Course Of Borderline Personality Disorder Research Articles

Anterior cingulate volume reduction in adolescents with borderline personality disorder and co-morbid major depression

Borderline Personality Disorder (BPD) is a serious illness characterized by emotional dysregulation, impulsivity, and impaired interpersonal relationships. Prior work shows the anterior cingulate gyrus (ACG)—a region primarily involved in assessing the salience of emotional information and regulating emotional responses--is smaller in adults with BPD. We tested the hypothesis that, similar to adults, adolescents with BPD would have reduced Brodmann area (BA)-24 volume. Thirteen adolescent inpatients with co-morbid BPD and Major Depressive Disorder (MDD) and 13 matched healthy controls received 3T-MRI scans. Using a cytoarchitecturally-derived approach measuring gray and white matter volume, we observed a Group × Cingulate BA (25,24,31,23,29) × Matter (gray, white) type interaction indicating the BPD/MDD adolescents had smaller BA24 volume in gray but not white matter. Greater number of suicide attempts and BPD symptom severity measured by the Diagnostic Interview for BPD-revised (DIB-R) total score but not depressive symptoms measured by the Beck Depression Inventory (BDI) was associated with smaller BA24 volume. Our preliminary findings suggest that BPD-related abnormalities in BA24 volume may occur early in the developmental course of BPD with MDD. Future studies examining samples of MDD patients with and without BPD co-morbidity will be needed to clarify whether BA24 volume reductions are specific to BPD.

The course of substance use disorders in patients with borderline personality disorder and Axis II comparison subjects: a 10‐year follow‐up study

The purpose of this study is to detail the course of substance use disorders (SUDs) over 10 years of prospective follow-up among patients with borderline personality disorder (BPD) and Axis II comparison subjects. This study uses data from the McLean Study of Adult Development (MSAD), a multi-faceted study of the longitudinal course of BPD using reliable repeated measures administered every 2 years over a decade of prospective follow-up. All subjects were initially in-patients at McLean Hospital in Belmont Massachusetts. PARTICIPANTS; A total of 290 patients with BPD and 72 Axis II comparison subjects were assessed at baseline and five waves of follow-up. The Structured Clinical Interview for DSM-III-R Axis I Disorders (SCID-I), the Revised Diagnostic Interview for Borderlines (DIB-R) and the Diagnostic Interview for DSM-III-R Personality Disorders (DIPD-R) were administered six times. Generalized estimating equations were used to assess longitudinal prevalence of SUDs. Kaplan-Meier analyses were used to assess time-to-remission, recurrence and new onsets of SUDs. The prevalence of SUDs among borderline patients and Axis II comparison subjects declined significantly over time, while remaining significantly more common among those with BPD. More than 90% of borderline patients meeting criteria for a SUD at baseline experienced a remission by 10-year follow-up. Recurrences and new onsets of SUDs were less common (35-40% and 21-23%). Remissions of alcohol and drug abuse/dependence among borderline patients are both common and relatively stable. Results also suggest that new onsets of these disorders are less common than might be expected.

Two-year follow-up of borderline personality disorder patients in Italy: A preliminary report on prognosis and prediction of outcome

Few naturalistic studies have examined the course of borderline personality disorder (BPD) outside North American countries. The aim of this prospective study was to investigate remission rate, changes in the level of BPD psychopathology and outcome prediction in a sample (n = 46) of Italian BPD outpatients over a two-year follow-up. Two years after baseline, remission rate from BPD and changes in the severity of BPD psychopathology were investigated. Initial measures of borderline, comorbid Axis I and II psychopathology and clinical severity, as well as historical and socio-demographic variables, were used to predict the number of BPD criteria met at follow-up. At the two-year interview, the mean number of BPD criteria endorsed decreased ( p = 0.04) and 12 participants (26.1%) fell below the diagnostic threshold for BPD. Borderline psychopathology at follow-up was predicted by the presence, at baseline, of substance use disorders and self-defeating personality traits, and by the absence of dependent traits (R(2) = 0.409; p < 0.001). However, these results cannot be generalized to patients lost to follow-up (15 out of an initial sample of 61), who may exhibit a more severe psychopathology at baseline and therefore a poorer prognosis. Borderline individuals seeking treatment at Italian public psychiatric centres may show some improvement in BPD psychopathology over a two-year follow-up; however, the remission rate seems to be lower than that found in North American samples. Furthermore, outcome predictors overlap only partially with those detected by North American studies.

