Borderline personality disorder (BPD) is a common psychiatric disorder that is often overlooked in treatment settings. This report describes the validation of a new self-report screening measure for ...DSM-IV BPD--the McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD). Two hundred subjects with treatment histories whose ages ranged from 18 to 59 filled out the MSI-BPD. Each subject was then interviewed, blind to MSI-BPD results, with the BPD module of the Diagnostic Interview for DSM-IV Personality Disorders (DIPD-IV; Zanarini, Frankenburg, Sickel, & Yong, 1996). Of these 200 subjects, 139 (69.5%) met DSM-IV criteria for BPD as assessed by the BPD module of the DIPD-IV and the remaining 61 subjects (30.5%) did not. Using logistic regression analyses, an MSI-BPD cutoff of 7 or more of the measure's 10 items was judged to be the best cutoff. This was so because it yielded both good sensitivity (.81; percentage of correctly identified cases) and specificity (.85; percentage of correctly identified noncases) for the diagnosis of DSM-IV BPD. For younger subjects, diagnostic efficiency was even greater. For example, sensitivity was .90 and specificity was .93 at a cutoff of 7 for the 63 subjects who were 25 years old or younger. The results of this study suggest that the MSI-BPD may be a useful screening instrument for the presence of DSM-IV borderline personality disorder.
The purpose of this study was to determine the course of the psychosocial functioning of patients with borderline personality disorder (BPD) over 6 years of prospective follow-up. The psychosocial ...functioning of 290 patients meeting both DIB-R and DSM-III-R criteria for BPD and 72 patients meeting DSM-III-R criteria for another Axis II disorder (and neither criteria set for BPD) was assessed at baseline using a semistructured interview of demonstrated reliability. Over 94% of surviving patients were reinterviewed about their psychosocial functioning blind to all previously collected information at three distinct follow-up waves: 2-, 4-, and 6-year follow-up. The psychosocial functioning of borderline patients improved substantially over time, with the percentage meeting criteria for good overall psychosocial functioning increasing from 26% at baseline to 56% during the third wave of follow-up. Despite this improvement, borderline patients functioned significantly more poorly than Axis II comparison subjects, particularly in the area of vocational achievement. However, a more detailed examination revealed that borderline patients who had experienced a symptomatic remission during the course of the study functioned significantly better both socially and vocationally than never-remitted borderline patients. More specifically, they were significantly more likely to have a good relationship with a spouse/partner and at least one parent, good work/school performance, a sustained work/school history, a GAF score of 61 or higher (43% vs. 0% 6 years after their index admission), and to have good overall psychosocial functioning (66% vs. 27% at 6 year follow-up). Taken together, the results of this study suggest that psychosocial improvement is both common among borderline patients and strongly related to their symptomatic status.
The purpose of this study was to determine the most clinically relevant baseline predictors of time to remission for patients with borderline personality disorder.
A total of 290 inpatients meeting ...criteria for both the Revised Diagnostic Interview for Borderlines and DSM-III-R for borderline personality disorder were assessed during their index admission with a series of semistructured interviews and self-report measures. Diagnostic status was reassessed at five contiguous 2-year time periods. Discrete survival analytic methods, which controlled for baseline severity of borderline psychopathology and time, were used to estimate hazard ratios.
Eighty-eight percent of the patients with borderline personality disorder studied achieved remission. In terms of time to remission, 39.3% of the 242 patients who experienced a remission of their disorder first remitted by their 2-year follow-up, an additional 22.3% first remitted by their 4-year follow-up, an additional 21.9% by their 6-year follow-up, an additional 12.8% by their 8-year follow-up, and another 3.7% by their 10-year follow-up. Sixteen variables were found to be significant bivariate predictors of earlier time to remission. Seven of these remained significant in multivariate analyses: younger age, absence of childhood sexual abuse, no family history of substance use disorder, good vocational record, absence of an anxious cluster personality disorder, low neuroticism, and high agreeableness.
The results of this study suggest that prediction of time to remission from borderline personality disorder is multifactorial in nature, involving factors that are routinely assessed in clinical practice and factors, particularly aspects of temperament, that are not.
To assess long-term effectiveness and safety of randomized antidepressant discontinuation after acute recovery from bipolar depression.
In the Systematic Treatment Enhancement Program for Bipolar ...Disorder (STEP-BD) study, conducted between 2000 and 2007, 70 patients with DSM-IV-diagnosed bipolar disorder (72.5% non-rapid cycling, 70% type I) with acute major depression, initially responding to treatment with antidepressants plus mood stabilizers, and euthymic for 2 months, were openly randomly assigned to antidepressant continuation versus discontinuation for 1-3 years. Mood stabilizers were continued in both groups.
The primary outcome was mean change on the depressive subscale of the STEP-BD Clinical Monitoring Form. Antidepressant continuation trended toward less severe depressive symptoms (mean difference in DSM-IV depression criteria = -1.84 95% CI, -0.08 to 3.77) and mildly delayed depressive episode relapse (HR = 2.13 1.00-4.56), without increased manic symptoms (mean difference in DSM-IV mania criteria = +0.23 -0.73 to 1.20). No benefits in prevalence or severity of new depressive or manic episodes, or overall time in remission, occurred. Type II bipolar disorder did not predict enhanced antidepressant response, but rapid-cycling course predicted 3 times more depressive episodes with antidepressant continuation (rapid cycling = 1.29 vs non-rapid cycling = 0.42 episodes/year, P = .04).
