Personality Disorder Severity Research Articles

Borderline Personality Disorder, PTSD, and Suicide

Borderline Personality Disorder, PTSD, and Suicide

Personality pathology recorded by severity: national survey

Current classifications of personality disorders do not classify severity despite clinical practice favouring such descriptions. To assess whether an existing measure of severity of personality disorder predicted clinical pathology and societal dysfunction in a community sample. UK national epidemiological study in which personality status was measured using the screening version of the Structured Clinical Interview for DSM-IV Personality Disorders (SCID-II) and reclassified to five levels using a modified severity index. Associations between levels of severity of personality pathology and social, demographic and clinical variables were measured. Of 8391 individuals interviewed and their personality status assessed, only a minority (n = 1933, 23%) had no personality pathology. The results supported the hypothesis. More severe personality pathology was associated incrementally with younger age, childhood institutional care, expulsion from school, contacts with the criminal justice system, economic inactivity, more Axis I pathology and greater service contact (primary care and secondary care, all P<0.001). Significant handicap was noted among people with even low levels of personality pathology. No differences contradicted the main hypothesis. A simple reconstruction of the existing classification of personality disorder is a good predictor of social dysfunction and supports the development of severity measures as a critical requirement in both DSM-V and ICD-11 classifications.

Impact of Co-Occurring Posttraumatic Stress Disorder on Suicidal Women With Borderline Personality Disorder

The authors examined the impact of co-occurring posttraumatic stress disorder (PTSD) on women with borderline personality disorder who had attempted suicide in the preceding year. Female borderline personality disorder outpatients (N=94) either with (N=53, 56.4%) or without PTSD (N=41, 43.6%) and with recent and repeated suicidal or self-injurious behavior were compared in nine areas of functioning. Borderline personality disorder patients with and without PTSD differed in the lethality, intent, and triggers for intentional self-injury, trauma history, emotion regulation, and axis I comorbidity. The two groups did not differ in borderline personality disorder severity, axis II comorbidity, psychosocial functioning, or mental health or medical treatment utilization. The results indicate greater impairment among individuals with both disorders and suggest that there are some unique features associated with co-occurring borderline personality disorder and PTSD that require further attention in assessment and treatment.

Comorbidity and Associated Severity of Borderline Personality Disorder and Physical Health Conditions in a Nationally Representative Sample

To investigate the comorbidity and severity of borderline personality disorder and physical health conditions in a nationally representative sample. Despite the recent trend of examining the relationship between physical and mental health, there has been limited research examining the association of physical health conditions and personality disorders, in particular, borderline personality disorder. The National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) Wave 2 (n = 34,653; cumulative response rate, 70.2%; age, ≥20 years) was used in the current study. The Alcohol Use Disorder and Associated Disabilities Interview Schedule-Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition was used to assess mental disorders, and self-reports were used to assess physical health conditions. Multiple logistic regression models examined the comorbidity of physical health conditions with borderline personality disorder and associated suicide attempts. After adjusting for sociodemographic variables, common Axis I mental disorders, and Axis II personality disorders, the presence of borderline personality disorder was significantly associated with arteriosclerosis or hypertension, hepatic disease, cardiovascular disease, gastrointestinal disease, arthritis, venereal disease, and "any assessed medical condition" (adjusted odds ratios, range 1.46-2.80). In the most stringent adjusted model, diabetes, stroke, and obesity were not associated with borderline personality disorder. Furthermore, a greater likelihood of suicide attempts was associated with cardiovascular disease, venereal disease, and "any assessed medical condition" with comorbid borderline personality disorder than borderline personality disorder alone. Careful screening and treatment of physical health conditions among people with borderline personality disorder are warranted.

The Borderline Personality Disorder Severity Index-IV: Psychometric evaluation and dimensional structure

The BPDSI-IV is a DSM-IV based semi-structured interview that assesses frequency and severity of Borderline Personality Disorder (BPD) manifestations during the last three months. The present study assessed its psychometric properties and underlying factor structure. Data from 108 BPD-patients, 31 Cluster-C PD patients, 27 Axis-I patients and 76 non-patients were analyzed. Interrater reliability, internal consistency, discriminant, construct and concurrent validity proved to be very good. Clinical norms with high sensitivity and specificity were derived. Confirmatory factor analyses supported both a one and nine-dimensional model based on the DSM-IV criteria. The nine-factor model was superior over 7 alternative models. In conclusion, the BPDSI-IV is a reliable and valid instrument to assess BPD-severity as well as severity of the nine DSM-IV BPD-criteria separately.