Superior temporal gyrus volume in teenagers with first-presentation borderline personality disorder

This magnetic resonance imaging study investigated the superior temporal gyrus (STG) subregion volumes in 20 teenagers with first-presentation borderline personality disorder (BPD) and 20 healthy controls. While the STG volume early in the course of BPD did not differ from that of healthy controls, the BPD participants with violent episodes had a smaller left caudal STG volume compared with those without such episodes during the previous 6 months. Our preliminary findings might reflect the neurobiological heterogeneity of the disorder.

A Study of Maladaptive Schemas and Borderline Personality Disorder in Young People

Maladaptive schemas are hypothesized to play a significant role in the development and maintenance of Borderline Personality Disorder (BPD). This study investigates which maladaptive schemas are present early in the course of BPD and whether specific maladaptive schemas are associated with particular BPD diagnostic criteria during this phase. Thirty outpatients (aged 15–24) diagnosed with BPD and 28 community controls completed the Young Schema Questionnaire—Short Form. Compared to controls, the BPD group had significantly higher scores for most maladaptive schemas and their scores were clinically elevated across all schema domains. BPD diagnostic criteria and schema profiles showed substantial heterogeneity and were not related to one another. These findings do not support the association of specific maladaptive schemas with BPD and emphasize the importance of individual case formulation of diagnostic and schema features in the early phase of BPD.

Anterior cingulate volume in adolescents with first-presentation borderline personality disorder

Reports of volumetric abnormalities in the anterior cingulate cortex (ACC) in adults with established borderline personality disorder (BPD) are inconsistent, and it is not known whether such abnormalities are present early in the disorder. We aimed to investigate ACC volume in a first-presentation teenage BPD sample with minimal exposure to treatment. Fifteen female BPD patients and 15 healthy female control participants underwent magnetic resonance imaging (MRI) scanning. ACC volumes were estimated using a reliable method that accounts for inter-individual variation in sulcal morphology, and measurements were compared between the two groups. Analysis of variance revealed a decrease in volume of the left ACC in BPD patients compared with control participants. This volumetric change was correlated with parasuicidal behavior and impulsivity. A measure of ACC volume asymmetry was also correlated with fear of abandonment symptoms. Our results suggest that ACC volumetric abnormalities early in the course of BPD might be related to clinical correlates of the disorder. Longitudinal studies are needed to examine the nature of this abnormality over the course of the disorder.

Borderline Personality Disorder: What do We Know? Diagnosis, Course, Co-Morbidity, and Aetiology

Evidence regarding the diagnostic dilemmas, course, co-morbidity, and aetiology of Borderline Personality Disorder (BPD) is reviewed. After considering problems that the clinician and researcher face in using BPD as a diagnostic category, I argue that current evidence indicates that there is reason to be more optimistic about the course of BPD. Emerging dilemmas in considering co-morbidity in the BPD patient are considered. Aetiological factors are presented in support of a ‘multiple pathways’ model of aetiology where characterological and temperamental characteristics interact in complex idiosyncratic ways.

Orbitofrontal, amygdala and hippocampal volumes in teenagers with first-presentation borderline personality disorder

It is not known whether the fronto-limbic volume reductions found in adults with established borderline personality disorder (BPD) are present early in the disorder. The aim of the study was to investigate orbitofrontal cortex (OFC), hippocampal and amygdala volumes in a first-presentation teenage BPD sample with minimal exposure to treatment. Groups of 20 BPD patients and 20 healthy control participants underwent magnetic resonance imaging. Hippocampal, amygdala, OFC and whole brain volumes were estimated and compared between the two groups. Analysis of variance revealed reversal of the normal (right > left) asymmetry of OFC grey matter volume in the BPD group, reflecting right-sided OFC grey matter loss in the BPD group compared with control participants. No significant differences were found for amygdala or hippocampal volumes comparing BPD with control participants. We identified OFC but not hippocampal or amygdala volumetric differences early in the course of BPD. Hippocampal and amygdala volume reductions observed in adult BPD samples might develop during the course of the disorder, although longitudinal studies are needed to examine this.

