dissociation are higher in BPD than in other psychiatric disorders in general, although this difference is moderate and the heterogeneity of effect sizes is large. In particular, individuals with BPD seem to show higher levels of dissociation than those with several psychiatric and personality disorders but not dissociative disorders or posttraumatic stress disorder. These findings support the fact that dissociation is not specifically a core feature of BPD and, in addition, sustain the existence of a continuum of severity within the psychiatric population. Nevertheless, the current work has several limitations related to the paucity of studies included, the heterogeneity of control groups, their clear definition, and the statistical robustness of the results. In addition, our conclusions require future research in order to explain the role of different forms of dissociation and their etiological factors among the psychiatric population. Eventually, we invite clinicians and researchers to systematically evaluate dissociation in order to reach a better diagnosis for a more specific treatment indication.     

The role of somatic health problems in the recognition of depressive and anxiety disorders by general practitioners

Background

Recognition of depression and anxiety by general practitioners (GPs) is suboptimal and there is uncertainty as to whether particular somatic health problems hinder or facilitate GP recognition. The objective of this study was to investigate the associations between somatic health problems and GP recognition of depression and anxiety.

Methods

We studied primary care patients with a DSM-IV based psychiatric diagnosis of depressive or anxiety disorder during a face-to-face interview (n=778). GPs′ registrations of depression and anxiety diagnoses, based on medical file extractions, were compared with the DSM-IV based psychiatric diagnoses as reference standard. Somatic health problems were based on self-report of several chronic somatic diseases and pain symptoms, using the Chronic Pain Grade (CPG), during the interview.

Results

Depression and anxiety was recognized in sixty percent of the patients. None of the health problems were negatively associated with recognition. Greater severity of pain symptoms (OR=1.18, p=.02), and chest pain (OR=1.56, p=.02), in particular, were associated with more GP recognition of depression and anxiety. Mediation analyses showed that depression and anxiety in these patients were better recognized through the presence of more severe psychiatric symptoms.

Limitations

Some specific chronic diseases had low prevalence.

Conclusions

This study shows that the presence of particular chronic diseases does not influence GP recognition of depression and anxiety. GPs tend to recognize depression and anxiety better in patients with pain symptoms, partly due to more severe psychiatric symptoms among those with pain.     

抑郁障碍患者人格特征与自杀风险研究

目的探讨抑郁障碍患者的人格特征及其与自杀风险的关系。方法对183例抑郁障碍患者进行艾森克个性问卷及汉密顿抑郁量表测查，对其结果进行分析。结果①抑郁障碍患者较正常对照组P、N、E分比较具有统计学差异（P〈0．05）；②病例组抑郁障碍患者艾森克问卷中P、N、E各因子与汉密顿关于自杀的因子用方差分析比较没有相关性（P〉0．05），把自杀因子变为有无自杀观念进行独立样本t检验，结果有无自杀与P、N、E各因子比较也没有显著性差异（P〉0．05）。结论①抑郁障碍患者的人格特征突出表现为神经质更明显，情绪更不稳定，更内向；②抑郁障碍患者的人格特征与其自杀风险关系不明显。     

Awareness of identity alteration and diagnostic preference between borderline personality disorder and dissociative disorders

