Impulsivity in patients with borderline personality disorder

This study investigated features of impulsivity in patients with borderline personality disorder (BPD) using the self-report Attention-Deficit Scales for Adults (ADSA) and computer-administered neurocognitive tasks. Forty-one patients with DSM-III-R BPD and 35 nonclinical control subjects were assessed by the ADSA, the National Adult Reading Test, and two computerized tasks mediated by the frontal lobes. Mean scores for seven ADSA scales (six of which relate to aspects of impulsivity) were significantly higher in the patient group compared with the control group. Also, the ADSA ratings for impaired coordination were increased in the BPD patients. The findings indicate that a range of aspects of impulsivity, as well as impaired coordination, are associated with patients selected on the basis of BPD. Also, in the patient group, but not in the control group, associations of the neurocognitive tasks indicated that, first, performance on a planning task related to dorsolateral frontal lobe functioning is correlated with aspects of impulsivity reflected by ADSA scale III ratings (involving disorganisation and lack of perseverance) and, second, performance on a decision-making task related to orbitofrontal functioning is correlated with ratings of impaired coordination. Further work is needed to establish the specificity of the findings.     

Classical conditioning in borderline personality disorder: an fMRI study

Previous research suggests disturbed emotional learning and memory in borderline personality disorder (BPD). Studies investigating the neural correlates of aversive differential delay conditioning in BPD are currently lacking. We aimed to investigate acquisition, within-session extinction, between-session extinction recall, and reacquisition. We expected increased activation in the insula, amygdala, and anterior cingulate, and decreased prefrontal activation in BPD patients. During functional magnetic resonance imaging, 27 medication-free female BPD patients and 26 female healthy controls (HC) performed a differential delay aversive conditioning paradigm. An electric shock served as unconditioned stimulus, two neutral pictures as conditioned stimuli (CS+/CS?). Dependent variables were blood-oxygen-level-dependent response, skin conductance response (SCR), and subjective ratings (valence, arousal). No significant between-group differences in brain activation were found [all p(FDR) > 0.05]. Within-group comparisons for CS+_unpaired > CS? revealed increased insula activity in BPD patients but not in HC during early acquisition; during late acquisition, both groups recruited fronto-parietal areas [p(FDR) < 0.05]. During extinction, BPD patients rated both CS+ and CS? as significantly more arousing and aversive than HC and activated the amygdala in response to CS+. In contrast, HC showed increased prefrontal activity in response to CS+ > CS during extinction. During extinction recall, there was a trend for stronger SCR to CS+ > CS in BPD patients. Amygdala habituation to CS+_paired (CS+ in temporal contingency with the aversive event) during acquisition was found in HC but not in patients. Our findings suggest altered temporal response patterns in terms of increased vigilance already during early acquisition and delayed extinction processes in individuals with BPD.     

Anatomical MRI study of borderline personality disorder patients

Hippocampal volume reduction has been reported in patients with borderline personality disorder (BPD), and is hypothesized to be associated with traumatic childhood experiences. We extended this investigation to explore additional brain regions and other potential clinical correlates of structural brain changes in BPD. Ten unmedicated BPD subjects and 20 healthy controls were assessed for current and past Axis I and II comorbidities and histories of childhood abuse. All had magnetic resonance imaging (MRI) studies with a 1.5 T GE Signa Imaging System, performing three-dimensional-gradient echo imaging (SPGR) with the following parameters: TR=25 ms, TE=5 ms, and slice-thickness=1.5 mm. Compared with healthy controls, BPD subjects had significantly smaller right and left hippocampal volumes, most marked in subjects with childhood abuse, and significantly increased right and left putamen volumes, especially in subjects with substance use disorders. No significant differences between groups were found for caudate, amygdala, temporal lobes, dorsolateral prefrontal cortex and total brain volumes. This study replicated prior findings of diminished hippocampal volumes in subjects with BPD. Also, increased putamen volumes were found in BPD, a finding that has not been previously reported. Early traumatic experiences may play a role in hippocampal atrophy, whereas substance use disorders may contribute to putamen enlargement.     

MRI study of corpus callosum in patients with borderline personality disorder: a pilot study

This pilot study examined the integrity of the corpus callosum in a sample of patients with borderline personality disorder (BPD), as abnormalities in inter-hemispheric communication could possibly be involved in illness pathophysiology. We utilized magnetic resonance imaging (MRI) signal intensity (SI) and morphometric measures. Ten BPD and 20 healthy control subjects were assessed for current and past Axis I and Axis II comorbidities and histories of childhood abuse. Regional CC SI and areas were measured with semi-automated software from three-dimensional gradient echo imaging scans. Analysis of covariance was conducted to evaluate the results. No significant differences were observed between BPD and controls in the SI or area of any CC region. Abnormalities in interhemispheric connectivity do not appear necessary for the development of BPD. Further studies with larger samples are needed to confirm this preliminary finding.     