Descriptive and Longitudinal Observations on the Relationship of Borderline Personality Disorder and Bipolar Disorder

The purpose of this study was to test whether borderline personality disorder is a variant of bipolar disorder by examining the rates of co-occurrence in both disorders, the effects of co-occurrence on a longitudinal course, and whether the presence of either disorder confers the risk for new onsets of the other. A prospective repeated-measures design with reliable independent diagnostic measures and 4 years of follow-up was used to assess 196 patients with borderline personality disorder and 433 patients with other personality disorders. Patients with borderline personality disorder had a significantly higher co-occurrence of bipolar disorder (19.4%) than did patients with other personality disorders. However, this co-occurrence did not appear to affect the subsequent course of borderline personality disorder. Although only 8.2% of the borderline personality disorder patients developed new onsets of bipolar disorder, this rate was higher than in patients with other personality disorders. Patients with other personality disorders with co-occurring bipolar disorder generally had more new onsets of borderline personality disorder (25%) than did patients with other personality disorders without co-occurring bipolar disorder (10%). A modest association between borderline personality disorder and bipolar disorder is reported.

Relationship of Borderline Personality Disorder and Bipolar Disorder

Relationship of Borderline Personality Disorder and Bipolar Disorder

Descriptive and Longitudinal Observations on the Relationship of Borderline Personality Disorder and Bipolar Disorder

The purpose of this study was to test whether borderline personality disorder is a variant of bipolar disorder by examining the rates of co-occurrence in both disorders, the effects of co-occurrence on a longitudinal course, and whether the presence of either disorder confers the risk for new onsets of the other. A prospective repeated-measures design with reliable independent diagnostic measures and 4 years of follow-up was used to assess 196 patients with borderline personality disorder and 433 patients with other personality disorders. Patients with borderline personality disorder had a significantly higher co-occurrence of bipolar disorder (19.4%) than did patients with other personality disorders. However, this co-occurrence did not appear to affect the subsequent course of borderline personality disorder. Although only 8.2% of the borderline personality disorder patients developed new onsets of bipolar disorder, this rate was higher than in patients with other personality disorders. Patients with other personality disorders with co-occurring bipolar disorder generally had more new onsets of borderline personality disorder (25%) than did patients with other personality disorders without co-occurring bipolar disorder (10%). A modest association between borderline personality disorder and bipolar disorder is reported.

Relationship of Borderline Personality Disorder and Bipolar Disorder

Relationship of Borderline Personality Disorder and Bipolar Disorder

Progress in the treatment of borderline personality disorder

We outline recent evidence suggesting that the natural course of borderline personality disorder is more benign than formerly believed. We explore possible reasons for the change in findings which include both the iatrogenic effects of earlier treatment models and the recent availability of effective interventions. Clinicians should be optimistic about improvement and long-term outcomes.

Predicting change in borderline personality: Using neurobehavioral systems indicators within an individual growth curve framework

The natural history and course of borderline personality disorder (BPD) has long been the focus of speculation, typically guided by impressions from clinical work with BPD-affected individuals. Not unlike the other personality disorders (PDs), it has long been assumed that BPD is relatively stable, traitlike, and enduring in nature. The extent to which BPD is or is not a plastic construct has implications not only for understanding its longitudinal course, but also for understanding its development and, ultimately, its treatment and/or prevention. This paper consists of two parts. The first part reviews the longitudinal research corpus that bears directly upon the issue of stability of BPD in both adolescents and adults. The consistent trend in very nearly all studies, whether using a categorical or dimensional approach to assessment, is one of considerable change over time. This literature presents complexities, however, because most of the extant studies examine BPD-affected individuals who have been exposed to treatment. However, at least two large-scale longitudinal studies, which include both treated and untreated persons, also provide support for viewing BPD as a malleable disorder that declines in severity over time. The second part presents original data from the Longitudinal Study of Personality Disorders that specifically examine the predictors of change in BPD using a neurobehavioral model of personality within an individual growth curve (IGC) analytical framework. This IGC analysis revealed important predictors of both overall level of BPD features as well as rate of change in BPD features, with particularly important roles played by the agentic positive emotion (i.e., incentive motivation) and anxiety (negative emotion) systems. The benefits of the IGC approach for understanding the developmental psychopathology of BPD is also stressed.

