Ethnic variations in the structure of borderline personality disorder symptomatology

The goal of this study was to examine differences in the factor structure of borderline personality disorder symptoms among different ethnic groups. The authors obtained information regarding ethnic identity and endorsement of borderline personality disorder criteria for an ethnically diverse community sample of 1140 young adult subjects from south Florida. Using this information the authors conducted an exploratory factor analysis examining differences between Caucasian, Hispanic and African American groups. A principal-components factor analysis (PCA) with Varimax rotation for each ethnic group revealed a reasonably generalizable four-factor structure: affective dysregulation, cognitive disturbance, disturbed relatedness and behavioral dysregulation. The emergence of a four-factor structure across three separate, relatively large samples suggests that the factors obtained have merit. However, the loadings of some BPD symptoms, such as impulsivity, varied for each ethnic group. The results of this study indicate that ethnic variations in borderline personality disorder should be considered during assessment and treatment of this disorder. Also, future research should examine if this same factor structure holds for ethnic minorities with BPD diagnoses, examine ethnic differences in the etiology and maintenance of BPD symptomatology, and explore the effects that these differences might have in treatment settings.     

Factor analysis of the DSM-III-R borderline personality disorder criteria in psychiatric inpatients

OBJECTIVE: The goal of this study was to examine the factor structure of the DSM-III-R criteria for borderline personality disorder in young adult psychiatric inpatients. METHOD: The authors assessed 141 acutely ill inpatients with the Personality Disorder Examination, a semistructured diagnostic interview for DSM-III-R personality disorders. They used correlational analyses to examine the associations among the different criteria for borderline personality disorder and performed an exploratory factor analysis. RESULTS: Cronbach's coefficient alpha for the borderline personality disorder criteria was 0.69. A principal components factor analysis with a varimax rotation accounted for 57.2% of the variance and revealed three homogeneous factors. These factors were disturbed relatedness (unstable relationships, identity disturbance, and chronic emptiness); behavioral dysregulation (impulsivity and suicidal/self-mutilative behavior); and affective dysregulation (affective instability, inappropriate anger, and efforts to avoid abandonment). CONCLUSIONS: Exploratory factor analysis revealed three homogeneous components of borderline personality disorder that may represent personality, behavioral, and affective features central to the disorder. Recognition of these components may inform treatment plans.     

Characterizing emotional dysfunction in borderline personality,major depression,and their co-occurrence

This research aimed to characterize patterns of emotional reactivity and dysregulation in borderline personality, depression, and their co-occurrence. In study 1, 488 young adult women from the community were categorized into four groups based on self-reported major depressive disorder (MDD) and borderline personality disorder (BPD) symptoms (Low BPD/Low MDD; Low BPD/High MDD; High BPD/Low MDD; High BPD/High MDD). Immediate and prolonged subjective emotional reactivity to a laboratory stressor were assessed, and participants completed self-report and behavioral measures of emotion dysregulation. Study 2 extended these findings, examining emotional reactivity and dysregulation in a clinical population of 176 substance dependent patients with diagnoses of BPD and MDD and including a biological index of emotional reactivity. Results revealed greater prolonged fear reactivity in the High BPD/High MDD (vs. Low BPD/Low MDD) group in study 1, and greater prolonged anxiety and negative affect reactivity in both High BPD groups (vs. Low BPD/Low MDD and Low BPD/High MDD groups) in study 2 (but no differences in cortisol reactivity). Results also demonstrated greater subjective (but not behavioral) emotion dysregulation in the High BPD/High MDD (vs. Low BPD/Low MDD) group in study 1 and both High BPD groups (vs. both Low BPD groups) in study 2. Finally, the High BPD/High MDD group reported greater difficulties controlling impulsive behaviors compared with all other groups in study 1 and the Low BPD groups in study 2. Findings suggest that BPD pathology (but not MDD pathology alone) is characterized by greater prolonged emotional (especially anxiety/fear-related) reactivity and heightened emotion dysregulation.     