Double-blind, placebo-controlled study of dialectical behavior therapy plus olanzapine for borderline personality disorder

OBJECTIVE: The aim of this study was to determine the efficacy and safety of dialectical behavior therapy plus olanzapine compared with dialectical behavior therapy plus placebo in patients with borderline personality disorder. METHOD: Sixty patients with borderline personality disorder were included in a 12-week, double-blind, placebo-controlled study. All patients received dialectical behavior therapy and were randomly assigned to receive either olanzapine or placebo following a 1-month baseline period. RESULTS: Seventy percent of the patients completed the 4-month trial. Combined treatment showed an overall improvement in most symptoms studied in both groups. Olanzapine was associated with a statistically significant improvement over placebo in depression, anxiety, and impulsivity/aggressive behavior. The mean dose of olanzapine was 8.83 mg/day. CONCLUSIONS: A combined psychotherapeutic plus pharmacological approach appears to lower dropout rates and constitutes an effective treatment for borderline personality disorder.     

Aversive tension in patients with borderline personality disorder: a computer-based controlled field study

OBJECTIVE: This study was designed to examine the subjective appraisal of aversive tension under conditions of daily life in patients with borderline personality disorder (BPD). METHOD: A sample of 63 female subjects with BPD and 40 mentally healthy controls were each given a hand-held computer. For two consecutive days, participants were prompted at hourly intervals to record their current state of aversive tension and prompting events. RESULTS: Compared with controls, states of aversive tension occurred significantly more frequently in BPD patients. The average levels of aversive tension were significantly higher, and the rate of increase in tension was markedly more rapid. Furthermore, states of aversive tension persisted for a longer period. Among BPD subjects three events (rejection, being alone, and failure) account for 39% of all events preceding states of tension. CONCLUSION: The study provides support for the theory that patients with BPD experience more frequent, stronger, and longer-lasting states of aversive tension.     

Genetics of patients with borderline personality disorder.

An overview of the existing literature suggests that traits similar to BPD are influenced by genes. It is too early to say to what extent BPD is also influenced by genes, but because personality traits generally show a strong genetic influence, this should also be true for BPD. Nonetheless, if the equal-environment assumption were to be violated for MZ and DZ pairs, twin studies may be overestimating genetic effects and hiding the effect of common family environment. The less than-ideal reliability of measurements used in this research may also reduce the effects of genes and common environment while increasing the effects of unique or nonshared environment. The effect of genes on the development of BPD is likely substantial. The effect of common family environment may be close to zero. More studies, large and small, are needed to reach firmer conclusions about the influence of genetics on BPD.     

Psychopharmacologic management of patients with borderline personality disorder

This paper reviews recent literature on the psychopharmacologic management of borderline personality disorder (BPD) patients and discusses an approach to drug therapy. Five randomized controlled trials have shown positive, but non-specific effects of antipsychotic drugs on the symptoms suffered by BPD patients. There were too few data on other types of drugs to draw any conclusion. We propose that BPD patients be treated on the basis of being in a state or episode of co-existing Axis I disorder.     

Neuropsychological testing of patients with borderline personality disorder

OBJECTIVE AND METHOD: This study examined whether a battery of neuropsychological tests could detect cognitive deficits--particularly in the areas of perception, learning, and memory--in patients with borderline personality disorder. The test battery was completed by 16 research outpatients with borderline personality disorder, typified by behavioral dyscontrol and diagnosed according to DSM-III-R criteria and the Diagnostic Interview for Borderline Patients. A comparison group of 16 normal volunteers also completed the test battery. RESULTS: The performance of the borderline patients was significantly impaired in comparison with that of the normal group on memory tests requiring uncued recall of complex, recently learned material. Cues given on an auditory memory task partially corrected that deficit. The patients' performance was also significantly impaired on several visual perceptual tests. These deficits do not appear to have been attributable to attentional problems, psychomotor impairment, current major depression, or history of alcohol abuse. CONCLUSIONS: The observed difficulties in separating essential from extraneous visual information and in recalling complex material may be relevant in understanding some of the clinical features of borderline personality disorder. The observed memory improvement resulting from cueing suggests specific strategies that may be used to aid patients' recall of complex material.     

Staff attitudes toward patients with borderline personality disorder

Objective

Our aims were (1) to develop 2 inventories for the measurement of cognitive and emotional attitudes toward borderline personality disorder (BPD) patients and their treatment and (2) to use these tools to understand and compare attitudes of psychiatrists, psychologists, and nurses toward BPD patients.