The McLean Study of Adult Development (MSAD): Overview and Implications of the First Six Years of Prospective Follow-Up

The McLean Study of Adult Development (MSAD) began 12 years ago. It is the first NIMH-funded prospective study of the course and outcome of borderline personality disorder (BPD). After careful analysis of the first six years of follow-up, 5 main findings concerning the symptomatic and psychosocial course of BPD have emerged from this study. The first finding is that remissions are far more common than previously recognized (about 74%). The second is that these remissions are quite stable and thus, recurrences are quite rare (about 6%). The third finding is that completed suicides are far more rare than anticipated (about 4% vs. 10%). The fourth finding is that a "complex" model of borderline psychopathology best describes BPD. In this model, some symptoms resolve relatively quickly, are the best markers for the disorder, and are often the immediate reason for needing costly forms of treatment, such as psychiatric hospitalizations. We termed these symptoms (e.g., self-mutilation, help-seeking suicide threats or attempts) acute symptoms. Other symptoms resolve more slowly, are not specific to BPD, and are closely associated with ongoing psychosocial impairment. We termed such symptoms (e.g., chronic feelings of intense anger, profound abandonment concerns) temperamental symptoms. Fifth, it was also found that borderline patients were improving psychosocially over time, particularly remitted borderline patients; psychosocial functioning of remitted patients continued to improve as time progressed, suggesting that they were somewhat belatedly achieving the milestones of young adulthood and not simply returning to a prodromal level of functioning. Taken together, these results suggest that the prognosis for BPD is better than previously recognized.

Introduction to the Special Issue on Longitudinal Studies

A major recent development in the study of personality disorder has been the publication of a series of important longitudinal studies. Until recently, ideas about the long-term course of the disorder were largely speculative. These studies have confirmed some of these speculations but, as is often the case when assumptions about personality disorder are subjected to empirical test, they also suggest that at least some of these speculations are wide of the mark. As a result, important questions are raised about the definition and classification of personality disorder. To date, the results of these studies have been disseminated in multiple publications scattered throughout the literature. Given their importance for the future development of the field, it seemed appropriate to try to draw these studies together and present the main conclusions in a single publication. To this end, the authors of three major studies were invited to present a synthesis of their findings and discuss their implications in a special issue of the Journal. Patricia Cohen and colleagues present the results of their impressive Children in the Community (CIC) Study, an epidemiological investigation that follows a sample of children from early childhood into adulthood. The other two studies follow a sample of individuals seeking treatment. Andrew Skodol and colleagues report on the Collaborative Longitudinal Personality Disorder Study (CLPS), which follows a sample of patients with schizotypal, borderline, avoidant, and obsessive-compulsive personality disorders, and Mary Zanarini and colleagues present the results the McLean Study of Human Development (MSAD), an in-depth analysis of the course of borderline personality disorder. Commentaries were subsequently invited from a wide range of authorities. These commentaries are presented after the three main articles in this special issue. Those published were the ones received when this issue of the Journal went to press. There are many aspects of these studies that warrant comment and discussion. Together they document the substantial public health implications of personality disorder and the burden it places on those who suffer from it and those around them. The finding that has attracted the most attention, however, is the remarkable instability of DSM diagnoses. This robust finding was not widely anticipated at the outset of this work. That changes occur in the years from adolescence to early adulthood as shown by the CIC study is not surprising. More surprising to many clinicians

The Association Between Borderline Personality Disorder and Chronic Medical Illnesses, Poor Health-Related Lifestyle Choices, and Costly Forms of Health Care Utilization