Complex personality disorder in bulimia nervosa

Objective Recent research has suggested a move toward a dimensional system for the classification of personality disorders (PDs). Tyrer's dimensional model using severity as a form of categorizing PDs was used to compare eating disorder outcome in women with bulimia nervosa (BN) over 3 years. Method One hundred thirty-four women with BN were divided into 4 groups based on PD severity: no PD (n = 32), personality difficulty (n = 27), simple PD (n = 29), and complex PD (n = 46). Eating disorder symptoms and attitudes, general psychosocial functioning, and depressive symptoms were examined at pretreatment and at 1-year and 3-year follow-up (posttreatment). Results The complex PD group had greater Axis I comorbidity and psychopathology than the remaining 3 groups at pretreatment. At 1-year and 3-year follow-up, there were no differences in eating disorder outcome, general psychosocial functioning, and depressive symptoms across the 4 groups. Conclusion These results suggest that having an increased number of PDs comorbid with BN does not influence eating disorder outcome up to 3 years after treatment.

Pharmacotherapy for borderline personality disorder: Cochrane systematic review of randomised trials

Many patients with borderline personality disorder receive pharmacological treatment, but there is uncertainty about the usefulness of such therapies. To evaluate the evidence of effectiveness of pharmacotherapy in treating different facets of the psychopathology of borderline personality disorder. A Cochrane Collaboration systematic review and meta-analysis of randomised comparisons of drug v. placebo, drug v. drug, or single drug v. combined drug treatment in adult patients with borderline personality disorder was conducted. Primary outcomes were overall disorder severity as well as specific core symptoms. Secondary outcomes comprised associated psychiatric pathology and drug tolerability. Twenty-seven trials were included in which first- and second-generation antipsychotics, mood stabilisers, antidepressants and omega-3 fatty acids were tested. Most beneficial effects were found for the mood stabilisers topiramate, lamotrigine and valproate semisodium, and the second-generation antipsychotics aripiprazole and olanzapine. However, the robustness of findings is low, since they are based mostly on single, small studies. Selective serotonin reuptake inhibitors so far lack high-level evidence of effectiveness. The current evidence from randomised controlled trials suggests that drug treatment, especially with mood stabilisers and second-generation antipsychotics, may be effective for treating a number of core symptoms and associated psychopathology, but the evidence does not currently support effectiveness for overall severity of borderline personality disorder. Pharmacotherapy should therefore be targeted at specific symptoms.

Recurrence of self‐harm &amp; severity of personality disorder

Recurrence of self‐harm &amp; severity of personality disorder

How to Deal with Cost Differences at Baseline

To our knowledge, adjustment for baseline imbalances in costs has never been performed in trial-based cost-effectiveness analyses. We used data from a clinical trial performed in the Netherlands comparing two outpatient psychotherapies: schema-focused therapy (SFT) versus transference-focused psychotherapy (TFP). Costs were assessed with a cost interview. Outcome was the proportion of recovered patients measured with the Borderline Personality Disorder Severity Index (BPDSI-IV). We used three methods to adjust the costs for baseline differences: (i) mean difference adjustment, calculating total costs after baseline by adjusting the difference between groups with the difference of the mean baseline costs; (ii) delta adjustment, calculating the individual differences between patient baseline and the subsequent measurements (concerning incremental costs, this is the same as mean difference adjustment); and (iii) regression-based adjustment, adjusting total costs with a regression model, with total costs as the dependent variable and baseline costs as the independent variable. Mean baseline costs were 3339 euros for SFT and 4238 euros for TFP, a mean difference of 899 euros. Total unadjusted follow-up costs were 30822 euros for SFT and 36812 euros for TFP. The fraction of recovered patients was 45% for SFT and 24% for TFP. Cost-effectiveness acceptability curves show that mean difference and delta adjustments are different from the regression-based methods. Although the routine starting point of an analysis should always be an unadjusted analysis of the cost effectiveness, a baseline difference between treatment groups should be adjusted for. This should be done by reported patient characteristics or, when these are not sufficiently present, by baseline costs as a substitute. This adjustment should be carried out most preferably with a regression-based method.