Emotion dysregulation as a maintenance factor of borderline personality disorder features

We examined within-individual changes in emotion dysregulation over the course of one year as a maintenance factor of borderline personality disorder (BPD) features. We evaluated the extent to which (1) BPD symptom severity at baseline predicted within-individual changes in emotion dysregulation and (2) within-individual changes in emotion dysregulation predicted four BPD features at 12-month follow-up: affective instability, identity disturbances, negative relationships, and impulsivity. The specificity of emotion dysregulation as a maintaining mechanism of BPD features was examined by controlling for a competing intervening variable, interpersonal conflict. BPD symptoms at baseline predicted overall level and increasing emotion dysregulation. Additionally, increasing emotion dysregulation predicted all four BPD features at 12-month follow-up after controlling for BPD symptoms at baseline. Further, overall level of emotion dysregulation mediated the association between BPD symptom severity at baseline and both affective instability and identity disturbance at 12-month follow-up, consistent with the notion of emotion dysregulation as a maintenance factor. Future research on the malleability of emotion dysregulation in laboratory paradigms and its effects on short-term changes in BPD features is needed to inform interventions.     

Altered emotional information processing in borderline personality disorder: An electrophysiological study

Emotional dysregulation is one of the key symptoms of patients with borderline personality disorder (BPD). In the present study it is hypothesized that borderline patients display a cortical hyper-responsivity to emotional stimuli compared with a healthy control group. Further, we aimed to examine whether BPD patients were able to suppress stimuli with negative emotional valence as well as healthy control participants could. This is the first study addressing the electrophysiological processing of emotional stimuli in BPD. The electrophysiological response to emotional information was studied among 30 BPD patients and compared with the response in 30 normal controls using event-related potentials (ERPs). Participants were shown pictures selected from the International Affective Picture System with neutral, positive, and negative valence. After performing an attentional task, the participants were asked to perform a reappraisal task. The assignment was to consciously suppress emotions that might occur after viewing pictures with an unpleasant content. Borderline patients displayed larger late positive potentials (LPP) to pictures with an unpleasant valence as compared with the control group, indicating an enhanced elaborative processing of unpleasant stimuli. However, they did not differ on the reappraisal task. Borderline patients show an enhanced emotional cortical reactivity to unpleasant stimuli as compared with a control group. This suggests an emotional dysfunctioning in BPD patients. This feature might be an important focus in the treatment of BPD.     

Operationalisierte Diagnostik der Borderline-Persönlichkeitsstörung Eine Befragung von Psychiatern und Psychologen bezüglich ihrer Syndromvorstellungen

Despite the diagnostic criteria of the ICD-10 and DSM-IV, the term borderline has been used in a non-specific way for a long time. For our investigation we constructed a questionnaire, which contained the ICD-10 diagnostic criteria for the borderline personality disorder (BPD), plus the criteria for the other personality disorders and for the schizotype disorder. The two additional criteria for the BPD used by the DSM-IV were added. 800 psychiatrists and psychologists were asked to mark all criteria, which they thought were typical for the BPD. By using the operational diagnostic approach for ICD-10 and DSM-IV a disorder was diagnosed from each of the 162 received questionnaires based on the marked criteria. 92.0% of the questionnaires contained marked criteria for the diagnosis of the BPD by ICD-10 and 96.3% by DSM-IV. In addition each questionnaire contained up to eight other diagnosis. This is a sign for the difficulty to separate the BPD from other personality disorders or the schizotype disorder by using operationalized criteria. Looking at the lack of specificity of the operational diagnostic systems for personality disorders, e.g. for the BPD which has been discussed by many authors for years, modification of the diagnostic systems should be considered.     

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.     