The physical health of patients with borderline personality disorder has not been well studied. The purpose of this study was to compare the physical health, lifestyle choices affecting physical health, and health care utilization of patients with remitted and nonremitted borderline personality disorder. 200 patients who no longer met the Revised Diagnostic Interview for Borderlines (DIB-R) and DSM-III-R criteria for borderline personality disorder and 64 patients who still met study criteria for borderline personality disorder were interviewed from June 1992 through December 2001 concerning their physical health, lifestyle choices, and use of medical care 6 years after their initial participation in a larger study of the longitudinal course of borderline personality disorder. Remitted borderline patients were found to be significantly less likely than non-remitted borderline patients to have a history of a "syndrome-like" condition (i.e., chronic fatigue, fibromyalgia, or temporomandibular joint syndrome) (p = .049) or to have a history of obesity (p = .026), osteoarthritis (p = .025), diabetes (p = .001), hypertension (p = .028), back pain (p < .001), or urinary incontinence (p < .001). They were also found to be significantly less likely to report pack per day smoking (p = .002), daily consumption of alcohol (p = .003), lack of regular exercise (p = .006), daily use of sleep medications (p < .001), and sustained use of pain medications (p = .026). In addition, remitted borderline patients were significantly less likely than nonremitted borderline patients to have had at least 1 medically related emergency room visit (p < .001), 1 medical hospitalization (p = .003), or 1 of each (p< .001). The failure to remit from borderline personality disorder seems to be associated with a heightened risk of suffering from chronic physical conditions, making poor health-related lifestyle choices, and using costly forms of medical services.

Impulsivity: core aspect of borderline personality disorder.

This prospective follow-up study addresses whether impulsivity versus other aspects of borderline personality disorder (BPD) are (1) stable over a 7-year follow-up period; (2) able to predict the persistence versus remittance of BPD over 7 years of follow-up, and (3) more predictive of the level of borderline psychopathology on follow-up than other aspects of the disorder. When the cohort was assembled, 88 of 130 subjects scored seven or higher on the Diagnostic Interview for Borderlines (DIB), indicating a definite diagnosis of BPD. The cohort was reassessed at 2 and 7 years after the index admission. At the 7-year follow up, 81(62.3%) of the original cohort were re-examined, two (1.6%) were deceased, six (4.6%) suicided, 36 (27.7%) refused to participate and five (3.8%) could not be located. The results indicated that the initial impulse action subscale score was highly correlated with the 7-year follow-up score (r = 0.53). Using a stepwise multiple regression technique, the impulse action subscale score from the DIB best predicted borderline psychopathology at the 7-year follow up, with an r2 of 0.24, F = 24.84, p < 0.001. This prospective study of subjects with BPD indicates that impulsivity is stable over time and highly predictive of borderline psychopathology over 7 years follow up. These results suggest the treatment of impulsivity may impact the course of BPD.

A developmental psychopathology approach

This paper recounts my work with Anna, a 26-year-old married woman working in two part-time jobs, who presented with major depression. The high prevalence rates of depression, the comorbidity of depression with personality disorders (see Farmer & Nelson-Gray, 1990 ), and the long-term and destructive course of borderline personality disorder (BPD) present a formidable challenge both to mental health professionals and clinical researchers ( A. T. Beck, Freeman, & Associates, 1990 ; Gunderson & Zanarini, 1987 ; Linehan, 1993 ; Ryle, Leighton, & Pollock, 1997 ). Two main themes will be emphasized. First, the last 10 years has seen a burgeoning of clinical accounts, theoretical expositions, and clinical research of comorbid depression and personality disorders in the cognitive-behavioral tradition. This paper seeks to draw on this literature in describing and explaining the case of Anna. Second, a developmental psychopathology cognitive-behavioral approach is adopted in conceptualization and treatment planning.

The Course of Borderline Personality Disorder

Little is known about the course of borderline personality disorder (BPD) or the effects of treatment on the self-destructive behavior that is characteristic of these patients. This prospective study followed 37 carefully diagnosed female inpatients with BPD for five years after the start of …