Aggression in Borderline Personality Disorder

This review examined aggressive behavior in Borderline Personality Disorder (BPD) and its management in adults. Aggression against self or against others is a core component of BPD. Impulsiveness is a clinical hallmark (as well as a DSM-IV-TR diagnostic criterion) of BPD, and aggressive acts by BPD patients are largely of the impulsive type. BPD has high comorbidity rates with substance use disorders, Bipolar Disorder, and Antisocial Personality Disorder; these conditions further elevate the risk for violence. Treatment of BDP includes psychodynamic, cognitive behavioral, schema therapy, dialectic behavioral, group and pharmacological interventions. Recent studies indicate that many medications, particularly atypical antipsychotics and anticonvulsants, may reduce impulsivity, affective lability as well as irritability and aggressive behavior. But there is still a lack of large, double blind, placebo controlled studies in this area.     

Gender Patterns in Borderline Personality Disorder

Gender differences in patients with borderline personality disorder are potentially relevant because they may guide clinicians in assessment and treatment. To date, a number of clinical features in borderline personality disorder have been examined for gender differences. As for prevalence, earlier research concluded that a higher proportion of women than men suffer from borderline personality disorder, although more recent research has determined no differences in prevalence by gender. In addition, there may not be gender differences in borderline personality disorder with respect to specific types of self-harm behavior, such as self-cutting or levels of psychological distress at clinical presentation. However, current evidence indicates that there are notable gender differences in borderline personality disorder with regard to personality traits, Axis I and II comorbidity, and treatment utilization. With regard to personality traits, men with borderline personality disorder are more likely to demonstrate an explosive temperament and higher levels of novelty seeking than women with borderline personality disorder. As for Axis I comorbidity, men with borderline personality disorder are more likely to evidence substance use disorders whereas women with borderline personality disorder are more likely to evidence eating, mood, anxiety, and posttraumatic stress disorders. With regard to Axis II comorbidity, men with borderline personality disorder are more likely than women to evidence antisocial personality disorder. Finally, in terms of treatment utilization, men with borderline personality disorder are more likely to have treatment histories relating to substance abuse whereas women are more likely to have treatment histories characterized by more pharmacotherapy and psychotherapy.     

Comparison of Attachment Styles in Borderline Personality Disorder and Obsessive-Compulsive Personality Disorder

The intense, unstable interpersonal relationships characteristic of patients with borderline personality disorder (BPD) are thought to represent insecure attachment. The Reciprocal Attachment Questionnaire was used to compare the attachment styles of patients with BPD to the styles of patients with a contrasting personality disorder, obsessive-compulsive personality disorder (OCPD). The results showed that patients with BPD were more likely to exhibit angry withdrawal and compulsive care-seeking attachment patterns. Patients with BPD also scored higher on the dimensions of lack of availability of the attachment figure, feared loss of the attachment figure, lack of use of the attachment figure, and separation protest. The findings may be relevant for understanding the core interpersonal psychopathology of BPD and for managing therapeutic relationships with these patients.     

Borderline Personality Disorder in the Courtroom

The insanity defense has been criticized with consequences for individuals with real mental illness. In the United States, several states have redefined the insanity defense by excluding antisocial personality disorder from consideration for the not guilty by reason of insanity plea. Four states have eliminated the insanity defense completely. The purpose of this article is to analyze the diagnosis of borderline personality disorder, its relevance in the courtroom setting, and how this speaks to the approach of the insanity defense in general. The history of the insanity defense, impulsive nature of borderline personality disorder, and the reasons that make personality disorders controversial are reviewed. The impulsive nature, and the association to childhood trauma, dissociation, and frontolimbic abnormalities support the continued protection of borderline personality disorder under the insanity defense. Knowledge of these facts will assist the forensic psychiatrist in effectively educating the courtroom about borderline personality disorder. Key words: borderline personality disorder, cortico-limbic model, dissociation, forensic psychiatry, insanity defense, splitting, suicide     

Borderline Personality Disorder and Depression: An Update

To review the literature related to recent temperamental and biological findings on borderline personality disorder (BPD) and major depression, the close link between the two disorders, and the latest therapeutical findings on BPD, focusing on the conditions of co-morbidity between depression and BPD. The National Institutes of Health's PubMed database was used to identify indexed studies on BPD, depression and the co-morbidity between the two. Only studies published between 2000 and 2011 were assessed. Similar temperamental features have been demonstrated in BPD and depression. The strong link between the two disorders seems to be widely recognized by scientific community. Psychotherapy and new antipsychotics are the topics of current major interest of research. The therapeutic targets in the case of co-morbidity are BPD features associated with depressive symptoms, thus influencing prognosis. A global assessment is, in fact, fundamental for a successful therapy for the treatment of the several aspects of a complex psychopathological phenomenon.     

Borderline Personality Disorder and Psychosis: A Review

Early views of borderline personality disorder (BPD) were based on the idea that patients with this pathology were “on the border” of psychosis. However, more recent studies have not supported this view, although they have found evidence of a malevolent interpersonal evaluation and a significant proportion of BPD patients showing psychotic symptoms. For example, in one study, 24% of BPD patients reported severe psychotic symptoms and about 75% had dissociative experiences and paranoid ideation. Thus, we start with an overview regarding the prevalence of psychotic symptoms in BPD patients. Furthermore, we report findings of studies investigating the role of comorbidity (eg, post-traumatic stress disorder) in the severity and frequency of psychotic symptoms in BPD patients. We then present results of genetic and neurobiological studies comparing BPD patients with patients with schizophrenia or nonschizophrenic psychotic disorders. In conclusion, this review reveals that psychotic symptoms in BPD patients may not predict the development of a psychotic disorder but are often permanent and severe and need careful consideration by clinicians. Therefore, adequate diagnosis and treatment of psychotic symptoms in BPD patients is emphasized.     

Psychotherapy for Borderline Personality Disorder: Progress and Remaining Challenges

Purpose

The main purpose of this review was to critically evaluate the literature on psychotherapies for borderline personality disorder (BPD) published over the past 5 years to identify the progress with remaining challenges and to determine priority areas for future research.

Method

A systematic review of the literature over the last 5 years was undertaken.

Results

The review yielded 184 relevant abstracts, and after applying inclusion criteria, 16 articles were fully reviewed based on the articles’ implications for future research and/or clinical practice.

Conclusion

Our review indicated that patients with various severities benefited from psychotherapy; more intensive therapies were not significantly superior to less intensive therapies; enhancing emotion regulation processes and fostering more coherent self-identity were important mechanisms of change; therapies had been extended to patients with BPD and posttraumatic stress disorder; and more research was needed to be directed at functional outcomes.

     

The Personality Disorders Institute/Borderline Personality Disorder Research Foundation Randomized Control Trial for Borderline Personality Disorder: Reliability of Axis I and II Diagnoses

The Personality Disorder Institute/Borderline Personality Disorder Research Foundation randomized control trial (PDI/BPDRF RCT) is a randomized control trial comparing three treatments for borderline personality disorder (BPD). An important issue for any RCT is diagnostic reliability, demonstration of which is necessary to evaluate claims of a treatment's efficacy for a given population. The present paper examines the interrater reliability of Axis I and II disorders in the context of a high base rate of BPD features for participants referred for inclusion in the RCT. Our results indicate good to excellent levels of interrater reliability for all Axis I and II disorders in this context. Assessors were able to reliably diagnose BPD, exclusionary criteria, and comorbid diagnoses. This data is important for comparing findings and sample composition across different studies using similar sampling strategies, especially as treatments are increasingly being developed and tested for BPD.