This first randomized discontinuation study with modern antidepressants showed no statistically significant symptomatic benefit with those agents in the long-term treatment of bipolar disorder, along with neither robust depressive episode prevention benefit nor enhanced remission rates. Trends toward mild benefits, however, were found in subjects who continued antidepressants. This study also found, similar to studies of tricyclic antidepressants, that rapid-cycling patients had worsened outcomes with modern antidepressant continuation.
clinicaltrials.gov Identifier: NCT00012558.
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.
The purpose of this study was to assess the psychometric properties of the Zanarini Rating Scale for Borderline Personality Disorder (ZAN-BPD), the first clinician-administered scale for the ...assessment of change in DSM-IV borderline psychopathology. The questions for the measure were adapted from the BPD module of the Diagnostic Interview for DSM-IV Personality Disorders (DIPD-IV) to reflect a 1-week time frame and each of the nine criteria for BPD is rated on a five-point anchored rating scale of 0 to 4, yielding a total score of 0 to 36. Two diagnostic interviews that assess the presence of BPD were administered to 200 nonpsychotic patients: the BPD module of the DIPD-IV and the Revised Diagnostic Interview for Borderlines (DIB-R). The ZAN-BPD was also administered, blind to diagnostic information. In addition, each patient filled out a self-report measure of general psychopathology that is often used in borderline treatment studies, the Symptom Checklist 90 (SCL-90). The convergent validity of the ZAN-BPD and relevant scales of the SCL-90 and the DIB-R was assessed and found to be highly significant. The discriminant validity of the various scores of the ZAN-BPD was also found to be highly significant, easily discriminating the 139 patients who met the DSM-IV criteria for BPD from the 61 patients who did not. In addition, internal consistency of the ZAN-BPD was found to be high (Cronbach's alpha=0.85). The interrater reliability of the ZAN-BPD was assessed using 32 conjoint interviews, while same day test-retest reliability was assessed in a separate sample of 40 patients. All reliability raters were blind to all previously collected information concerning each subject. All intraclass correlations were in the good to excellent range. Finally, the sensitivity of the ZAN-BPD to change was assessed using a third sample of 41 patients who were reinterviewed by a blind rater 7 to 10 days after the ZAN-BPD was first administered. The SCL-90 was also readministered at this time. The correlations between difference scores of the ZAN-BPD and difference scores of the SCL-90 were found to be significant, indicating that the ZAN-BPD measures change in a clinically meaningful manner. Taken together, the results of this study suggest that the ZAN-BPD is a promising clinician-administered scale for the assessment of change in borderline psychopathology over time.
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, 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.
The main objective of this study was to assess the rates of adult experiences of verbal, emotional, physical, and sexual abuse reported by borderline patients and Axis II comparison subjects during 6 ...years of prospective follow-up. A semistructured interview was administered to 290 borderline patients and 72 Axis II comparison subjects during their index admission. A follow-up analogue to this interview was administered at three contiguous 2-year follow-up periods. Over 94% of surviving patients were re-interviewed at all three follow-up waves. The rates of all four forms of reported abuse declined significantly over time for all subjects considered together. However, each of these types of abuse was reported by a significantly higher percentage of borderline patients than Axis II comparison subjects. When the presence of these forms of abuse was used to predict time to remission, all but sexual abuse were strongly associated with the failure to achieve symptomatic remission from borderline personality disorder. Taken together, the results of this study suggest that the rates of adult abuse reported by borderline patients decline significantly with time but remain relatively high. They also suggest that adult experiences of abuse are strongly associated with a failure to remit from borderline personality disorder.
The purpose of this study was to determine the percentage of borderline patients who first engaged in self-mutilation as children and to compare the parameters of their self-harm to those of ...borderline patients who first harmed themselves at an older age. Two hundred and ninety inpatients meeting both Revised Diagnostic Interview for Borderlines (DIB-R; Zanarini, Gunderson, Frankenburg, & Chauncey, 1989) and Diagnostic and Statistical Manual of Mental Disorders (3rd ed. ref.) (DSM-III-R; APA, 1987) criteria for borderline personality disorder were interviewed about their history of self-mutilation. Of the 91% with a history of self mutilation, 32.8% reported first harming themselves as children (12 years of age or younger), 30.2% as adolescents (13-17 years of age), and 37% as adults (18 or older). Using logistic regression analyses and controlling for baseline age, it was found that those with a childhood onset reported more episodes of self-harm, a longer duration of self-harm, and a greater number of methods of self-harm than either those with an adolescent or adult onset to their self-mutilation. The results of this study suggest that a sizable minority of borderline patients first engage in self-harm as children and that the course of their self-mutilation may be particularly malignant.
The purpose of this study was to assess the prevalence of each of the nine DSM criteria for borderline personality disorder and the prevalence of the disorder itself in the first-degree relatives of ...borderline probands and Axis II comparison subjects. Four hundred and forty-five inpatients were interviewed about familial borderline psychopathology using the Revised Family History Questionnaire--a semistructured interview of demonstrated reliability. Of these 445 subjects, 341 met both DIB-R and DSM-III-R criteria for BPD and 104 met DSM-III-R criteria for another type of personality disorder (and neither criteria set for BPD). The psychopathology of 1,580 first-degree relatives of borderline probands and 472 relatives of Axis II comparison subjects was assessed. Both DSM-III-R and DSM-IV BPD were found to be more common among the relatives of borderline than Axis II comparison probands. However, five of the criteria for BPD (inappropriate anger, affective instability, paranoia/dissociation, general impulsivity, and intense, unstable relationships) and all four sectors of borderline psychopathology (affect, cognition, impulsivity, and interpersonal relationships) were found to be both more common and discriminating than the BPD diagnosis itself. Taken together, the results of this study suggest that the subsyndromal phenomenology of BPD may be more common than the borderline diagnosis itself.
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