Staff and Patient’s Perceptions of Each Other’s Interpersonal Style

Extreme and varied reactions are often encountered when working with patients with personality disorders. Similarly, patients with personality disorder may also hold polarised opinions of the staff involved in their treatment. This study explored the relationship between severity of personality disorder and interpersonal style in patients admitted for treatment to a secure psychiatric unit. Up to four nurses rated each patient's interpersonal style using the Impact Message Inventory, a self-report transactional inventory. Patients then rated the interpersonal style of these same staff. Contrary to expectations, severity of personality disorder was not associated with patients' interpersonal style or to variance in nurses' assessments of patients' interpersonal style. However, patients with more severe personality disorder tended to show greater variability in their assessment of nurses' interpersonal style, specifically their appraisal of staff members' interpersonal dominance. Implications for the assessment of offenders admitted for treatment of their personality disorder are discussed.

Borderline Personality Disorder

Borderline Personality Disorder

Trait impulsivity and response inhibition in antisocial personality disorder

Background Impulsive behavior is a prominent characteristic of antisocial personality disorder. Impulsivity is a complex construct, however, representing distinct domains of cognition and action. Leading models refer to impulsivity as an inability to evaluate a stimulus fully before responding to it (rapid-response impulsivity), and as an inability to delay responding despite a larger reward (reward-delay impulsivity). We investigated these models in terms of the diagnosis and severity of antisocial personality disorder. Methods Thirty-four male subjects on probation/parole who met DSM-IV criteria for ASPD, and 30 male healthy comparison subjects, matched by ethnicity, were recruited from the community. The Barratt Impulsiveness Scale (BIS-11) provided an integrated measure of trait impulsivity. Rapid-response impulsivity was assessed using the Immediate Memory Task (IMT), a continuous performance test. Reward delay impulsivity was assessed using the Two-choice Impulsivity Paradigm (TCIP), where subjects had the choice of smaller-sooner or larger-delayed rewards, and the Single Key Impulsivity Paradigm (SKIP), a free-operant responding task. Results Compared to controls, subjects with ASPD had higher BIS-11 scores (Effect Size (E.S.) = 0.95). They had slower reaction times to IMT commission errors (E.S. = 0.45). Correct detections, a measure of attention, were identical to controls. On the SKIP, they had a shorter maximum delay for reward (E.S. = 0.76), but this was not significant after correction for age and education. The groups did not differ on impulsive choices on the TCIP (E.S. < 0.1). On probit analysis with age and education as additional independent variables, BIS-11 score, IMT reaction time to a commission error, and IMT positive response bias contributed significantly to diagnosis of ASPD; SKIP delay for reward did not. Severity of ASPD, assessed by the number of ASPD symptoms endorsed on the SCID-II, correlated significantly with commission errors (impulsive responses) on the IMT, and with liberal IMT response bias. This relationship persisted with correction for age and education. Discussion These results suggest that ASPD is characterized by increased rapid-response impulsivity. Aspects of impulsivity related to reward-delay or attention appear relatively intact.

A comparison of women who continue and discontinue treatment for borderline personality disorder

AbstractBackground Treatment non‐completion is a significant problem for personality disorder treatment services.Aims We investigated differences between treatment continuers and treatment discontinuers of a tertiary specialist service for people with borderline personality disorder. The two groups were compared on: (1) personality disorder severity; (2) motivation for therapy; (3) mood; and (4) social problem solving.Method Patients' personality disorders were examined using the International Personality Disorder Examination. Three self‐report questionnaires were administered at the start of treatment: the Treatment Motivation Questionnaire, the Hospital Anxiety and Depression Scale (HADS), and the Social Problem Solving Inventory‐Revised.Results Of 14 outpatients recruited to the service during 2005 to 2007, seven continued and seven discontinued treatment. Those who did not continue with therapy had more complex personality disorder profiles, were more externally motivated for treatment and were less internally motivated for treatment. All patients scored high on the HADS. Problem‐solving abilities were apparently intact, but adversely affected by a negative problem orientation. Treatment discontinuers spent, on average, three times longer in hospital than continuers.Conclusion Engaging people with complex personality disorders, low internal motivation for therapy and negative problem orientation is a challenge for services. Non‐completion of treatment is associated with more days in hospital and higher service costs. Copyright © 2009 John Wiley &amp; Sons, Ltd.