Aim: This study inquires into identity alteration among college students and its relationship to borderline personality disorder (BPD) and/or dissociative disorders (DDs). Methods: Steinberg Identity Alteration Questionnaire (SIAQ), Childhood Trauma Questionnaire (CTQ), and self-report screening tool of the BPD section of the Structured Clinical Interview for DSM-IV (SCID-BPD) were administered to 1301 college students. Participants who fit the diagnostic criteria of BPD (n = 80) according to the clinician-administered SCID-BPD and 111 non-BPD controls were evaluated using the Structured Clinical Interview for DSM-IV DDs (SCID-D) by two psychiatrists blind to the group membership and scale scores. Results: Test-retest evaluations and internal consistency analyses suggested that SIAQ was a reliable instrument. Of the participants, 11.3% reported a SIAQ score 25 or above alongside some impairment. SIAQ scores differentiated participants who fit the diagnostic criteria for a DD from those who did not. While self-report identity alteration was correlated with all childhood trauma types, clinician-assessed identity alteration was correlated with childhood sexual abuse only. Those who fit criteria for both disorders had the highest identity alteration scores in self-report and clinician-assessment. Although both syndromes had significant effect on self-report identity alteration total scores, in contrast to DD, BPD did not have an effect on the clinician-administered evaluation. Conclusion: An impression of personality disorder rather than a DD may seem more likely when identity alteration remains subtle in clinical assessment, notwithstanding its presence in self-report. Lack of recognition of identity alteration may lead to overdiagnosis of BPD among individuals who have a DD.     

Fact or fiction: diagnosing borderline personality disorder in adolescents

Borderline Personality Disorder (BPD) has long been considered a mental health problem that results in considerable costs in terms of human suffering and psychiatric expenses among adult patients. Although the diagnosis of BPD for adolescents is frequently used in clinical settings, the field of mental health has questioned whether one should diagnose BPD among adolescents. This paper reviews the recent empirical literature (identified through PsycINFO 1980 to present) to evaluate prevalence, reliability, and validity of a BPD diagnosis in adolescents. It is concluded that the features BPD diagnoses in adolescents are comparable to those in adults. Furthermore, there appears to be a legitimate subgroup of adolescents for whom the diagnosis remains stable over time as well as a less severe subgroup that moves in and out of the diagnosis. While caution is warranted, formal assessment of BPD in adolescents may yield more accurate and effective treatment for adolescents experiencing BPD symptomatology. More longitudinal research is necessary to further explicate the issues of diagnosing BPD in adolescents.     

Factors predicting the outcome of psychotherapy for borderline personality disorder: a systematic review

Background

There is substantial variation between individuals with borderline personality disorder (BPD) in the degree of benefit gained from psychotherapy. Information on factors predicting the outcome of therapy for this group could facilitate identification of those at risk for poor outcome, and could enable helpful therapy processes to be identified.

Method

A systematic search of PsycInfo, EMBASE, CINHAL and Medline identified research on factors predicting symptom change during therapy for patients with a BPD diagnosis. Non-English language papers and dissertations were included.

Results

Two consistent positive predictors of symptom change were identified: pre-treatment symptom severity and patient-rated therapeutic alliance. Contrary to theories predicting increasing immutability with age, there was no evidence that age predicted poorer outcome.

Conclusion

More severely ill patients may have greater potential to achieve change during therapy, and should remain a focus for psychotherapy services. The therapeutic alliance is an important common factor predicting outcome in patients with BPD, even in highly disorder-specific treatments. Outcomes may be improved by further clinical and research focus on forming strong therapeutic alliances. The advancement of the field requires identification and testing of new predictors of outcome, especially those related to specific theories of therapeutic change in BPD.     

Serotonin 2A receptor gene is associated with personality traits, but not to disorder, in patients with borderline personality disorder

Borderline personality disorder (BPD) is a chronic, disabling, and high-risk mental disorder characterized by a pervasive pattern of instability in regulation of emotion, interpersonal relationships, self-image, and impulse control beginning in early adulthood. BPD affects about 1%-2% of the general population and has a high mortality rate as a result of suicide and impulsive behaviour. The serotonin 2A receptor gene (HTR2A) is considered a candidate gene for BPD because multiple lines of evidence suggest that it plays an important role in suicide, impulsivity and emotional liability. To test for an association between HTR2A and BPD, we genotyped four polymorphisms, rs6313 (T102C), rs4941573, rs2296972 and rs6314 (His452Tyr), in 111 Caucasian patients with BPD and 287 Caucasian healthy controls. The program UNPHASED was used to compare allele and haplotype frequencies between cases and controls. We did not find a significant association between HTR2A and BPD based on allele, genotype or haplotype analyses. However, there were significant associations between HTR2A and personality traits in the BPD patients. The C allele of rs6313 and the A allele of rs4941573 associated with a higher Extraversion score. Our results suggest that the serotonin 2A receptor gene may not play a major role in the aetiology of borderline personality disorder, but may have a role in personality traits.     