Brief report: Borderline personality symptoms and perceived caregiver criticism in adolescents

Despite findings of an association between adolescent psychopathology and perceived parental criticism, the relation between adolescent borderline personality disorder (BPD) symptoms and perceived parental criticism has not been examined. Given the centrality of interpersonal sensitivity to BPD (relative to other forms of psychopathology), we hypothesized that adolescent BPD symptoms would be uniquely related to perceived caregiver criticism, above and beyond other forms of psychopathology and general emotion dysregulation. Adolescents (N = 109) in a residential psychiatric treatment facility completed self-report measures of BPD symptoms, perceived caregiver criticism, emotion dysregulation, and symptoms of depression, anxiety, and posttraumatic stress disorder. Results revealed a unique relation of adolescent BPD symptoms to perceived caregiver criticism, above and beyond age, gender, and other forms of psychopathology. Findings suggest that adolescent BPD symptoms may have unique relevance for adolescents' perceptions of caregivers' attitudes and behaviors, increasing the likelihood of negative perceptions.     

Personality disorders in parasuicide

To examine the prevalence of personality disorders in a representative sample of patients admitted to inpatient care after a parasuicide, 64 consecutive patients were investigated with structured interviews for DSM-IV personality disorders and clinical interviews for Axis I disorders and suicidal behaviour. We found a borderline personality disorder (BPD) as principal diagnosis in 55% of the subjects and some other personality disorder (OPD) in an additional 23%. Multiple Axis II disorders were significantly more common in the BPD group, in which 71% met criteria for three or more personality disorders, compared with 7% in the OPD group. In the BPD group 20% did not have a concomitant Axis I disorder, whereas this was very uncommon in the other groups. A relatively large proportion (34%) in the BPD group used other parasuicide methods than drug intoxication, whereas in the other groups this was rare. The mean number of previous parasuicidal acts was significantly higher in the BPD group, in which 57% had three or more previous parasuicides, and a high proportion (60%) also had repeated a parasuicidal act within the last year. In the BPD group 69% had ongoing outpatient treatment. Only 25% of these outpatients had a borderline personality disorder reported in the hospital records, suggesting that the personality disorder might go undiagnosed. The study gives support to the importance of a focused and structured personality disorder diagnosis in customizing treatment for the person with a recent parasuicide.     

Personality disorders in parasuicide

To examine the prevalence of personality disorders in a representative sample of patients admitted to inpatient care after a parasuicide, 64 consecutive patients were investigated with structured interviews for DSM-IV personality disorders and clinical interviews for Axis I disorders and suicidal behaviour. We found a borderline personality disorder (BPD) as principal diagnosis in 55% of the subjects and some other personality disorder (OPD) in an additional 23%. Multiple Axis II disorders were significantly more common in the BPD group, in which 71% met criteria for three or more personality disorders, compared with 7% in the OPD group. In the BPD group 20% did not have a concomitant Axis I disorder, whereas this was very uncommon in the other groups. A relatively large proportion (34%) in the BPD group used other parasuicide methods than drug intoxication, whereas in the other groups this was rare. The mean number of previous parasuicidal acts was significantly higher in the BPD group, in which 57% had three or more previous parasuicides, and a high proportion (60%) also had repeated a parasuicidal act within the last year. In the BPD group 69% had ongoing outpatient treatment. Only 25% of these outpatients had a borderline personality disorder reported in the hospital records, suggesting that the personality disorder might go undiagnosed. The study gives support to the importance of a focused and structured personality disorder diagnosis in customizing treatment for the person with a recent parasuicide.     

Partial seizure-like symptoms in borderline personality disorder

The clinical presentation of borderline personality disorder (BPD) bears a striking resemblance to the behavioral alterations associated with temporal lobe epilepsy. Using the Limbic System Checklist-33, we found that BPD subjects reported more symptoms associated with partial seizures than did control subjects. BPD patients also exhibited deficits on immediate and delayed recall of the Rey-Osterrieth Complex Figure and produced distorted drawings of the Rey Figure. Their degree of impairment correlated with their report of temporolimbic symptoms. Results are consistent with the proposal that temporolimbic dysfunction underlies the behavioral dyscontrol and affective dysregulation present in BPD.     

Cognitive and perceptual distortions in borderline personality disorder and schizotypal personality disorder in a vignette sample.

Clinical vignettes of patients with borderline personality disorder (BPD) and schizotypal personality disorder (STPD) were evaluated and rated for evidence of cognitive and perceptual distortions. The differences in the distortions of each group were then compared. The findings show that while STPD patients have significantly more cognitive and perceptual distortions than borderlines, there is an abundance of such distortions in the borderline group. The borderline group may differ, moreover, in that their cognitive and perceptual distortions were found to be significantly more object-related than those of the schizotypal group.     