Impact of severity of personality disorder on the outcome of depression

The influence of severity of personality disorder on outcome of depression is unclear. Four hundred and ten patients with depression in 9 urban and rural communities in Finland, Ireland, Norway, Spain and the United Kingdom, were randomised to individual problem-solving treatment ( n = 121), group sessions on depression prevention ( n = 106) or treatment as usual ( n = 183). Depressive symptoms were recorded at baseline, 6 and 12 months. Personality assessment was performed using the Personality Assessment Schedule and analysed by severity (no personality disorder, personality difficulty, simple personality disorder, complex personality disorder). Complete personality assessments were performed on 301 individuals of whom 49.8% had no personality disorder; 19.3% had personality difficulties; 13.0% had simple personality disorder; and 17.9% had complex personality disorder. Severity of personality disorder was correlated with Beck Depression Inventory (BDI) scores at baseline (Spearman's r = 0.21; p < 0.001), 6 months ( r = 0.14; p = 0.02) and 12 months ( r = 0.21; p = 0.001). On multi-variable analysis, BDI at baseline ( p < 0.001) and type of treatment offered (individual therapy, group therapy, treatment as usual) ( p = 0.01) were significant independent predictors of BDI at 6 months. BDI at baseline was the sole significant independent predictor of BDI at 12 months ( p < 0.001). There was no interaction between personality disorder and treatment type for depression. While multi-variable analyses indicate that depressive symptoms at baseline are the strongest predictor of depressive symptoms at 6 and 12 months, the strong correlations between severity of personality disorder and depressive symptoms make it difficult to establish the independent effect of personality disorder on outcome of depression.

Severity of personality disorders and suicide attempt

Severity of personality disorders (PDs) may be more useful in estimating suicide risk than the diagnosis of specific PDs. We hypothesized that suicide attempters with severe PD would present more attempts and attempts of greater severity/lethality. Four hundred and forty-six suicide attempters were assessed. PD diagnosis was made using the International Personality Disorder Questionnaire--Screening Questionnaire. PDs were classified using Tyrer and Johnson's classification of severity (no PD, simple PD, diffuse PD). Severity/lethality of attempts was measured with the Suicide Intent Scale, Risk-Rescue Rating Scale and Lethality Rating Scale. Attempters with severe (diffuse) PD had more attempts than the other groups. After controlling for age and gender, this difference remained significant only for the younger age group and women. There was no relationship between severity of PDs and severity/lethality of attempts. Younger female attempters with severe PD are prone to repeated attempts. However, the severity of PD was not related to the severity/lethality of suicide attempts.

The EQ-5D: A useful quality of life measure in borderline personality disorder?

Introduction Borderline Personality Disorder (BPD) is a severe psychiatric disorder and is associated with significant impairment in quality of life. The aim of the present study is to assess the internal and external responsiveness of the EuroQoL-5D (EQ-5D) in BPD patients. Patients and Methods Data from 49 patients included in a multi-center Dutch randomized trial were used. We used both the EQ-5D utility score and the Visual Analogue Scale of the EuroQoL, and the Borderline Personality Disorder Severity Index-IV (BPDSI-IV). To determine internal responsiveness, we calculated the standardized response mean (SRM). To determine external responsiveness, we calculated Spearman correlations for the change scores, and compared EQ-5D scores for clinically improved vs. non-clinically improved patients as measured with the BPDSI-IV. Results Patient scores improved on all instruments during the three years. SRMs for BPDSI-IV were significantly higher than EQ-5D utility. Three-year Spearman correlation between change scores of BPDSI-IV and EQ-5D utility was 0.487, between BPDSI-IV and EQ-VAS it was 0.404, both statistically significant. EQ-5D utility scores for patients who clinically improved were significantly higher than for patients who did not. Discussion We conclude that the EQ-5D is fairly responsive in BPD, and, therefore, especially because of its brevity and user-friendliness, can serve as a useful tool in economic evaluations in patients with BPD.