Creativity and borderline personality disorder: evidence from a voxel-based morphometry study

Introduction: Throughout the history, various examples of eminent creative people suffering from mental disorders along with some empirical research reports strengthened the idea of a potential link between creativity and psychopathology.

Methods: This study investigated different facets of psychometrically determined creativity in 20 females diagnosed with borderline personality disorder (BPD) relative to 19 healthy female controls. In addition, group differences in grey matter (GM) were examined.

Results: Behavioural findings revealed no significant differences between the BPD group and healthy controls with respect to verbal and figural-graphic creative task performance and creativity-related personality characteristics. Whole-brain voxel-based morphometry analyses revealed a distinct pattern of GM reductions in the BPD group (relative to controls) in a network of brain regions closely associated with various cognitive and emotional functions (including the bilateral orbital inferior frontal gyri and the left superior temporal gyrus), partly overlapping with creativity-related brain regions. Correlation analyses moreover revealed that in the BPD group GM reductions in the orbital parts of the inferior and middle frontal gyri were associated with lower levels of creativity.

Conclusions: This study provides no indications in favour of the putative link between creativity and psychopathology, as sometimes reported in the literature.     

Evidence of disturbed amygdalar energy metabolism in patients with borderline personality disorder

In order to detect possible links between structural and neurochemical brain abnormalities we applied high resolution morphometric imaging and short-echo time absolute-quantification magnetic resonance spectroscopy (MRS) at the left hand side to the amygdala in 12 patients with borderline personality disorder (BPD) and 10 group-matched healthy controls. Confirming earlier reports we found a significant 11–17% reduction of amygdalar volumes in patients with BPD. In addition there was a significant 17% increase of left amygdalar creatine concentrations in BPD patients. Left amygdalar creatine concentration correlated positively with measures of anxiety and negatively with amygdalar volume. This pilot study of simultaneous amygdalar morphometry and spectroscopy in BPD reveals a possible link between amygdalar volume loss, psychopathology and neurochemical abnormalities in terms of creatine signals.     

合并边缘人格障碍的抑郁障碍者的病史特征

目的：比较合并及非合并边缘人格障碍者的抑郁障碍者病史特征的差异及其相关因素。方法：采用HAMD，PDQ-4＋，SCID—Ⅱ对122名共病组患者和100名非共病组患者测试。结果：共病组的抑郁初次发病年龄、抑郁病程，自杀、抑郁发作次数，创伤史都和非共病组有显著差异，但是总住院时间无显著差异，共病组HAMD分值、PDQ-4＋中边缘型、回避型、分裂型、偏执型、自恋型、表演型、反社会型、强迫型、依赖型分值显著高于非共病组．而抑郁型、分裂性、被动-攻击型的分值两组无显著差异。结论：边缘人格障碍和抑郁障碍者共病者与非共病者有明显的病史差异。     

Childhood familial environment,maltreatment and borderline personality disorder symptoms in a non‐clinical sample: A cognitive behavioural perspective

The present study sought to determine if cognitive beliefs and schemas mediated the relationship between retrospectively reported childhood events and adult borderline personality disorder (BPD) symptoms in a non‐clinical sample. One hundred and seventy‐eight non‐clinical participants completed questionnaires measuring BPD symptoms, core beliefs, and retrospective reports of childhood family functioning and childhood maltreatment. Results of a series of multiple regressions showed that core beliefs hypothesised to be related to BPD mediated the relationship between BPD symptoms and retrospective reports of childhood emotional abuse. Hence, the current study adds further support to the cognitive mediation hypothesis in BPD and provides theoretical support for cognitive behavioural formulations and treatments for BPD.     