Confirmatory factor analysis of DSM-IV criteria for borderline personality disorder: findings from the collaborative longitudinal personality disorders study

OBJECTIVE: This study tested the factor structure of the DSM-IV criteria for borderline personality disorder by using confirmatory methods for the analysis of covariance structures in a large group from a multisite study. METHOD: A total of 668 primarily treatment-seeking subjects were reliably assessed for personality disorders by using the Diagnostic Interview for DSM-IV Personality Disorders. Associations among criteria for borderline personality disorder were examined. A confirmatory factor analysis was performed to test diagnosis as a unitary construct and to test an earlier-reported three-factor model comprising disturbed relatedness, behavioral dysregulation, and affective dysregulation. The three-factor model was subsequently tested by using a subset (N=498) of the study group that was reassessed 2 years later by independent evaluators who were blind to original diagnoses. RESULTS: Internal consistency of the borderline personality disorder diagnosis was adequate for both baseline and follow-up assessments. A confirmatory factor analysis model testing the borderline personality disorder diagnosis as a unitary construct provided good fit, and the three-factor model offered a significantly better fit for the baseline assessment. The three-factor model was replicated with the 2-year follow-up data. CONCLUSIONS: The diagnostic criteria for borderline personality disorder appear to reflect a statistically coherent construct. Three homogeneous components were supported empirically, lending conceptual clarity to different classes of the criteria for borderline personality disorder.     

Neuropsychological impairment in borderline personality disorder.

In spite of accumulating evidence from neurological, neuroimaging, neuropsychological, and, more recently, developmental studies, borderline personality disorder (BPD) is not considered routinely a neurocognitive disorder. A review of the neuropsychological literature shows that the preponderance of BPD studies failed to examine a broad range of cognitive domains and, in particular, have not adequately evaluated attention. Nevertheless, most neuropsychological studies suggest that these patients' cognitive skills are compromised. The authors administered a neuropsychological battery designed to evaluate nine cognitive domains in twelve female inpatients diagnosed with BPD. Relative to a healthy normative group, inpatients with BPD were impaired in seven cognitive domains, with attention-vigilance and verbal learning and memory most pronounced. Neuropsychological performance was significantly related to degree of psychopathology. The authors recommend that clinicians routinely screen BPD patients for cognitive dysfunction and highlight the roles that this important knowledge can have in treatment.     

Clinical features and impairment in women with Borderline Personality Disorder (BPD) with Posttraumatic Stress Disorder (PTSD), BPD without PTSD, and other personality disorders with PTSD

The aims of this study were to examine differences in clinical features, impairment, and types of childhood traumas among women with borderline personality disorder (BPD), women with BPD and posttraumatic stress disorder (PTSD), and those with other personality disorders and PTSD. Using baseline data from the Collaborative Longitudinal Study of Personality Disorders, 186 women were divided into 3 groups (BPD+PTSD, BPD, PTSD), based on structured diagnostic interviews for Axis I and Axis II disorders and compared on selected clinical variables. The additional diagnosis of PTSD in borderline women did not significantly increase the degree of borderline pathology and psychiatric morbidity but did significantly increase general dysfunction and the occurrence of hospitalization. The additional diagnosis of BPD in women with PTSD significantly increased the features of suicide proneness and impulsiveness. Both groups of women with PTSD reported significantly more types of childhood traumas relative to borderline women without PTSD. Consistent with other research, the findings suggest that PTSD does not appear to alter the central features of BPD. The clinical implications of our findings are considered.     