Method

Two lists of items referring to cognitive (47 items) and emotional attitudes (20 items) toward BPD patients were formulated. Fifty-seven clinicians (25 nurses, 13 psychologists, and 19 psychiatrists), who had been working in public psychiatric institutions for more than 1 year, rated their level of agreement with each item. The list of cognitive attitudes yielded 3 factors (required treatment, suicidal tendencies, and antagonistic judgment). The list of emotional attitudes yielded 3 other factors (negative emotions, experienced difficulties in treatment, and empathy).

Results

Psychologists scored lower than psychiatrists and nurses on antagonistic judgments, whereas nurses scored lower than psychiatrists and psychologists on empathy. Regression stepwise analyses conducted on the 3 emotional attitudes separately showed that suicidal tendencies of BPD patients mainly explained the negative emotions and the difficulties in treating these patients. All groups were interested in learning more about the treatment of these patients.

Conclusions

Suicidal tendencies of BPD patients provoke antagonistic judgments among the 3 professions. Nevertheless, psychiatrists, psychologists, and nurses hold distinctive cognitive and emotional attitudes toward these patients. Mapping these differences can improve the education and training in the management of BPD patients.     

Obsessive-compulsive disorder comorbid with borderline personality disorder: A long-term case study

Abstract Three case reports of patients with borderline personality disorder (BPD) and obsessive-compulsive disorder (OCD) for more than 10 years are used to illustrate the relationship between OCD and borderline pathology. The recognizable features of the obsessive-compulsive symptoms in these reports are: (i) pervasiveness, the symptomatic overlap of obsessive-compulsive symptoms; (ii) poor insight and resistance; and (iii) obsessive control evident in personal relationships. These features are manifestations of OCD psychopathology as well as of a personality disorder. The symptoms with these features are located hypothetically towards the severe end of the symptomatic spectrum of OCD. The comorbidity is not a simple relationship, and the symptomatology of the comorbid patient is derived from OCD pathology linked with the personality disorder rather than from independent BPD pathology.     

Delusions and hallucinations in patients with borderline personality disorder

Abstract  To clarify the nature of delusional and hallucinatory symptoms in borderline personality disorder (BPD), the authors investigated five patients with BPD who developed those symptoms, and discussed their duration, recurrence, types of variants and relation to the situation. The duration of these symptoms tended to vary widely, although six of 11 episodes lasted more than 7 days. Episodes tended to recur in all patients two or three times. Each episode could be classified into three types of delusions and hallucinations, such as delusions without hallucinations, complicated delusion and hallucination, and hallucinations without delusion. Delusions without hallucination occurred a total of four times in two patients and had a tendency to occur when the patient confronted personal adversities. They projected their feelings directly toward the person concerned. A complicated delusion and hallucination was observed three times in two patients. This type of symptom also tended to occur at the time of interpersonal problems but the patient's attitude was more passive. Hallucination without delusion occurred a total of four times in three patients. This symptom tended to occur when the patient avoided an interpersonal relationship. In this case the patients isolated themselves from others and withdrew.     

Diminished impulsivity in older patients with borderline personality disorder

OBJECTIVE: The aim of this study was to test, in terms of impulsivity, the hypothesis that borderline personality disorder "burns out" with age. METHOD: Linear regression analyses, with age as a predictor variable, were conducted on subsection scores of the Revised Diagnostic Interview for Borderlines (DIB-R) for 123 individuals with a diagnosis of borderline personality disorder who were accepted into an outpatient-based psychotherapy program. The subsection scores of the DIB-R allow quantification of the core features of the disorder: affective disturbance, relationship disturbance, cognitive disturbance, and impulsive behavior. RESULTS: Older patients with borderline personality disorder showed less impulsivity than younger patients, but there was no difference in terms of affect disturbance, identity disturbance, and interpersonal problems. CONCLUSIONS: The view that borderline personality disorder burns out with age is supported in terms of impulsivity.     

Sexual practices among patients with borderline personality disorder

The authors found that 12 (57%) of 21 consecutive male patients with borderline personality disorder who presented for psychiatric treatment at two distant geographic sites were homosexual. They then obtained the sexual histories of 80 patients who met standardized criteria for borderline disorder and found that 17 (21%) of these patients were homosexual, four (5%) were bisexual, and nine (11%) had diagnoses of paraphilias. Ten (53%) of the 19 men with borderline disorder were homosexual, compared with seven (11%) of the 61 women. Homosexuality was 10 times more common among the men and six times more common among the women with borderline personality disorder than in the general population or in a depressed control group.