Electrophysiological correlates of error processing in borderline personality disorder

The electrophysiological correlates of error processing were investigated in patients with borderline personality disorder (BPD) using event-related potentials (ERP). Twelve patients with BPD and 12 healthy controls were additionally rated with the Barratt impulsiveness scale (BIS-10). Participants performed a Go/Nogo task while a 64 channel EEG was recorded. Three ERP components were of special interest: error-related negativity (ERN)/error negativity (Ne), early error positivity (early Pe) reflecting automatic error processing, and the late Pe component which is thought to mirror the awareness of erroneous responses. We found smaller amplitudes of the ERN/Ne in patients with BPD compared to controls. Moreover, significant correlations with the BIS-10 non-planning sub-score could be demonstrated for both the entire group and the patient group. No between-group differences were observed for the early and late Pe components. ERP measures appear to be a suitable tool to study clinical time courses in BPD.     

The association between borderline personality disorder and somatoform disorders: A systematic review and meta‐analysis

A systematic review and meta‐analysis were conducted to characterize the prevalence of somatoform disorders among those with borderline personality disorder (BPD) and of BPD among those with somatoform disorders. Searches of PsycINFO and PubMed revealed 34 empirical studies 1980‐present that assessed the co‐occurrence of BPD and somatoform disorders. Pooled estimates of 30% and 14% were found for the prevalence of somatoform disorders among those with BPD and of BPD among those with somatoform disorders, respectively. The results are discussed in terms of the implications for potential common mechanisms and for treatment.     

Neuroligand binding endophenotypes in blood cells distinguish two subsets of borderline personality disorder patients

Neurotransmitter ligand binding in blood cells was assessed in borderline personality disorder (BDP) patients, testing the possibility that different biochemical endophenotypes might lie beneath a specific clinical presentation. The density of peripheral benzodiazepine receptors (PBR) and serotonin transporters were assessed in peripheral blood mononuclear cells (PBMC) and platelets, respectively, showing a decrease of both parameters. Moreover, a further significant decrease of PBR in PBMC was shown for those patients with a depressive trait. Further confirmation of the presence of different molecular endophenotypes underlying the dissimilar clinical presentations in BPD may advance our possibility of successfully treating these patients.     

The role of attachment characteristics in dialectical behavior therapy for patients with borderline personality disorder

Attachment characteristics play a key role in understanding borderline‐specific problems with respect to childhood maltreatment. The aim of this study was to investigate how attachment representations may influence the trajectory of change in a 1‐year outpatient dialectical behavior therapy (DBT) for patients with borderline personality disorder (BPD). Attachment representations were assessed in 26 BPD patients and 26 healthy controls (HC) using the Adult Attachment Projective Picture System (AAP) before treatment. Borderline and global symptom severity and interpersonal problems were examined before, during, and after completing the intervention. Analysis of variance and stepwise hierarchical regression analyses were used to explore the course of symptomatology. As expected, BPD patients displayed a predominance of unresolved attachment in the AAP compared with HC, by showing a lack of ability to integrate attachment related trauma. Whereas both resolved and unresolved attachment groups revealed significant improvement in symptom severity during treatment, dimensional AAP scores showed differences. Patients with higher scores in “synchrony” demonstrated more indicators of mutual care in their narratives to dyadic pictures and displayed a significantly stronger decrease of interpersonal problems than patients with lower synchrony scores. Assessing attachment representations prior to DBT might provide a helpful insight into individual attachment related resources or lack of these capacities. Responsiveness and synchrony in dyadic interactions with significant others are crucial for healthy interpersonal relations. A stronger therapeutic focus on the patient's capacity to show synchrony in dyadic attachment situations might improve the patient's interpersonal problems towards sensitive and mutual interaction.