Efficacy and tolerability of aripiprazole augmentation in sertraline-resistant patients with borderline personality disorder

Information is available on aripiprazole as a treatment for borderline personality disorder (BPD), but no data have yet been presented concerning the use of this drug as an adjunctive treatment for drug-resistant BPD patients. This study investigates aripiprazole augmentation of ongoing sertraline therapy in drug-resistant BPD patients. Twenty-one outpatients with a DSM-IV-TR diagnosis of BPD who did not respond to sertraline, 100–200 mg/day for 12 weeks, were treated for 12 weeks with the addition of aripiprazole, 10–15 mg/day. Patients were assessed at baseline, week 4, and week 12 with the Clinical Global Impression Scale — Severity item (CGI-S), the Brief Psychiatric Rating Scale (BPRS), the Hamilton scales for depression and anxiety (HAM-D, HAM-A), the Social Occupational Functioning Assessment Scale (SOFAS) for social functioning, the Borderline Personality Disorder Severity Index (BPDSI), and the Barratt Impulsiveness Scale (BIS-11). Adverse effects were evaluated using the Dosage Record and Treatment Emergent Symptom Scale (DOTES). Sixteen patients completed the study. Five patients (23.8%) dropped out due to anxiety/insomnia or non-compliance. Nine patients (56.3%) were responders. Analysis of variance revealed significant changes in the following measures: CGI-S, BPRS, BPDSI total score, BPDSI "impulsivity" and "dissociation/paranoid ideation" items, and BIS-11. Adverse effects were mild headache, insomnia, and anxiety. Aripiprazole is an efficacious and well-tolerated add-on treatment for sertraline-resistant BPD patients. It acts on impulsive and psychotic-like symptoms.

Social Functioning of Patients With Personality Disorder in Secondary Care

Social Functioning of Patients With Personality Disorder in Secondary Care

Social Functioning of Patients With Personality Disorder in Secondary Care

Patients with personality disorder are often viewed as falling outside the primary therapeutic role of specialist care. This focus on axis I disorders can lead to overlooking patients' personality function. This study explored the social dysfunction associated with personality function and its severity within secondary care. A cross-sectional survey using census data, face-to-face interviews, and audit of case notes was used to collect information from secondary care populations in four urban settings in the United Kingdom. The Quick Personality Assessment Schedule, the Comprehensive Psychopathology Rating Scale, and operational criteria for diagnosis were used to confirm axis I and axis II disorders. Social functioning was assessed with the Camberwell Assessment of Need and the Social Functioning Questionnaire. Because this was a secondary analysis, a priori hypotheses were tested to the p=.01 level to minimize the possibility of type I error. A total of 2,528 key workers completed questionnaires (99%), and 282 randomly selected patients were interviewed (71%). Severity of personality disorder accounted for 14% of the variance in objective measure of social dysfunction and for 19% of the variance in subjective measure of social dysfunction. Of other mental disorders, only depression interacted significantly with either measure, according to multiple stepwise linear regression. Personality disturbance led to social dysfunction to a greater extent than most other pathology. In order to address the issue of social dysfunction, a variety of approaches are needed to turnattention toward personality pathology.

The Relationship of Impairment to Personality Disorder Severity Among Individuals with Specific Axis I Disorders: Results from the National Epidemiologic Survey on Alcohol and Related Conditions

The present study examined one dimensional approach to personality disorders (PDs) in a large (n = 43,093), nationally representative sample of the U.S. population. Respondents were classified in four personality severity categories (no PD, subthreshold PD, simple PD, complex PD). Linear regression analyses were conducted to examine mental disability by PD severity for major DSM-IV substance use, mood and anxiety disorders. Significant increases in disability were observed between no PD and simple PD and between simple PD and complex PD for each Axis I disorder except drug dependence, but few differences in disability were found between no PD and subthreshold PD. This study found support for the clinical utility of the dimensional classification of PD severity with regard to the distinction between simple and complex PD and for a combined no PD-subthreshold PD level of severity. Future planned analyses will address the clinical utility of the classification prospectively, with a full battery of all Axis II PDs.