A multimodal assessment of the relationship between emotion dysregulation and borderline personality disorder among inner-city substance users in residential treatment

The concept of emotion dysregulation has been integrated into theory and treatment for borderline personality disorder (BPD), despite limited empirical support. Expanding upon existing research on the relationship between emotion dysregulation and BPD, the present study utilized a multimodal approach to the assessment of emotion dysregulation (including two behavioral measures of the willingness to tolerate emotional distress, and a self-report measure of emotion dysregulation broadly defined) to examine the relationship between emotion dysregulation and BPD among inner-city substance users in residential treatment (n = 76, with 25 meeting criteria for BPD). Results provide laboratory-based evidence for heightened emotion dysregulation in BPD, extending extant research on BPD to underserved clinical populations. Specifically, the presence of a BPD diagnosis among a sample of inner-city inpatient substance users was associated with both higher scores on the self-report measure of emotion dysregulation and less willingness to tolerate emotional distress on the behavioral measures of emotion dysregulation. Moreover, both self-report and behavioral measures of emotion dysregulation accounted for unique variance in BPD status, suggesting the importance of utilizing comprehensive assessments of emotion dysregulation within studies of BPD. Findings suggest the need to further explore the role of emotion dysregulation in the development and maintenance of BPD among inner-city substance users in residential treatment.     

Impulsivity in Borderline Personality Disorder: A Matter of Disturbed Impulse Control or a Facet of Emotional Dysregulation?

Impulsivity is regarded as a clinical, diagnostic and pathophysiological hallmark of borderline personality disorder (BPD). Self-report measures of impulsivity consistently support the notion of higher impulsive traits in BPD patients as compared to healthy control subjects. Laboratory tests of impulsivity, i.e. neuropsychological tests of impulse control render weak and inconsistent results both across different cognitive components of impulse control and within the same cognitive component of impulse control. One important factor worsening impulsive behaviors and impulse control deficits in BPD is comorbid attention-deficit/hyperactivity disorder (ADHD). In addition, emotional dysregulation interacts with impulse control especially for BPD salient emotions. In sum, although basic mechanisms of impulse control seem not to be disturbed in BPD, clinically well observed impulsive behaviors may be explained by comorbid ADHD or may be the consequence of dysregulation of BPD salient emotions.     

Cortisol response to interpersonal stress in young adults with borderline personality disorder: a pilot study.

Hypothalamic-pituitary-adrenal axis dysregulation after stress was found to be associated with borderline personality disorder (BPD). Nine female BPD young adults and 12 control subjects were investigated for stress reactivity and recovery after an interpersonal conflict discussion with their mothers. BPD subjects showed a delayed cortisol response after psychosocial stress.     

Bordering on bipolar: the overlap between borderline personality and bipolarity

Objective: There is much debate over whether borderline personality disorder (BPD) belongs to the bipolar spectrum. The diagnosis of bipolar disorder (BD) in BPD patients, and conversely, BPD in BD patients is common, indicating prevalent co-morbidity, as well as potential misdiagnosis in either group. BD and BPD are often indistinguishable given the core characteristics of emotional dysregulation and impulsivity that feature in both. However, it may be argued that the manifestation of these characteristics in the two groups is different, and that the symptoms are driven by distinct aetiological factors. The primary objective of this paper was to examine where potential areas of discrimination lie between BD and BPD. Methods: A literature search was conducted using MEDLINE and PubMed databases to identify studies that have researched BD and BPD across the recognised domains of emotional dysregulation, impulsivity, childhood trauma, and their putative neurobiological substrates. Results: Research comparing BD and BPD patients on self-report measures is limited, and no studies have examined their neurobiological underpinnings in the same design. One possible differentiating variable is childhood trauma which shapes the circumstances in which emotional dysregulation and impulsivity are triggered, the types of behaviours exhibited, and the frequency and duration of mood states. There is growing evidence that childhood trauma not only predisposes individuals to both disorders, but also modulates the clinical expression and course of bipolar illness, particularly rapid cycling BD, a form of bipolarity that resembles the clinical profile of BPD, yet presents quite distinctly from other BD subtypes. Conclusions: This paper provides an overview of BD and BPD with respect to emotional dysregulation, impulsivity, childhood factors, and neurobiological substrates. Based on findings predominantly within the independent areas of BD and BPD, it tentatively provides an integrated behavioural, aetiological and neurobiological approach for investigating the question of whether BPD belongs to the bipolar spectrum.